Although Dr. Kato knew Mr. Collison’s surgery would be a challenge, it turned out to be even more difficult than he had expected and the longest operation he had ever performed.  Mr. Collison, a wry, gray-haired man who has his own business selling metal-cutting tools, had a liposarcoma, an uncommon type of tumor that arises from fat cells. He had no symptoms until October 2008, when he began to itch all over and became jaundiced. A CT scan found a tumor the size of a softball pressing on his liver and blocking his bile duct. Just three years earlier, his wife, Mary, said, a scan of his abdomen had been clear.  Blood vessels caught in the tumor made surgery too dangerous, his doctors in Milwaukee said, so they tried to shrink it with chemotherapy and radiation in hopes of making it operable. But a year later it was the size of a football and still growing, while Mr. Collison had begun to waste away, losing 70 pounds.  One of the strangest things about his case is that in 1993 he had another large tumor of a completely different type, also in his abdomen. That one, a neurofibroma the size of a basketball, was not malignant, and was surgically removed. He had a picture of it put on a coffee mug as a joke for his wife, a nurse, and neither of them imagined that such a thing could ever happen to him again. It is not clear why Mr. Collison developed two enormous tumors. It could be a horrible coincidence, but doctors say some unknown genetic condition is a more likely cause.  Last Tuesday, the first incision was made at about 10 a.m. It was tough going from the start. Scar tissue from the radiation treatment had essentially welded Mr. Collison’s insides together, requiring hours and hours of delicate dissection just to free organs and tissues so that surgeons could work on them. In addition, the bulging tumor had shoved organs and blood vessels out of its way, distorting Mr. Collison’s anatomy. The right side of his liver was squashed flat. Nothing was where it was supposed to be. Dr. Kato and his team had to rummage through their patient’s belly in search of veins they could normally have found with their eyes closed.  As the operation wore on through a day and a night, and then another day, exhausted nurses and surgeons rotated in and out. Dr. Kato, calm and soft-spoken, rarely left the room. Much of the time, Evelina Badalov, his physician’s assistant, worked by his side. Dr. Kato’s focus, patience and stamina did not ebb.  “He’s like a machine,” one of the surgeons said. “He loves this.”  The surgery was really a series of dauntingly complex operations. A certain amount of ground had to be ceded to the tumor, because it had a stranglehold on parts of Mr. Collison’s stomach, intestines and pancreas. Each of those organs had to be cut in two, so the healthy parts would stay with Mr. Collison while the entangled parts, including two-thirds of the stomach, would be taken out with the tumor. The portions that stayed had to be reconnected to the digestive tract.  Several blood vessels had also been captured by the tumor and would have to be replaced. Dr. Kato had to rebuild parts of two major veins with Gore-Tex tubes and replace another with the internal jugular vein from Mr. Collison’s own neck.  And because major blood vessels would have to be clamped off before the liver could be removed, Dr. Kato would also have to reroute Mr. Collison’s circulation temporarily through a pumping machine.  Surgery is a stunning blend of finesse and brute force. The incision was a huge, cross-shaped cut that ran from Mr. Collison’s breastbone to his pubic bone, then across his belly near the navel. Metal retractors needed to hold open the wound looked like tools from a hardware store, and it took three people to wrestle them into place. Electrocautery pens that did much of the cutting sparked, smoked and sent up a stench of burning flesh. Suction probes like bigger versions of the ones that dentists use gurgled as they vacuumed blood from the incisions.  The finesse is in the hands. Dr. Kato’s moved with confidence and grace that became all the more apparent when he worked across the operating table from someone less deft. An anesthesiologist said Dr. Kato had “soft hands,” reflected in the monitors tracking the patient’s pulse, breathing, electrocardiogram and blood pressure. When soft hands cut, stitched and moved organs around, the monitor readings held steady, but they spiked up and down when rough hands took over.  Surgeons tie knots in every single stitch. Dr. Kato said he made anywhere from 3 to 10 knots per stitch, depending on the type of suture material and the tissue being sewn. Nylon takes more knots than silk, arteries more than veins. Looking over his shoulder was like watching a magician: with a wave of his fingers, a knot would form, and it was possible to see the trick over and over without quite knowing how it was done. For Mr. Collison’s operation, he would ultimately tie 5,000 knots.  And they had to be tied just so. When a surgeon still in training pulled a knot too tight, Dr. Kato said, softly but insistent, “Don’t break the tissue, please.” At times, if helping hands fumbled, he would gently brush them away and say, “No, let me do it.”  When the liver finally came out, the tumor hanging from it was a dense, meaty-looking mass the size of a football. Embedded in the tumor were segments of Mr. Collison’s stomach, pancreas and intestines. Dr. Kato handed it to Dr. Jean C. Emond, the hospital’s director of transplantation, who cradled it in a purple towel like a grotesque baby. He estimated that the whole reddish-brown slab — tumor, liver and parts of other organs — weighed about 15 pounds. Ten of which were tumor.  Then Dr. Emond and Dr. Benjamin Samstein slid the grisly thing into a basin of icy salt water and went to work on it. The idea was to strip away the tumor, with minimal damage to the liver and its blood vessels and ducts, and then reimplant the liver.  Meanwhile, Dr. Kato worked on rebuilding the blood vessels that the liver would need.  The Operation: Days 2 and 3  By 4:30 p.m. on Wednesday — 30 hours into the operation — the liver was back inside Mr. Collison. That is always a tense moment in this kind of surgery, because many things can go wrong when blood first starts flowing through a newly implanted liver that has just been through surgery itself. And in Mr. Collison’s case, things did quickly start to spin out of control.  The liver bled profusely. Transfusions could barely keep up. Over the next few hours he needed 30 pints of blood. But even as the bleeding abated, his blood pressure and body temperature dropped, and his blood turned dangerously acidic. Drugs to correct one problem made others worse. He was sinking into a vicious cycle that could kill him. At 9:30 p.m. on Wednesday, after 35 hours of surgery, Dr. Kato and his colleagues did something they had never tried during an ex vivo procedure: even though Mr. Collison’s digestive tract was not fully reconnected, they halted the surgery, put a patch over the incision without sewing it up and took him to the intensive care unit to be stabilized.  The seemingly desperate maneuver worked. On Thursday night, Mr. Collison was ready for surgery again. Dr. Kato worked on him from 8:30 p.m. until 4:30 a.m. and finished all the needed repairs — after a total of 43 hours of surgery.  By Saturday, Mr. Collison was awake, off the ventilator and talking. Confused at first, he told nurses he had been in a plane crash.  “He’s doing great,” Dr. Kato said.  “I’m telling you, this man has come through so much,” she said. “I still can’t believe it. Any normal person would’ve died during it, probably. He really wanted to live.”  Even if the surgery buys her husband only a few years, it will have been worth it, she said.  Dr. Kato said that Mr. Collison’s prognosis was “fairly good,” though there was no guarantee that the tumor would not grow back.  “If it doesn’t recur,” Dr. Kato said, “he could have a long, long time ahead of him.”  A 43-hour operation inevitably raises questions about the best way to use medical resources.  Dr. Emond, who eagerly hired Dr. Kato as a rising star who could push the envelope in transplant surgery, said that even he was somewhat conflicted about operations that he called “extravaganzas.”  “What does this mean for medicine, doing these incredibly complex procedures to save individual lives?” Dr. Emond asked. “It’s an important philosophical question.”  He referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”  Another argument for the surgery is like the rationale for sending people to the Moon, Dr. Emond said: “Understanding things better or extending the limits of care in these extreme situations somehow moves the whole field of medicine forward.”  Both he and Dr. Kato likened ex vivo operations to the early days of liver transplants, which originally took twice as long as they do now and met with harsh criticism.  “Hopefully, we’ll get more efficient and make the surgery better,” Dr. Emond said. He noted that surgeons had a saying: “The great surgeon invents an operation that only he can do, and the truly great surgeon invents an operation that everyone can do.”  A version of this article appears in print on December 15, 2009, on Page D1 of the National edition with the headline: In Surgery, a Tangled Tumor Meets Its Match. Order Reprints| Today's Paper|Subscribe
At NewYork-Presbyterian Hospital/Columbia, surgeons spent 43 hours performing an ex vivo procedure on a man whose liver was engulfed by a cancerous tumor.