Are the growing capabilities of therapeutic flexible endoscopy leading to a new era in treatment of gastrointestinal conditions? Are the most important areas for initial NOTES study safe peritoneal access and secure gastric closure, intraperitoneal contamination, image display and maintenance of spatial orientation, development of stable working platforms, physiologic perturbations, and tissue approximation methods?
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When Albert Pagliuca got gallstones, his surgeon offered to remove his gallbladder with a new operation designed to hurt less, get him back to work more quickly and leave no visible scars. But there was one catch: Doctors would pull the organ out through his mouth…
After doctors guaranteed that would not happen, he agreed, becoming one of several dozen Americans who have undergone experimental procedures that could take minimally invasive surgery to a new level — operations that do not cut the skin open. Instead, surgeons enter the body through a “natural orifice…”
Many surgeons are enthusiastic about the possibilities, but some question the need for the new procedures when safe, only slightly invasive alternatives exist. And they fear that doctors will rush ahead before they have perfected their techniques and made sure that the benefits are worth the risks…
David Cronin, an associate professor of surgery at the Medical College of Wisconsin, is especially concerned that non-surgeons will start doing the operations. He said: “Not every idea is a good idea. I’ve been following this one with clenched teeth.”
Proponents argue that they are well aware of the pitfalls and have taken steps to prevent them. Two key medical specialties joined together to try to ensure that the operations are carefully studied before becoming widespread, in the hope of avoiding the kinds of complications caused by laparoscopic surgeries in the early 1990s…
The approach, called NOTES — for natural orifice transluminal endoscopic surgery — seeks to move beyond arthroscopic and laparoscopic techniques, which for many procedures replaced large incisions with several small ones, shortening hospital stays and recovery time, reducing pain and risks, and leaving much smaller scars.
More recently, surgeons realized they could enter the body through natural openings with flexible endoscopes, which are routinely used for diagnostic purposes such as colon cancer screening. After experimenting for years on pigs and human cadavers, a team in India announced in 2005 the first successful procedure in humans…
Surgeons have now performed the procedures on more than 400 patients worldwide, mostly in South America and India. Doctors in Europe are experimenting with them, and a handful of surgeons began trying the approach in the United States in the past year.
The technique has been used mostly to remove gallbladders through the mouth or the vagina. But a few patients have had appendectomies, and doctors are experimenting with stomach surgery for obesity and other conditions…
To remove a gallbladder or an appendix through the mouth, surgeons give patients general anesthesia and slide an endoscope down the throat and into the stomach. They inflate the abdominal area to make it easier to see and sterilize the stomach. In addition to a camera that transmits images, the endoscope is equipped with a variety of small instruments, including a tiny scalpel that cuts a hole in the stomach wall, allowing the surgeon to snake the endoscope to the organ needing removal. Other instruments enable the surgeon to move the organ, cauterize bleeding blood vessels, suture and clip the internal incisions and pull out the organ.
So far, most surgeons are making at least one external incision in the abdomen, usually in the bellybutton, to insert a laparoscope to help them see where they are working and sometimes assist with other aspects of the procedure, such as lifting the organ. But at least one group has started removing gallbladders through the vagina without any external incisions, and the goal is to refine the techniques and instruments to operate entirely internally.
All of the 40 or so reported U.S. procedures have been done under guidelines established by NOSCAR, the Natural Orifice Surgery Consortium for Assessment and Research. The consortium was created by the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons to try to develop the technique safely…