Doctors in New York have achieved a major breakthrough in abdominal surgery by removing a woman's gallbladder through her vagina.
This technique, they say, will cause less pain and scarring than the usual operation, and allow a quicker recovery. The technique can eliminate the need to cut through abdominal muscles, a major source of pain after surgery.
The New York patient, 66, had her gallbladder removed on March 21 and is recovering well, said her surgeon, Dr. Marc Bessler, the director of laparoscopic surgery at NewYork-Presbyterian/Columbia University Medical Center.
The operation was experimental, part of a study that is being done to find out whether people will fare better if abdominal surgery is performed through natural openings in the body rather than cuts in the belly.
The surgery still requires cutting, through the wall of the vagina, stomach or colon, but doctors say it should hurt less because those tissues are far less sensitive than the abdominal muscles.
Interest in this idea heightened after doctors from India made a video in 2004 showing an appendix being taken out through a patient's mouth. The patient had abdominal scars that would have made conventional surgery difficult.
Nageshwar Reddy and G.V. Rao of the Asian Institute of Gastroenterology, Hyderabad, had performed the first human cases of removal of the appendix through the stomach.
Then the "no-scar surgery" caught on. Laparoscopic surgeons from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and a group of expert interventional endoscopists representing the American Society for Gastrointestinal Endoscopy (ASGE) came together to form The Natural Orifice Surgery Consortium for Assessment and Research.
The Natural Orifice Translumenal Endoscopic Surgery (NOTES), their objective, is said to represent the next major advancement in minimally invasive therapy.
The new project focuses on removal of abdominal organs — like the gall bladder, appendix, adrenal, spleen and pancreas — using endoscopes passed through the mouth, anus or vagina. In a typical procedure, a specially designed flexible endoscope is passed through the mouth and a small hole created in the stomach wall. The surgeon passes instruments through this hole to dissect the target organ, eventually extracting it through the stomach and out of the mouth. End result: no scars on the belly, no pain of cuts or wound infections.
Dr.Bresler who performed the latest operation said that companies were beginning to make special surgical tools for such specialist operations. Millions of dollars were pouring into the project.
However, there are some who object. Dr. Christine Ren, an associate professor of surgery at New York University's school of medicine, called the vaginal procedure "repulsive" and said: "As a woman I find it very invasive, physically and emotionally. To me it's quite distasteful. You will really have to prove to me that there is a benefit."
Moshe Schein, author of several surgical books and associate editor of World Journal of Surgery, is also critical. "The idea is superficially appealing. But, to me, violating the integrity of the stomach wall to take out the gall bladder is against the basic rules of surgery, including the Kiss principle (Keep it simple, stupid). Do you really want to punch a hole in the stomach and then fix it — risking leaks — in order to take out an appendix or a gallbladder? Not me!" he says.
At Stanford, Dr. Myriam J. Curet, a professor of surgery, said, "It has some promise, and there's a lot of interest in the surgical community, a lot of attention being paid to it as a wave of the future."
Dr. Curet acknowledged that the idea was a bit disturbing at first, and said that even an audience of doctors shuddered at the video of the appendix being pulled out through the patient's mouth. But if the recovery does turn out to be quicker and less painful than the current methods allow, patients might want the procedure, including women in whom it would be performed vaginally.
Dr. Bessler said he and his colleagues had been doing practice operations in the laboratory on pigs for the past year, removing gallbladders, spleens, kidneys and stomachs through the mouth or vagina.
Eventually, Dr. Bessler said, he expected to use the natural-opening technique on men as well as women, with instruments passed down the throat or into the rectum to cut through the wall of the stomach or intestine to reach the gallbladder or other organs. But first, surgeons have to develop techniques to make sure that the cuts in the stomach and intestine can be sealed completely after the operation so that they do not leak into the abdomen, which could cause serious complications. Incisions through the wall of the vagina rarely caused leaks, he said.