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UPDATE //

A New Step in Scarless Surgery

Years ahead of schedule, doctors perform on humans a surgery that involves reaching internal organs via the mouth or other natural orifices.

By Charles Slack // Summer 2007
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Natural orifice translumenal endoscopic surgery (NOTES)

ThinkStock/Age Fotostock

When I wrote about a novel surgical approach for reaching internal organs via the mouth or other natural orifices (“Down the Hatch,” Spring 2006), even the most enthusiastic proponents estimated it would be two to five years or more before the technique might be tried on humans in the United States. Yet on March 21, a scant year after my article appeared, surgeons at New York– Presbyterian/Columbia University Medical Center in New York City inserted instruments through an incision in a woman’s vaginal wall to remove her gallbladder.

The New York surgeons and other champions of this technique, dubbed NOTES (natural orifice translumenal endoscopic surgery), say the advantages include the absence of exterior scarring and significant reduction in pain. (Internal organs are relatively free from nerves, unlike the abdominal wall and parietal peritoneum, which must be cut through in conventional or laparoscopic surgery.)

The New York procedure was in fact a hybrid: To ensure the patient’s safety, the surgeons also created a series of abdominal incisions for laparoscopic instruments that aided in the operation. But less than two weeks later, on April 2, surgeons at the University Hospital of Strasbourg, in France, removed the gallbladder of a 30-year-old woman through her vagina with the aid of a single laparoscopic incision.

Such developments underscore the excitement surrounding a concept that as recently as the late 1990s was little more than a controversial idea being tossed around by a handful of physicians. They eventually formed a committee that in 2005 outlined both the promise and challenges of NOTES. Yet significant hurdles remain before the technique can gain popular acceptance. Detractors range from those who cite the danger of infections to those who assert that laparoscopy already provides safe, minimally invasive surgery. (Proponents counter that laparoscopy itself was considered controversial until its advantages became clear.) Still others, including some physicians, find the prospect of removing organs through the vagina or mouth too off-putting.

The NOTES procedure that most intrigues surgeons involves threading endoscopes through the mouth, down the esophagus and through a hole cut in the stomach. With its central location, the stomach offers unsurpassed access to organs in the abdominal cavity. Yet the stomach (and the rectum, another possible avenue) may be prone to complications from infections, should an incision fail to close properly. While surgeons seek surefire methods and more delicate tools to securely close abdominal incisions, most trials continue to be conducted on pigs and other animals.

Still, significant progress is being made toward the day when accessing internal organs via the stomach could be routine. A team at Ohio State University, for example, is already using the gastric route to investigate the spread of pancreatic cancer in patients. And perhaps the best indicator of the rapid growth of interest in the technique is that no fewer than 115 abstracts outlining new research in the field will be presented at an annual NOTES conference to be held in Boston in July 2007.

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Down the Hatch

scarless surgery

A new opening could lead surgeons past endoscopy and laparoscopy to a procedure that leaves no scars.

Quest for the Perfect Crime

The tools of minimally invasive surgery are becoming smaller and stealthier.

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