"No Scar" Surgery

The evolution of surgery into its present state has taken a long way. Since the ancient times, physicians have resorted to almost any and all means to seek for the best possible ways to treat patients through innovation and experimentation with the common goals of finding better and safer modalities of therapy.

The trend is undoubtedly pointing towards the minimally invasive approach as a gold standard by which most surgical procedures must be performed. Laparoscopic and Endoscopic surgery have come a long way since Hippocrates performed a rectal examination using a speculum at about 400BC. This was the first minimally invasive surgical procedure ever recorded. Since then, the progress of minimally invasive surgery has been a plateau due to unavailability of equipment and lack of surgeon interest. It was only in the late 18th century that a sparkle of light, almost literally, pushed minimally invasive surgery a notch higher when Phillip Bozzini invented the Lichtleiter which provided a light source for the “primitive” endoscopes.

The advent of the digital age, however, has caused a sudden surge in interest with minimally invasive surgery. New technology was now available and modern medicine continued to develop, refine, and re-define itself with emphasis on superior clinical outcomes and patient satisfaction acceptable to the cost conscious political, social, and economic climate of today. The first laparoscopic cholecystectomy by Phillipe Mouret in 1987 drew widespread negative criticism and mockery from his colleagues. But for the few surgeons who understood the concept at heart, this was the 1st step to a gigantic leap forward which revolutionized and changed the way we do surgery today.

Minimally invasive surgery experienced a boom in the last two decades – a steep rise in demand, interest, investments, and innovation. Doctors, hospitals, and technological companies found themselves in a tight race to develop new techniques and better equipment for laparoscopic surgery with the ultimate goal of delivering safer treatment through the least invasive means possible.

Sound ideas, futuristic thoughts, science fiction inspired, or simply human adventurism or worst, plain boredom – these are just few of the words used to describe the latest innovation into the minimally invasive surgery scuffle. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been gaining momentum. It is a brand new method of delivering “minimal access” surgery without skin incisions at all. It is, however, replaced by incisions through hollow viscus accessible via natural orifices such as the mouth, anus, and vagina with the use of flexible endoscopes. But is it really the impetus of better things to come that will propel our standard of care into the next level? Or is it a complete contradiction of the age honored basic principles of surgery?

Natural orifice surgery has been practiced by urologists, neurosurgeons, and gynecologists when they perform trans-urethral surgeries, trans-sphenoidal tumor resections, and trans-vaginal hysterectomies, respectively. The main purposes of utilizing these natural orifices as access points are to provide a less invasive procedure which can translate into decreased morbidity and better outcomes. So why is the new NOTES craze in General Surgery so different from all these near routine procedures?

Surgeons are taught to avoid perforating the bowel and never to violate planar compartments keeping in mind that maintaining the integrity of anatomical boundaries is a logical and sound principle that will prevent potentially life threatening complications. It is this very principle of surgery that the new NOTES era is unintentionally challenging. The thought of deliberately going through a pristine wall of hollow viscus to gain access into the peritoneal cavity is enough motive for apprehension for most surgeons.

But amidst all the debate and hesitation, some surgeons have gone ahead and explored the feasibility of this exciting new field. After graduating from animal studies, the team of Drs. Reddy & Rao from India successfully performed their initial seven trans-gastric appendectomies using a flexible endoscope. Although, a laparoscope was simultaneously inserted (hybrid procedure) to ensure that spillage into the abdominal cavity as well as iatrogenic injuries during the procedure could be easily visualized since this was an experimental procedure, the daring innovation has caught the eye of many surgeons from all over the world. Just recently, Dr. Marc Bessler from the Columbia University Medical Center in the USA successfully performed a transvaginal Endoscopic cholecystectomy. A similar procedure was also performed by Prof. Jacques Marescauex in Strasbourg, France. Definitely, there are more and more centers around the globe recently performing more of these procedures but all in hybrid fashion. There have also been reports from the USA of successfully utilizing this experimental procedure to perform peritoneal lavage and re-do surgery in cases of dislodged Percutaneous Endoscopic Gastrostomy (PEG) tubes.

The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has been quick to sound the alarm and form an organization to ensure the safe and proper development and application of NOTES. With a substantial grant from Johnson & Johnson (and later by Covidien), SAGES has aptly formed NOSCAR which stands for Natural Orifice Surgery Consortium for Assessment and Research. The excitement and interest brought about by NOTES is global. Just recently, the European Association of Transluminal Surgery (EATS) was formed and an Asia-Pacific conglomerate of surgeons and gastro-enterologists conducting NOTES research is in the making.

There is truly one thing that is always constant and that is – change. But changes are not always good. They do not always point us to the right direction; often we stumble along the way only to find out we shouldn’t have taken the road less taken. The introduction of NOTES into the surgical armamentarium is a welcome addition but must be treated with caution and proper evaluation. Skepticism is healthy but total dismissal would also be considered reckless in our quest for advancement. We cannot just reject outright the potential benefits of this innovation. NOTES trials should be done by expert endoscopists and minimally invasive surgeons under a controlled environment and with meticulous concern for detail.

New developments are always exciting. The road to success is hard and long but the farther the travel and the longer the wait, the sweeter the rewards and the fulfillment unparalleled.