Scarless surgery

September 29, 2008

Surgery is a big deal. It can seem scary, even when it’s essential for our health we can’t help worrying about what is going to happen, and if we are going to have a big ugly scar. Well the good news is that you can avoid the scar, if not the scare, by having what’s being called ‘Natural Orifice Surgery’.

You won’t be cut open, instead there are now at least two dozen Americans who have undergone a new operation designed to hurt less, get you back to work more quickly and leave no visible scars. For one patient, Albert Pagliuca, who needed his gallbladder removed, he nearly balked when told that doctors would pull it out through his mouth. Not unnaturally he was worried it might get stuck in his windpipe and he would choke, but after doctors guaranteed that it would not happen, he agreed – makes a frog in the throat seem quite normal doesn’t it?

This is not entirely new, as three years ago surgeons realised 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.

To remove a gallbladder or an appendix through the mouth, surgeons give patients a general anaesthetic and slide an endoscope down the throat and into the stomach. They inflate the abdominal area to make it easier to see and sterilise 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.

Surgeons have now performed the procedures on more than 400 patients worldwide, mostly in South America and India. 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.

Doctors in Europe are also now experimenting with them, and many surgeons are already 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.

Worryingly, other surgeons agree: “That’s exactly what’s going to happen,” said Ira J. Kodner, a surgery professor and a bioethicist at Washington University School of Medicine in St. Louis. “Those who haven’t been trained are going to go out and do it. They are going to take a weekend course and start offering it. It’s going to happen. I guarantee it.”

The idea of a ‘weekend course’ is frightening enough in itself, and I find myself sympathetic to the views of David Cronin, an associate professor of surgery at the Medical College of Wisconsin who said: “Not every idea is a good idea. I’ve been following this one with clenched teeth.”

Laparoscopic surgeries in the early 1990s were also hailed as a great innovation, but caused medical complications so this time round there is a call for making sure that patient safety is paramount and the technique developed in a responsible and careful manner. For the most part, the benefit is there’s no visible hole on the patient’s body but there is a risk that the incision in the stomach wall might leak, you may perforate an organ and cause a patient a really serious complication such as a life-threatening infection. All this just to avoid a cosmetic scar, and you have to ask if it’s worth it.

One patient who had no doubts is Awilda Sanchez of New York, who went home the same day she had her gallbladder removed through her vagina in March. She said: “I think everybody should get this. Now when it’s bikini time, I won’t have to worry about a scar. I think it’s great.” On the other hand, Colleen Caddell, from Oregan was not so thrilled as she described experiencing several days of throat pain so intense and excruciating she could barely swallow, and a week of vomiting, after having her gallbladder removed through her mouth.

One more optimist is Marc Bessler, director of laparoscopic surgery at New York-Presbyterian Hospital who said: “So far it doesn’t seem to be risky, the patients definitely have a cosmetic benefit, recovery seems to be better, and they seem to have less pain. If we can get to recovery-free, pain-free, and scar-free surgery, then that would be a revolution.”

My concern, given the very high value US society places on physical beauty and fast response, is the desire for quick, no-scarring surgery could move too fast for safety. So don’t ask your surgeon for it just yet!


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