April 23, 2007 -- In a first-of-its-kind procedure last month, a team of surgeons successfully removed a woman's gallbladder using instruments passed through her vagina.
Marc Bessler, director of laparoscopic surgery at New York Presbyterian Hospital-Columbia University Medical Center, presented a video of the experimental surgery Sunday at a gastroenterology meeting in Las Vegas.
The first surgery was performed on a 66-year-old patient. Nine days later, a similar procedure was conducted in France, leading Bessler and others to say that such "natural orifice" procedures could well define the future of surgery.
The idea, he says, is to offer patients operations with less pain and fewer visible scars.
And the notion makes sense. Such procedures would allow surgeons to avoid cutting through a patient's abdominal wall, which contains a bounty of nerves and takes time to heal.
"The advances are decreased scars -- and eventually no scars -- decreased pain and quicker recovery," Bessler said.
But critics say the idea of conducting surgery through the vagina is simply too revolting to gain wide appeal.
"To put something like that through the vagina -- I just think it is crude, and there aren't many things that should be going in and out of the vagina," said Christine Ren, assistant professor at New York University's school of medicine. "I don't think a gallbladder should be, or those instruments."
More importantly, Ren notes, the technique comes attached with new considerations that could put women at an increased health risk during procedures now considered low risk and routine.
The New Minimally Invasive
Bessler says the transvaginal surgery is just one of a new host of procedures surgeons are developing that are conducted through natural openings such as the mouth or rectum instead of through the skin.
Some gastroenterologists say this tactic could well define surgery in the years and decades to come.
"I think this novel approach does represent the wave of the future," said Roshini Rajapaksa, assistant professor of medicine at the NYU school of medicine's division of gastroenterology.
"Patients are more interested than ever on less invasive surgeries, and doctors agree when they can be performed safely with less scarring and quicker recovery time," he said
Aside from the extra pain and healing time needed after skin incisions, many patients are likely to be intrigued by the avoidance of skin scarring.
"Natural orifice surgery is a developing surgical technique that is very exciting. Most patients would prefer not to have abdominal scars," said Charlene Prather, associate professor of internal medicine at Saint Louis University's Division of Gastroenterology and Hepatology.
This is not the first time that surgeons have used natural orifices as entry points for surgery. In 2004, a video that showed doctors from India conducting appendix surgery through a patient's stomach -- and removing the organ from his body through his mouth -- piqued the interest of surgeons around the world.
In recent months, doctors at other medical centers have worked toward developing instruments and procedures for such operations. Some surgeons are already comparing the current advances in natural orifice surgery to those seen with laparoscopic surgery, in which tiny instruments are used to perform abdominal operations through small incisions, nearly two decades ago.
"This is deja vu of 1988," Bessler said. "At a meeting a doctor presented his first laparoscopic removal, and surgeons were aghast as to how terrible this was and people asked what the benefits are."
"Now most gallbladders -- more than 90 percent -- are removed laparoscopically."
New Surgery, New Risks
But with the new technique comes new risks -- risks that Ren says are unnecessary because current options already provide relatively pain-free options with little healing time.
"When you look at what is there now -- laparoscopic gallbladder removal or laparoscopic appendectomy -- they are excellent operations," she said, adding that patients of these procedures could usually return home on the day of their surgery.
"Why make something with excellent results more complicated?"
Some other surgeons agree.
"I am not sure of the value since most patients who have laparoscopic gallbladder surgery go home the same day and have not much pain after surgery," said David Posner, chief of gastroenterology at Mercy Medical Center. "This is a technique still looking for a need."
Ren says performing an operation through the vagina opens up a new set of complications.
"You can have something called a fistula," she said. "That is a connection between the vagina and the rectum. That may not happen a lot, but you are introducing an intrinsic risk and potential complications that you do not have with standard laparoscopic gallbladder surgery."
Even those excited about natural orifice surgery say time is needed before such procedures become the norm.
"There is a clearly a need for much more data before we can establish safety," Rajapaksa said. "When we are traveling through an indirect route to get at the gallbladder, there is the potential to damage other organs along the way."
"My concern with this technique is whether there would be issues related to a scar in the vagina," Prather said. "Would this increase the risk of uterine prolapse or scarring in the area of the fallopian tubes that could increase the risk of infertility or tubal pregnancy -- an issue for female patients younger than the one in the article?"
A 'Distasteful' Operation?
Along with the risks, some regard the idea of conducting surgery through the vagina as far too odd for comfort. Even among other natural orifice surgeries, the transvaginal approach comes attached with a level of shock value that may scare away many patients.
"Everyone that has heard about this that I have talked to, they are taken aback. They say it is very distasteful," Ren said.
"A man wouldn't want to have an organ removed out of his penis. It is the same with the vagina."
Bessler, however, predicts a higher level of acceptance.
"I'm sorry that Dr. Ren feels that way," Bessler said. "I don't think women will find this repulsive -- people have vaginal surgery all the time."
"People may be shocked by this, because it is a distinctive advance and a little off the beaten path, but that is why it is interesting."
Bessler adds that other natural orifice surgeries are currently being devised that could open up the field of options to include a number of other orifices besides the vagina.
Eventually, he says, the procedures could make visible scars and long recovery a thing of the past for some surgeries.
"There are some operations today where you wouldn't consider having a six-inch incision because laparoscopic surgery is available," Bessler said. "And in 10 years they may never consider having a laparoscopic surgery when you can do it through a natural orifice."