March 19, 2008 — -- Scientists are moving closer to developing the techniques and the technology that could someday allow surgeons to perform many operations without cutting the skin.
Sound far-fetched? Not according to researchers at the University of California, San Diego, who removed a patient's appendix a few days ago by pulling it out through his mouth.
That was a bit of a milestone, since it had never been done in this country before, although surgeons in India performed the same operation in 2005 using different technology.
The work is still in its infancy, and research is being conducted at a number of institutions. The goal, at this stage, is to determine if the procedure is safe, and if patients benefit from having no surface incisions.
"The question is do patients do better or not?" said Santiago Horgan, professor and director of the Center for the Future of Surgery at UC San Diego's Medical Center.
Horgan was part of a surgical team that removed the diseased appendix of a patient, Jeff Scholz, 42, on March 12 through his mouth. In a telephone interview, Horgan emphasized that the procedure is still in the trial phase, and it will be years before the technique becomes routine, if ever.
In a statement issued by the university, Mark A. Talamini, chair of the department of surgery, described the research as "groundbreaking."
"As far as I know, this is the first time an appendectomy has been done in this country using this technique," Jeffrey Hazey, a general surgeon specializing in minimally invasive surgery at the Ohio State University Medical Center, said in an e-mail.
The research is pushing the boundaries of laparoscopic surgery, a minimally invasive technique that leaves fewer and smaller scars by inserting a camera and surgical instruments through a very small incision.
"Through laparoscopic surgery we learned that by minimizing the number of incisions, and going from a seven or eight inch incision to a one inch incision, patients improved in terms of hospital stay, complications of the wounds, post operative hernia, pain, and so forth," Horgan said.
He and others now want to take that a step farther and see if patients fare even better if no external incisions are made. He and his colleagues have already removed a gall bladder by taking it out through a patient's vagina.
The procedure is called natural orifice translucently endoscopic surgery (NOTES) by which surgery is performed by inserting a camera and tiny instruments through natural openings — the mouth, rectum and the vagina. That minimizes the need to cut into the abdomen, thus leaving no surface scars and accelerating the healing process.
In the appendectomy performed on Scholz, the surgeons stopped short of their ultimate goal.
"In order for us to go in safely, with the knowledge we have today," Horgan said, the team needed an "external view" as they cut the appendix loose and pulled it out the patient's mouth. So they made a tiny incision in the belly button and placed an endoscopic camera inside so they could see into the stomach. Then a second endoscopic tool was pushed through the mouth and down into the stomach, where it made a small incision in the stomach wall and cut the appendix loose.
Even that incision was especially small because the surgeons used a "wound dilator" to stretch the opening enough to get the appendix through it.
The incision in the patient's belly button is so small that it would seem insignificant, but any cut through the skin is subject to infection and other problems, not to mention scarring.
"We hope that in the future, maybe, we can do everything without opening the abdominal wall at all," Horgan said.
But first, they will need more advanced equipment, and more training for surgeons, so Horgan doubts that this is likely to become so routine that standard surgery techniques will be replaced. So it may not be coming to every neighborhood anytime soon.
And more evidence needs to show that, as Horgan put it, patients actually benefit from this procedure.
So much depends on what people like Scholz, who volunteered for the program, has to say about it. A statement from Scholz released by the university makes it clear that he's a convert, at least for now.
"A day after surgery, I have little pain, a '2' on a scale of 1 to 10," he said.
Lee Dye is a former science writer for the Los Angeles Times. He now lives in Juneau, Alaska.