No-Scar Surgery Through the Mouth or Vagina

Even surgeons who belong to the Natural Orifice Surgery Consortium for Assessment and Research, a group formed to advance the research on and safety of these procedures, have reservations. "What are the real benefits, after you get past all the marketing and hype?" asks NOSCAR Research Subcommittee Cochair Steven Schwaitzberg, chief of surgery at the Cambridge Health Alliance in Massachusetts. When laparoscopic surgery arrived in the late '80s, the benefits were clear cut and dramatic—though it, too, was at first met with doubt, he recalls. No longer were long incisions required for simple gallbladder removal, for example. NOTES doesn't offer patients that same gain, he says, especially now that laparoscopic surgery itself may just require a single incision through the bellybutton. "People's lives are not devastated by having three or four holes on their abdomen," he says. So how much risk makes sense in order to avoid a small scar and some pain medication?

Quick recovery. David Askay, a 26-year-old Ventura, Calif., native, found the decision an easy one. Faced with a necessary appendectomy with only weeks until he had to drive cross country for graduate school, he chose to have his appendix out through his mouth in June. His mother, however, wasn't so keen on the idea. "What about your vocal cords? This is crazy!" he recalls her saying. (It took two weeks for Askay to convince her that his doctor wasn't a "wackadoo.") "It was really nice that I was healed up, being able to enjoy my trip," he reflects, "as opposed to having open wounds."

The same was true for Sanchez, for whom scarring might mean keloids—the large, rubbery lesions she believed she was prone to as a black Hispanic. "One little scar can turn into a huge scar," she says. Too few surgeries have been done to create much dissatisfaction yet, but in at least one case, an out-the-mouth gallbladder operation led to an extremely sore throat and days of vomiting.

Until there's a critical mass of data on these procedures, they're unlikely to spread beyond the research institutions, says Santiago Horgan, director of UCSD's Center for the Future of Surgery and the surgeon who operated on Askay. "I think it will take two to three years to become mainstream," he predicts. Meantime, patients making a choice will have to rely on anecdotal success stories and a surgeon's reputation for guidance and be comfortable with the fact that their doctor may have mastered the technique in pigs. "I asked seven patients before the first one said they were interested," says Lee Swanström, director of Legacy Health System's Minimally Invasive Surgery Program in Oregon, who has removed four gallbladders through the mouth. When patients wondered how many of the procedures he had performed, his "you'd-be-the-first-one" response elicited some dubious glances.

Swanström expects that rather than becoming a widely used new way to treat gallbladder and appendix disease, NOTES will lead to better ways of performing other operations—colon resection, for example, in which a diseased piece of the large intestine is sliced out and the remaining parts stapled back together. Even when resection is done laparoscopically, most patients require a 4-to-6-inch incision. It may also prove useful as a minimally invasive way of appraising the stage of a patient's cancer. And obese patients may do better with natural orifice operations, since many have trouble with wound healing.