The No-Incision Appendectomy

Over the past year, U.S. doctors have made strides in the use of a technique called “natural orifice” surgery, an approach they hope will do away with the scarring, pain and the long recoveries associated with some traditional operations.

Last month, in an American surgical first, doctors at the University of California, San Diego, removed the appendix of a 24-year-old patient through her vagina. Surgeons Santiago Horgan and Mark Talamini made a small incision in the wall of the patient’s vagina, through which they passed surgical tools and a small camera to the appendix, removing the organ through the same incision. Surgeons also made a small cut in the bottom of the patient’s bellybutton and inserted another camera through it to help guide surgery. The procedure took 50 minutes from start to finish, 20 minutes longer than a standard laparoscopic appendectomy.

Two days later, the patient, Diana Schlamadinger, a biophysics graduate student at UCSD, was recovering with almost no pain: “I feel kind of like I did too many sit-ups,” she said. Schlamadinger said she opted for transvaginal surgery after Dr. Horgan outlined its potential post-operative benefits — and assured her that he had similarly removed 12 gallbladders. That the surgery was experimental was another selling point. “This appealed to the scientist in me,” Schlamadinger said. “I was really interested in being a part of something that could help other women in thefuture not suffer as much.”

That is the kind of sentiment that proponents of the technique are hoping for. Using patients’ natural openings (the mouth, vagina or rectum) as entry points to the body is perhaps the intuitive next step to laparoscopic surgery — which, while significantly less invasive than open surgery, still requires several tiny incisions through the abdominal wall. Cutting through abdominal muscle is not only painful, but can also cause complications: up to 5% of (or 50,000) surgery patients later develop hernias, Horgan estimates. The new technique requires cutting too, but generally just one incision through internal tissue — of the stomach, vagina or colon — which is far less sensitive and which heals more quickly than external wounds. “What we are saying now is how do we improve laparoscopic surgery? How do we go from five incisions to one, or five to none?” says Horgan.

The expectation is that patients will cope better after the operation with the less-invasive new techniques — no external scarring, less pain (most of Horgan’s patients take nothing stronger than Tylenol after surgery), shorter recoveries and no risk of hernia. Surgeons have created a national organization called the Natural Orifice Consortium for Assessment and Research, or NOSCAR, to track the procedure’s success and safety, and to collect data on patients’ progress. NOSCAR also monitors the risk of infection with natural-orifice surgery, which doctors anticipate will be significantly lower than with traditional laparoscopic procedures — since the longer it takes an incision to heal, the greater the risk of infection.

But the new procedure creates new complications. Though wound healing may be improved, the danger of internal leakage and subsequent infection is a serious one — particularly with cuts through the stomach or colon. Doctors are also still using traditional laparoscopic surgical tools — not ideal, because they aren’t as flexible as surgeons really need for such extensive internal maneuvering. So far, however, several surgical teams in the U.S. have performed partial hysterectomies and removed appendixes, gallbladders and kidneys via patients’ natural orifices, and are hoping to attempt more complicated gastrointestinal procedures in the future. But the technique is still highly experimental. “This is much more a research project than it is a new area of surgery,” says Talamini, chair of UCSD’s surgery department.

In addition, many patients still have qualms about such procedures. “Speaking with my wife,” says Talamani, “the concept of operating through the vagina, was, well, quite foreign to her. That would be a kind way to put it.” Dr. Marc Bessler, director of laparoscopic surgery at New York-Presbyterian Hospital, who is conducting a study on transvaginal gallbladder removal, says knee-jerk discomfort with the idea may be keeping patients away. “I was hoping after doing the first few that patients would come looking for this,” he says, but they have been slow to arrive. Bessler has thus far removed three patients’ gallbladders, but is aiming for 100.

Yet in a recent survey of UCSD undergraduates, conducted by Horgan and Talamini, the majority of female respondents said they would choose transvaginal surgery over the traditional alternative, given the benefits of less pain, shorter recovery and no scarring. Talamini plans to present the results of the survey this week in Philadelphia at the annual conference for the Society of American Gastrointestinal and Endoscopic Surgeons, of which he is the newly appointed president.

Horgan thinks that as natural-orifice surgery becomes more familiar and as more procedures are successfully performed, the acceptance of it will grow. “In 1999, 100% of gallbladders were [removed] in open surgery. In 2008, 98% are done laparoscopically. In five years, either our approach or something similar to what we’re doing will become standard care,” he says. “This technique is changing the way we think about surgery.”