Monday, April 23, 2007
OK, so surgeons in New York pulled a lady's gallbladder out her vagina. There's a punch line in there somewhere. Anyhow, whereas that particular route is new, the concept of "natural orifice transluminal endoscopic surgery" (NOTES) is not. Or at least not as new. One has to wonder what is the motivation. According to those that advocate such things as pulling an appendix out a person's mouth or anus, the aim is to reduce pain and scarring for patients. I call bullshit. I think the motivation is "Hey, look at me!"
See, we're already at a point where most operations done laparoscopically require holes around a quarter inch in size, with maybe one more, 'bout half an inch. Cosmetically, not a major problem. Pain-wise, pretty minimal, most of the time. So we're talking, according to the rationale, about lessening something already pretty minimal. Moreover, since it's literally impossible completely to sterilize the mouth, rectum, or vagina, any procedure done through them will necessarily introduce organisms into the abdominal cavity. A small number may not always be significant. Still, it's of concern. And the hole that's made needs to be sealed back up safely, especially one in the stomach or colon. Finally there's this: these procedures take longer and afford a less-good view of the target area, unless at least one or two holes are made in the abdomen anyway. That's what was done in the vaginal operation.
It's a tough world out there: find a way to do something that no one else is doing, convince people they need it, and maybe you'll make an extra buck. Or at least get some good pub. To me, it's time to apply a little reason to the field: when the benefit is vanishingly small and the costs (and, until we know otherwise, the risks) are higher, a little stepping away from the scalpel for a moment of thought is in order. There are actually devices that allow an entire hand to be inserted into an abdomen through a special sort of air-lock (laparoscopy requires the belly to be filled and distended with gas) to accomplish "hand-assisted laparoscopy." Say what? The hole that's made is large enough that many people could do the whole operation through it, avoiding all the extra operative time and costs of the scope procedure. But there it is.
The only surgery in which I'm now involved is laparoscopic. I like it. It's fun. I enjoy learning new techniques, and I'm constantly impressed with the latest engineering marvel up with which some brilliant geek has come. But this NOTES stuff: from what I've seen so far, it's an irrational ego-trip which -- because it adds extra risk of infection or leakage, and because unless at least a few holes are made in the abdominal wall it affords a less-good view of the work -- will make a big splash, convince a few people to try it, and then retreat in hiding. I could be wrong. For now, I think the answer to the question "Why do this?" is the same as to why a dog licks his balls.