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.


Anonymous said...

Well, the Indian doctors taking the patient's appendix out via his mouth still has more of a "wow" factor. Or something.

I wonder what types of instruments that required.

Greg P said...

I'm glad you wrote this -- I was thinking the same thing, but being a nonsurgeon, hardly up my alley, so to speak.

Garth Marenghi said...

I am inclined to agree with you on this, surely they are opening up a bag of worms of other new potential complications?

Lynn Price said...

Sid, I always love your posts. They're always a mix of wit, facts, and feeling. I spent the day in jury duty and had the opportunity to finish your book.

What can I say? You had me laughing out loud, clucking, shaking my head, and reaching for tissues among four hundred other people who would rather had their eyelashes plucked out with rusty pliers than be serving jury duty.

As a medical fiction writer, I've recieved ripe food for thought and the ability to bring added life to my fictional characters. People don't often see the human side of medicine, and Dr. Schwab does it better than anyone else. Thank you, Sid, for sharing your life with me. My guffaws may have bought you more books, as people were leaning over to see what I was reading.

I recommend that everyone run, don't walk to their nearest or bookstore and purchase this wonderful tale of what it's like to be a surgeon in training.

Sid...I trust you're sending me my fifty bucks in the mail, right?

SeaSpray said...

Hi Dr Schwab - interesting post.

It will be interesting to see how this plays out in the future. Just because one can do it doesn't mean they should.

I would not want any procedure that could add any extra risk. If it were KNOWN to be safer - than go for it otherwise - no thank you.

Sid Schwab said...

lynn: only fifty? Send me a refund when the check arrives.

beajerry said...

I SO want to make a head-out-of-butt joke here.

Charity Doc said...

"...why a dog licks its balls." HAHAHAHA. That just about says it all!

During my training when I was an intern in neurosurgery, we had this prisoner with an epidural hematoma that we took to the OR and evacuate. He kept on spiking a fever with a high leukocytosis. Pan blood, urine, CSF cultures were all negative. CXR, full body CT scans were all negative. The guy kept on spiking high fevers and befuddled the hell out of me. We couldn't wean him of the vent. Finally, I decided to culture the drainage from his COLOSTOMY. GC!

I can see it now, all of these transvaginal appy, chole, of these days, a patient will end up with gonococcal peritonitis!

Eric, AKA The Pragmatic Caregiver said...

There is, of course, the following very old joke....

A recently-retired colorectal surgeon decided that he needed a hobby to keep him busy in his dotage; he'd always loved classic British cars, and thought that learning to restore jaunty little runabouts would be just the thing...

Not knowing the *first* thing about cars, though, might prove to be a barrier. So he decided to take a class at the local technical college.

He struggled mightily at first - working on soft squishy things is different than rusted-tight bolts and stuck gaskets, but as he moved up from tune-ups to body work and paint, and then into restoration, he found he really enjoyed it.

Almost two years later, he had taken almost every class the college offered...except the final course, Advanced Engine Rebuild.

It's true, students struggled with the course - the instructor was a stickler, the procedures difficult. For someone learning for fun, it was fine, but a number of the students needed the class for their career path, and the washout rate was high.

Things really came to a head during finals week, where the coup de grace was to rebuild a specimen straight from the junkyard. The good doctor selected a *sweet* Austin Healey Sprite. . .hadn't ran in years, but the body looked great.

The final was rough. He found himself fighting trouble at every turn - seized bolts, rust for days, intake valves that hadn't been bare metal since Harold Macmillan still took his mail at 10 Downing Street. With hours of effort and much invective, he prevailed, though...the engine purred.

It wasn't until he went to look at the posted grades a few days later that he realized he had a *problem*. Fellow classmates wouldn't even make eye contact with them as they walked away from the grade list.

When he looked at the grade list, the problem was evident; he'd been given 150 points on the 100 point scale, blowing the curve.

Disturbed, he went to find the instructor to protest. It was never his objective to make fellow students look bad, and the grading could really affect them going forward! What was he to do?

Well, at long last he found the instructor in the workshop, and said "Look, I don't mean to be an ingrate, but I'm just here for fun, and that grade really hurt a lot of the other students."

The instructor replied, "Well, your work was really technically exceptional - the engine is so smooth, and you started from a terrible place."

"Yes, but Bruce had that junker MG, and he did equally excellent work. You only gave him a 100."

"Well, yes. The final was worth 100 points - I gave you fifty points for the quality of the results and fifty points for your work process, same as Bruce"

"So what's with the extra fifty points?"

"I really felt you deserved the extra credit for doing the entire rebuild through the exhaust pipe."

Eric, Shamefully.

Sid Schwab said...

Shamefully, indeed, Eric:

It reminds me of the priest and rabbi who each got new cars, and wondered if they should bless them. So the priest sprinkled some holy water on his, and for the other, the rabbi sawed off the end of the tailpipe.

Worse: it reminds me of the guy who had a glass eye and used to pop it out periodically and swish it in his mouth to clean it, then pop it back in. As you might expect, he accidently swallowed it, possibly when a pragmatic caregiver slapped him on the back for some reason. Waiting an appropriate time for it to pass, he finally gave up and got a new one, eventually forgetting about it. Months later he developed intermittant cramps, and saw his doctor, who did a sigmoidoscopy. The doctor was suprised, half way up the colon, to find an eyeball staring back at him. His response was to say, "Mr Jones, you need to relax and trust me."

And that reminds me of W.C Fields....

Richard A Schoor MD FACS said...

I applaud your effort to not end a sentence with a preposition. Very Churchill-like.

Dr. Rob Oliver Jr. said...


This type of surgery is so flawed coneptually I don't even know where to begin. Like you point out, it's taking something (laparoscopy) which is already a compromise from traditional approaches/access/palpability and making it even more complex, riskier, with no real imaginable benefit.

Anonymous said...

The thing that struck me the most about this whole "using a natural orifice" surgery was that most of our natural orifices are teeming with bacteria that can be exceedingly troublesome in the wrong situation. Why would anyone drag organs through bacteria-laden places in a (theoretically) sterile OR? It goes against any sort of common sense. Isn't it better to have a (relatively) clean surgical wound on the outside of your body rather than risking contamination of your internal organs just trying to save the existence of a scar?

And your eyeball story in the comments was good for a laugh. When I finally do get back on my feet (after a recent surgery, no less), I will look into seeing if I can get my hands on your book; I like how you write, and I've always had an interest in most things medical and/or surgical.

Anonymous said...

Excuuuuuuse me, but if and when my gall bladder needs removal, it's coming out a hole in my gut.

So many things to say, so few appropriate! LOL!

My husband had his chole last year. Good thing they didn't offer him this option....

Anonymous said...

"up with which some brilliant geek has come."

Churchill would be proud.

Anonymous said...

Your blog about NOTES surgery scores many accurate points. One additional to mention... Corporate driven medicine. Much of the "research" proposed is sponsored by Ethicon and others. These folks can make some $$$ by promoting the new technology. This subject of course is much broader (examples of the Sepsis drug development, Embolism prophylaxis by Aventis, Medicare Drug costs negotiations etc.)and deserves an entire chapter.

Anonymous said...


Great comments. I sure your skepticism (I do primarily lap procedures as well) but I remember the introduction of Laparoscopy and the withering criticism by the older surgeons.

I also remember an older surgeons maxim, "Folly that succeeds is Folly nonetheless"

We will see.

Jeffrey said...

interestingly i tried to look up infection rates:

While secure closure of gastric or colonic incisions are critical and difficult, the experience of gynecologists performing transvaginal procedures has demonstrated the safety of this route: infection rate is 0.001%, rectal injury is 0.002%, localized bleeding is 0.2%1,2. This compares favourably with the risks related to the use of trocars in laparoscopic surgery: 0.03-0.3% of visceral and vascular injuries, 0.7-1.8% of incisional hernia3-6.



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