Saturday, July 14, 2007

Pulling organs out your vagina

We're always pushing the envelope in Surgery. How can I do it faster and easier, with less pain, less invasiveness. The first laparoscopic cholecystectomy was performed in 1985 in Germany. The first series of lap choles in America were done in 1989. But it wasn't until the 90's that the technique took off. Nowadays, if you aren't taking gallbladders out laparoscopically, you might as well start slapping leeches on patients who come in with CHF. The technique of laparoscopic cholecystectomy has been perfected to the point where it now takes 15-40 minutes skin to skin, with four small incisions, and most patients return home later that same day. Outpatient surgery for a procedure that used to result in a one week hospitalization with significant post operative pain. It represented the apotheosis of the fusion of surgical expertise with technological innovation. Laparoscopy was then expanded to other procedures. Laparoscopic Nissen Fundiplication for GERD/hiatal hernia. Laparoscopic appendectomy. Inguinal and ventral hernias are now being addressed minimally invasively. And of course laparoscopic colectomies are being done routinely for benign and malignant disease.

And now we have the Next Big Thing: Natural Orifice Transluminal Endoscopic Surgery, or N.O.T.E.S. Incidentally, can we please place a moratorium on stupid acronyms in the medical field? NOTES? Are you kidding? That's not even a cool word, like NATO or LASER. It's terrible. In fact, I'm not even going to call it that anymore. For now on, it will be known as POOV (pulling organs out vagina). That's it. It's settled.

So what is it, I'm sure you're wondering. Well, we'll start with the good. It's incisionless surgery. Hooray. No more unsightly 1 cm scars under your belly button that you can't even see anyway. An endoscope is advanced either through the mouth or vagina and the peritoneal cavity is accessed by creating a transluminal incision in either the stomach or female organs. Instruments are then inserted and the gallbladder or appendix or whatever is dissected and removed via the mouth or vagina. Sounds appealing right? Miniscule scars begone! Replaced by a man made sliceroo in the old stomach (gastrotomy) or, even better, through a woman's vagina. Let me repeat that. A cut is intentionally made in a woman's vagina through which a dirty, inflamed appendix is sucked out.

The technique was pioneered in India. Excitement for anything new in surgery spreads like wildfire, and inevitably it has arrived on our shores. Dr. Lee Swanstrom just removed a woman's gallbladder in Oregon on June 25 of this year. The question: is this cause for celebration or alarm?

An innovation in surgical technique, different from established standards of care has to prove that the benefits of implementation will outweigh the costs of new equipment and the time involved in training surgeons across the nation a brand new procedure. Furthermore, the safety of the new procedure needs to be evaluated and compared with the standard procedure and proven to be at least as safe. And the long term safety of POOV won't be known until a large series of patients has been collected and followed. The first patient who ends up with peritonitis from a leaking gastrotomy closure or the woman who comes in with dyspareunia from vaginal scarring perhaps will bring a quick end to the POOV era.

So what are we comparing here? Incisionless transluminal surgery versus laparoscopy. Laparoscopy provides a minimally invasive, relatively pain free technique to treat some of the most common gastrointestinal surgical diseases on an outpatient basis. That's a pretty tough customer for POOV to have to beat. What is being improved upon? The mere absence of incisions is enough to justify scrapping a perfectly good surgical procedure? I don't get it. And the idea of creating an intentional enterotomy seems to run counter to fundamental surgial principles. Not to mention the fact that the vagina and mouth are crawling with bacteria, inevitably to be dragged into a sterile peritoneal cavity. I think we, as surgeons, sometimes get infected with LookAtMe-itis. Look what i can do! Well, great. Is that doing the patient any favors? Is it doing our already overburdened health care system any favors, financially?

This isn't laparoscopy versus open surgery part II. That's not a fair comparison. The benefits of laparoscopy are tangible and real. Shorter hospital stays, fewer wound complications, less patient discomfort, fewer adhesions and bowel obstructions long term. And on and on. What are we gaining with POOV? A scar on your vagina or stomach versus tiny scars on the abdominal wall? I think you're going to have to do better than that. It's like scanning the 2006 Colts roster and noticing that maybe the left guard was below average and instead of simply replacing him, replacing the whole freaking team. That's what POOV is to me. The surgical equivalent of cutting Peyton Manning.

Anyway, that's enough on that. Doc Schwab had a good post on NOTES back in April.My wife just finished her anesthesia boards. We're going to go out for drinks. She worries about me and this blogging business....


Sid Schwab said...

Since they're also doing it via gastroscopes, maybe we should call it POOF, for pulling organs out your face....

Bongi said...

good post. i also can't help being sceptical for all the same reasons.
i agree that lap choles are the standard, but in my country in state hospitals outside large centers, open choles are often done because of administrative bungiling (not being able to find someone in the family of whichever politician that actually sells working laparoscopic equipment).
to be honest i suspect the medical people do actually slap leeches on people with congestive heart failure.

Jeffrey Parks MD FACS said...

I agree POOF is catchier. Perhaps an entire subspecialization will develop: POOFERS vs. POOVERS.