G enerations of American children
have drawn their first impressions of surgery trying
to save the life
of Sam, a patient in the iconic board game Operation.
Using metal tweezers, players try to remove body parts (wishbone, butterflies
in the stomach) without touching the metal sides of body cavities. Slip
up, and Sam’s
red nose flashes. The game bears little resemblance
to real surgery except in one crucial regard—it recognizes that
there are serious penalties for setting off the body’s alarms.
In an actual patient, of course, the alarm systems
are infinitely more sensitive and complex. And now
the analogy shifts from a children’s board game to a museum guarded by lasers and sophisticated
motion detectors. Surgeons targeting organs in the abdominal cavity traverse
a delicate, complicated network of nerves, antibodies and chemical messengers
designed to recognize and attack all invaders—bacteria, a surgeon’s
scalpel—with lightning speed. To get past these defenses, surgeons
rely on stealth and subterfuge. They make ever-smaller incisions and employ
less invasive equipment. In that sense, the entire history of surgery
is a quest for the perfect crime.
While the internal organs themselves are relatively
free from nerves, getting at them, even with minimally invasive techniques
such as laparoscopy, requires cutting through the nerve-laden abdominal
wall and parietal peritoneum. That’s where most of the pain from
abdominal surgery comes from. But what if a surgeon could find another
way into the body, and thus avoid cutting through the abdominal wall at
all? Advances in endoscopy already provide close-up views of the entire
digestive tract, utilizing probes and cameras not just to diagnose but
also to treat a variety of gastrointestinal disorders. What if the next
logical step were to approach the heavily guarded bodily museum through
the mouth or anus and then sneak into the abdominal cavity, gaining access
to internal organs, through an incision in the stomach wall?
To a growing group of proponents, this has become
much more than a pipe dream. Already the new procedure has a name—NOTES,
for natural orifice translumenal endoscopic surgery—and several
American surgeons have been honing their techniques on test animals. Meanwhile,
two surgeons in India have reportedly done limited experiments on humans,
using a combination of laparoscopic and natural orifice surgery. (A few
U.S. researchers have seen a short video of the procedures, but the results
haven’t been published and few details are known.) Estimates for
when human trials will begin in the United States range from two years
to five or more.
For natural orifice surgery to succeed, surgeons
will have to win over critics, who contend that the new approach offers
scant improvement over laparoscopic technology and may not be worth the
risks, which include fatal infection. But supporters say the procedure,
if perfected, could offer a revolutionary prospect to patients suffering
from problems of the gallbladder, appendix, spleen or other organs: abdominal
surgery with no pain, no scars and almost no recovery time.
In an operating room at Brigham and Women’s Hospital in Boston,
gastroenterologist Christopher Thompson is feeding a black endoscope down
the throat of a morbidly obese man. The man had undergone gastric bypass
surgery, in which doctors fashion a new, smaller stomach pouch that bypasses
part of the small intestine to promote weight loss. Since the first operation,
though, the patient has been in considerable pain, and his weight hasn’t
gone down. Doctors have found a fistula, or small hole, between his new
stomach and the old one, and it’s Thompson’s job to repair
it.
Watching his progress on a video screen beside the
operating table, Thompson manipulates the endoscope with controls at its
base. One knob moves the scope left and right; another makes up and down
adjustments. But as Thompson probes the sleeping man’s gut for the
fistula, he discovers an unexpected complication. Scarring has dangerously
narrowed the hole created to serve as the new passageway to the man’s
intestines.
So Thompson must widen one hole even as he closes
another. It takes two hours, twice as long as he had expected. The scope
slithers up, down and around inside the moist orange cavity of the man’s
esophagus and gut; on the screen, the movements look like some endless,
slightly deranged amusement park ride. Finally, the work is done, and
an exhausted Thompson and his assistant exchange high fives. Thompson
takes a last admiring look at the inside of his 57-year-old patient’s
gut, noting, as only a gastroenterologist would, “That’s just
beautiful, man.” |
