If Anthony N. Kalloo, chief of the division of gastroenterology
and hepatology at Johns Hopkins Hospital, has his way, the stomach or
colon will someday no longer be the destination of endoscopic surgery
but, rather, an access route, a portal to the many organs of the abdominal
cavity. Kalloo is credited with having originated that concept during
the late 1990s. But when he first broached the idea of what would later
be called NOTES, many physicians felt it bordered on malpractice. “To
any gastroenterologist, making a hole in the stomach is about the worst
thing you can do to a patient in terms of complications,” Kalloo
says. “And here I was saying you should intentionally create a perforation
to treat disease processes that seemed to be well managed by laparoscopic
surgery.”
Undeterred by these concerns, Kalloo forged ahead,
and in 2004 he and his Johns Hopkins team published a report in the journal
Gastrointestinal Endoscopy describing their experiments on pigs. The NOTES
concept began to attract adherents at major medical schools around the
United States.
But with additional animal studies under way, it
has become increasingly clear that existing surgical and endoscopic devices
won’t be adequate for NOTES procedures on people. “We don’t
have the appropriate tools yet,” says Jeffrey Ponsky, chairman of
surgery at Case Western University School of Medicine and University Hospitals
of Cleveland. “We’re still working with instruments that were
designed for a different purpose.”
Among the greatest needs: better ways to close the
hole that surgeons must punch through the stomach wall. Conventional stapling
and suturing techniques work moderately well, but in those tight, dark,
twisting confines, doctors need greater flexibility and maneuverability.
In a trial in which Thompson operated on more than 20 pigs, two developed
potentially fatal peritonitis when holes failed to seal properly. New
suturing systems now being developed may solve that problem.
Operating inside the peritoneal cavity is greatly
complicated by the distance between surgeon and subject. “We’re
working several feet away from our hands,” Ponsky says. “That’s
triple or quadruple the distance of laparoscopic surgery, and here we’re
performing very complex, intricate maneuvers.” To succeed, surgeons
need what they call a better “platform” of tools—meaning
the ability to perform multiple tasks at once, such as holding organs
securely apart while they cut or stitch. Possible solutions lie in more
precise scissors and knives, better grasping forceps and perhaps even
voice-activated controls and small robots. “A robot could duplicate
human hand motion at a distance through a very tiny incision,” Ponsky
suggests.
Yet another challenge involves spatial orientation.
Because of the stomach’s configuration, feeding instruments down
the esophagus and through the stomach may require a 180-degree turn to
reach the upper part of the abdominal cavity. That reverses the images
surgeons see, essentially requiring them to work backward. New cameras
with automatic correcting technology might provide a head-on view, or
multiple cameras could show the work area from several angles. Another
solution would be to go through the anus or vagina to gain a straight-ahead
shot.
There’s little doubt that the technical issues impeding NOTES will
be resolved. But there’s a bigger question. Given the advanced state
of laparoscopic surgery today, is a new approach even necessary? Barry
Salky, chief of the division of laparoscopic surgery at New York City’s
Mount Sinai Medical Center, isn’t sure. “I’m not against
new technology,” Salky insists, noting that he was among the first
surgeons to convert to doing only laparoscopic surgery, in 1992. “The
difference between taking out a gallbladder with open surgery versus laparoscopy
is pretty dramatic,” Salky says. “With open surgery, most
people were in the hospital five to seven days because you had to cut
the muscles of the abdominal wall. Laparoscopic cases are either ambulatory
or involve an overnight admission. We’ve cut down length of stay
tremendously.”
Yet Salky has serious reservations about natural
orifice surgery. “When you consider the retooling that would have
to occur for surgeons to learn how to do this, what kind of advantage
would there really be for the patient?” he wonders. “And what
kinds of risks would we be subjecting patients to?”
Salky thinks that two major selling points of natural
orifice surgery—no visible scars and less post-operative pain—may
not even represent much of an advance over the current state of the art.
Barring infection, laparoscopic scars are nearly invisible after a year,
according to Salky. And in terms of pain reduction, “after a laparoscopic
gallbladder removal, most patients just need one or two Percocets and
a heating pad,” he says. “That’s about it.” Moreover,
he worries about cutting into the stomach or colon. “Now you’ve
got an incision in a piece of intestine that is potentially contaminated
with bacteria,” says Salky.
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