The Future of Surgery: No Scars in Sight
Moving beyond laparoscopic surgery's small incisions surgeons at the Department of Surgery are committed to improving surgical techniques even further. The wave of the future, according to Marc Bessler, MD, Director, Minimal Access Surgery Center, holds the promise of surgery that leaves no visible trace at all. Dr. Bessler and colleagues are using, testing, and refining three new methods of performing surgery that leave no external scars on the body.
Endolumenal surgery is performed by inserting fine instruments through a natural orifice such as the mouth. This approach is currently being used to prevent acid reflux by inserting a tube into the mouth and esophagus and creating a valve at the point where the esophagus meets the stomach (the esophago-gastric junction). Employing a device approved by the FDA in 2007 (EsophyX™), the procedure may provide an important alternative to medication for the 30 million Americans with chronic, progressive reflux disease.
In endolumenal weight loss surgery, surgical instrumentation is advanced through the mouth into the stomach, where it is used to staple or suture the stomach pouch from the inside. The reduced stomach pouch limits food intake in a similar fashion to the gastroplasty or banding procedures, but without any incisions in the abdomen or leaving a device in place. This approach is approved in Europe as a weight loss procedure, and is available in the U.S. for revisional surgery to help patients who have regained weight after an initial weight loss procedure. At this time, the Transoral Gastroplasty (TOGA®) trial is enrolling patients at Columbia to evaluate the use of this investigational approach as a firstline approach to weight loss surgery.
In addition to esophageal and weight loss procedures, endolumenal surgery is being used to remove small tumors or polyps from the stomach.
Natural orifice endoscopic translumenal surgery, or NOTES, also entails the use of fine instrumentation advanced through a natural orifice such as the mouth, vagina, or rectum. In this approach, once the instrumentation is in place, an incision is made through an internal organ in order to access the abdominal cavity and perform the surgery. This approach may be used for operations such as:
- gallbladder removal through an incision in the vaginal wall;
- appendix operations performed through the vaginal wall;
- intestinal biopsies, or removal of parts of the intestine, performed with instrumentation advanced through the rectum; and
- removal of lesions in the colon, also via the rectum.
Operations through incisions in the stomach may also be performed in the future, but this approach carries risk of leakage if the stomach incision does not heal well. The vaginal approach does not present this risk, explains Dr. Bessler.
Small incisions through the vaginal or intestinal wall leave little or no pain, because those tissues have minimal pain sensation, and patients experience faster recovery than after open or laparoscopic procedures. Initially performing the procedure with one laparoscopic incision, surgeons at Columbia have been able to ensure safety and perform the procedure with no skin incisions.
Transumbilical surgery, also called 'single incision surgery,' involves the use of one small incision in the belly button. With three or four instruments advanced through that single incision, Dr. Bessler and colleagues can do the following:
- remove the gallbladder;
- insert or remove adjustable gastric bands for weight loss;
- perform sleeve gastrectomy for weight loss;
- remove the appendix;
- correct hernias; and
- surgically treat gastroesophageal reflux.
As with the procedures discussed above, this approach provides a minimally invasive alternative with excellent access to the abdominal organs and little or no visible scar.
Evolution from standard laparoscopy to surgery with no external scars depends on refinement of the miniature surgical and imaging tools that surgeons use in this approach, and the training of surgeons in the use of these new methods. At this time, select surgeons in the Department of Surgery are offering scarless procedures to patients as part of clinical studies and limited protocols. TOGA patients have been losing weight, patients are not needing pain medication after EsophyX for reflux, and overall, patients are recovering very quickly and very well, reports Dr. Bessler. "Since laparoscopic surgery requires three to five incisions, these scarless approaches will make surgery even easier for patients," he states, adding, "So far most patients have been very pleased with the results."