Respectful Insolence

A transvaginal gall bladder operation?

When I saw this, I thought it had to be a joke. But it’s not:

Doctors in New York have removed a woman’s gallbladder with instruments passed through her vagina, a technique they hope will cause less pain and scarring than the usual operation, and allow a quicker recovery. The technique can eliminate the need to cut through abdominal muscles, a major source of pain after surgery.

The operation was experimental, part of a study that is being done to find out whether people will fare better if abdominal surgery is performed through natural openings in the body rather than cuts in the belly. The surgery still requires cutting, through the wall of the vagina, stomach or colon, but doctors say it should hurt less because those tissues are far less sensitive than the abdominal muscles.

Interest in this idea heightened after doctors from India made a video in 2004 showing an appendix being taken out through a patient’s mouth. The patient had abdominal scars that would have made conventional surgery difficult.

The New York patient, 66, had her gallbladder removed on March 21 and is recovering well, said her surgeon, Dr. Marc Bessler, the director of laparoscopic surgery at NewYork-Presbyterian/Columbia University Medical Center. Dr. Bessler said he thought it was the first time the operation had been performed in the United States, and he plans to show a video of the operation at a gastroenterology meeting in Las Vegas on Sunday.

“Going through a natural orifice, the mouth or rectum or vagina, to get into the abdomen and do an operation, is being excitedly worked on by a whole lot of people,” Dr. Bessler said, adding that companies were beginning to make special surgical tools for the operations and that doctors had formed an organization called Noscar (www.Noscar.org), which stands for Natural Orifice Surgery Consortium for Assessment and Research.

I basically agree with Sid Schwab on this one:

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, closer to 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.

Surgeons have egos (surprise! surprise!), and these egos sometimes lead them to a sort of “can you top this?” competition to see who can be the most studly. Clearly the transvaginal cholecystectomy is an example of just that, and, after these surgeons show the videotape of the operation at a surgical meeting as planned, you can expect a lot of other surgeons wanting to try this operation. I guess guys are out of luck. If we want a “no scar” gallbladder operation, we’ll have to let surgeons make holes in our stomachs to pass the endoscope through, with the chance of leakage of stomach acid into the abdominal cavity if there are problems healing the hole in the stomach. Going through the rectum, given the level of contamination there, would probably not be such a good idea, although I’m sure someone will try it.

This competition is not necessarily all bad, as it led to the rapid proliferation of laparoscopic surgery, allowing the performance of complex operations through ever smaller incisions, with the attendant decrease in pain and hospital stay, although the curmudgeon in me can’t help but point out that laparoscopic colon resections, for instance, produce only a marginal decrease in the time it takes for bowel function to return (less than a day less, in fact, than conventional open surgery). In any case, this report seems to little more than the case of surgeons, like birds, showing their plumage to other surgeons to warn them that they’re the studliest surgeons of all.

Comments

  1. #1 Sastra
    April 26, 2007

    I’m surprised a woman agreed to it. To avoid a scar on the abdomen? “It’s never been done before, but going up your vagina will probably hurt a whole lot less?” What was the incentive? Puzzling.

  2. #2 Anonymous
    April 26, 2007

    According to my wife’s OB, her uterus has fused to her abdominal wall. (Perhaps because of her first C-section). He discovered this during a second c-section and it didn’t seem to make him happy.

    He made it very, very clear that, because of the fusion, a future laparoscopy could endanger her life. Unfortunately, my knowledge of medicine is too limited to explain why.

    But where the uterus has fused to the abdominal wall, might a approach OTHER than through the abdomen be of some value?

  3. #3 Alan
    April 26, 2007

    There is currently a study ongoing at Mass General Hospital using pigs to improve success following partial pancreas removal – apparently this has a high level of complications such as leakage. The talk I saw looked pretty promising, with initial pilot studies showing some improvement over existing procedures. There is a good article here.

  4. #4 Justin Moretti
    April 26, 2007

    “In other news, bush surgeons in Australia described the transvaginal cholecystectomy as a c*** of an operation to perform.”

    Showoffs.

  5. #5 IAMB
    April 26, 2007

    This honestly reminds me of the joke where the OB/GYN decides on a career change, goes to auto mechanic school and scores 150% on the final exam (where he has to remove and then replace the engine) because not only did he perform the work flawlessly… he did the entire thing through the tailpipe.

  6. #6 csrster
    April 27, 2007

    So next time in a bar fight and some guys yells at me that he’s going to rip my spleen out through my nose, we’ll have something to talk about.

  7. #7 llewelly
    April 27, 2007

    I forsee overuse of this technique due to cosmetic reasons.

  8. #8 Barry
    April 27, 2007

    “The surgery still requires cutting, through the wall of the vagina, stomach or colon, but doctors say it should hurt less because those tissues are far less sensitive than the abdominal muscles.”

    I’ll lay $20 that the surgeons in question don’t have vaginas, if you know what I mean.

  9. #9 Barry Leiba
    April 27, 2007

    I’m surprised a woman agreed to it. [...] What was the incentive?

    My bet: free surgery (or at a greatly reduced fee).

  10. #10 clone3g
    April 27, 2007

    Putting the Lap back in Laproscopic surgery.

  11. #11 Calli Arcale
    April 27, 2007

    Given how many women experience painful complications due to tearing and/or episiotomies during birth, I have a very hard time believing this would be sufficiently less painful to justify risking damage to the vagina. It’s common enough for women to develop adhesions even after relatively uncomplicated births, bad enough to make intercourse excruciatingly painful. Me, I’d rather take a slightly longer recovery time over the risk of life-long sexual dysfunction.

  12. #12 epador
    April 28, 2007

    ROFLMAO clone3g.

  13. #13 epador
    April 28, 2007

    Guess I’ll have to stop threatening to do those transrectal tonsillectomies on loudmouth administrators. They might take me seriously.

  14. #14 LadyGrey
    April 28, 2007

    One of the things that stood out for me was that they were starting with vaginas, and hence their first 100 experimental cases were going to be women. As the proud owner of both body parts, I’d agree that there’s some truth to their “vaginas are cleaner than rectums” argument for that — but ugh. Practicing on women to get good enough to do it on men still worries me.

  15. #15 James Barlow
    May 5, 2007

    I imagine it’s only the difficulty finding volunteers that precludes the trial of a trans-urethral procedure.