It's your surgeon's turn to say 'open wide'

  • Article by: MAURA LERNER , Star Tribune
  • Updated: November 23, 2008 - 8:42 AM

Some Minnesota doctors are ready to operate without a scalpel and without leaving a scar.

Dr. Christopher Gostout remembers the first time he heard anyone suggest such a thing.

He was in a roomful of doctors at a seaside resort, brainstorming about the future.

Perform surgery without piercing the skin?

Take out someone's appendix through the mouth?

"We all fell off our seats, laughing," he recalled.

But today Gostout is one of a handful of Minnesota doctors about to start testing a new way of operating that could make the surgical scar a thing of the past.

It's called natural orifice surgery. And yes, it means using the body's natural openings -- wherever they may be -- as a way to reach internal organs that need a doctor's care.

Early next year, Gostout, a gastroenterologist at the Mayo Clinic, plans to begin removing gallbladders with a specially designed device that goes in -- and comes out -- through the mouth or the vagina.

At the University of Minnesota, surgeons are getting ready to perform weight-loss surgery with another experimental device that slides down the mouth to the stomach.

Only a few medical centers in the country have performed this type of surgery. But in theory, supporters say, it could lead to new ways to remove tumors, biopsy cancers and repair internal injuries. All the while leaving patients with less pain, shorter recovery times and no visible scars.

"It is truly relatively painless," said Gostout. "You literally can get up off the surgery table and maybe take a Tylenol."

At the same time, even supporters worry that doctors may be too eager to rush in with a lot of pricey new technology before they know whether it's really much better than what they use now.

To be sure, the whole idea of removing body parts through other body parts is a bit unsettling.

Earlier this year, when a California doctor removed a woman's gallbladder through her genitals, it made the syndicated column "News of the Weird." A female surgeon, in an interview with the New York Times, called the surgery "repulsive." Newsweek warned readers to "prepare to cringe" in a story headlined: "Open Wide. No, Wider."

But Dr. Sayeed Ikramuddin, a surgeon at the University of Minnesota, says it's a natural next step in the evolution of surgery. Once, 20 years ago, the only way to remove a gallbladder was with a large incision. Then along came "keyhole" or laparoscopic surgery that required only a few tiny slits in the skin. So why not imagine a device that could operate through one small slit? Or none? "It's where we're trying to go," he said, "which is really hands off."

For years, Ikramuddin has performed weight-loss surgery the minimally invasive way, through five or six small incisions in the abdomen. But now he's taking part in a national study to test a device that goes in through the mouth.

The device, made by a California company called Satiety Inc., is a high-tech stapler that's thin enough to slide down the esophagus into the stomach. Once inside, it performs a ballet of maneuvers to tie off parts of the stomach so patients will feel full after a small meal. It's essentially stomach-stapling -- from the inside.

Ikramuddin expects to perform the operation on his first patient in the next few weeks, and on 20 to 30 more volunteers in the next year.

If it works as planned, there could be several advantages, he and his colleagues say. By avoiding any cuts in the skin, they'll reduce the risk of post-operative infections, hernias and other complications that could prolong a patient's stay in the hospital. Patients should recover faster with less discomfort. Plus, for those worried about the stigma of obesity surgery: no telltale stitches.

The field, though, remains in its infancy. Only a few hundred people worldwide have had incision-free surgery, said Gostout, of the Mayo Clinic. So far, the most popular procedure is removing the gallbladder -- a 3- to 4-inch, pear-shaped organ tucked beneath the liver.

Gostout is one of a number of scientists, nicknamed the "Apollo Group," who pioneered the surgery and inspired a new company, called Apollo Endosurgery Inc., to develop the tools to do it. The Mayo Clinic is one of its investors.

One of those tools is designed to go through the mouth and poke a hole in the stomach wall. A small camera helps the doctor search the abdominal cavity by remote control, capture the gallbladder and place it in a bag so it can be safely removed.

At Mayo, "we're gearing up to actually start in January," said Gostout. "I've got patients calling me very regularly saying 'I need to get my gallbladder out. I want to be on the list.'"

For women, there's another option.

Carey Vitosh, a 39-year-old nurse from suburban Chicago, had her gallbladder removed genitally.

In July, she traveled to the University of California at San Diego, one of the few places currently offering the procedure. "My husband was skeptical," she admitted. But Vitosh, who needed surgery because of gallstones, had read about the new operation in a hospital magazine. "The ability to have surgery with less pain was very attractive."

The alternative -- laparoscopic surgery -- is also relatively quick and easy, with recovery time measured in days. But Vitosh dreaded the abdominal scars, and as a young mother, feared she'd be out of commission for a week or more. So she opted to fly to California.

"The day after surgery, I felt like a new person," she said. She left the hospital 23 hours after the procedure and stayed in town a few days for medical observation. "I actually felt well enough to do some sightseeing," she said. While there was some discomfort, she added, it was minor. "A week after surgery, I felt terrific and had to constantly remind myself that I was not supposed to do any heavy lifting."

Marginal improvement?

Dr. C. Daniel Smith isn't sure this is a great leap forward for American medicine. Why, he asks, spend money on costly new technology to replace procedures "that are currently done extremely well."

Smith, the head of surgery at the Mayo Clinic in Jacksonville, Fla., notes that most gallbladder operations are now outpatient procedures, so any improvement would be marginal. "I don't think you can get out of the hospital any faster than the same day."

Nonetheless, Smith, who is president-elect of a national society of endoscopic surgeons, believes there's a future for natural orifice surgery. It could improve safety and simplicity for more risky procedures, such as taking lung biopsies or removing masses inside the chest, he said. It could have even broader uses in developing countries because doing away with incisions means, at least theoretically, that they wouldn't need operating rooms or sterile settings for surgery.

For now, though, supporters say the benefits of natural orifice surgery are yet to be proven. "Long-term results don't exist," said Ikramuddin. That's why they conduct studies.

But those same doubts haunted the debut of minimally invasive surgery two decades ago, notes Dr. Todd Andrew Kellogg, another University of Minnesota surgeon who is collaborating on the study.

"Those who pioneered it persisted. And it turned out to be a great thing for patients," he said. "This is how breakthroughs are made."

Maura Lerner • 612-673-7384

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