Surgery for Surgeons

In the beginning of the most medical books, one can read that the medicine (and of course the surgery) is an ever growing field. Now we know that the laparoscopic cholecystectomy is a good idea, whereas the laparoscopic hernia repair is not a good one. The evidence based knowledge doesn’t need much trials. Therefore I dare to share some thoughts about a recent discussions concerning minimizing the “Minimal Invasive Surgery”.

There is a paper in a recent issue of “Endoscopy“, discussing the transgastric endoscopy. The autor claims that untill now only operations on animals were performed (I suddenly felt like a veterinarian reading the paper and looked if I had the right journal in the hand). A collegue of mine told me that an endoscopist from India recently reported some transgastric human cholecystectomies on a meeting in Duesseldorf, Germany. Using two endoscopes he could perform the operation. I don’t have any further information about this adventure.

I am sure, one can perform almost everything laparoscopically and, if desired in the future, also transgastric. The main problem developing new techniques remains the question “why?”! Why should I do a transgastric cholecystectomy or even a simple peritoneal exploration? Mr. Fritscher-Ravens claims there were advantages over the alternative ways, mainly the fact that the transgastric surgeon can avoid scars. He surely meant skin scars. I could not find any more advantages for this method in the paper of Mr. Fritscher-Ravens. Though I could find some disadvantages which was of course not stated as cons.

• Entering the abdominal cavity requires a hole in a part of the body. In the described thransgastric approach, a scar in the gastric wall is accepted over a skin scar, claiming this would be an advantage. I see this as a clear disadvantage because I have more respect for the inner organs than for the skin. And I cannot imagine an abdominal surgeon, with enough experience, who does not take the abdominal cavity with all the stuph in seriously enough. Considering the problems occuring with the stitches of a bowel wall as complications of a bigger surgery, the unsolicitous making another one would be a very tough adventurous procedure.
  The skin wounds can be easily evaluated. The intraabdominal ones cannot! Who is the guy who would prefer the second ones just to prevent skin scars?
• Another aspect of the transgastic approach is the angle of the instruments and devices to each other. The laparoscopic way offers the possibility to choose the right angles for the trokars. Whatever comes regarding new devices, one can forget the freely choosable angle in a transgastic operation… just my 5 cents.
• Third: the time needed for performing a transgastric operation would be inevitable longer. The laparoscopic surgery needs in the most cases also longer times, which were shortened with the growing experience of the surgeons but there is a reasonable list of factors which justifies this. How can you explain your transgastric approach? And how long would you accept complications in you transgastric operations for the sake of future successes?

A transgastric idea for operating could be followed by a transvesical (urine bladder) and/or transuterine, transvaginal, transcolonic experiments. And every time there would be enough debile people, who would shout to the heaven, that this would be the future. They would exactly point at the history of the laparoscopic surgery, as they do now for explaining the “initial” problems of the new method.

“We need trials and further experiments as well as new devices”, you would say. My opinion is evidence based, I don’t need any trials to know that you would perform transgastric operations, well knowing that you would accept a higher mortality, which maybe will never fall back to the one of the current approaches. You would then have unpleasant conversations with former patients in the hell. :)

And this is all for the reason to prevent skin scars? Go on and make me laugh! People say laughing is healthy. :)