Surgery Blog for Surgeons


About a year ago I wrote about a transgastric approach in some gastroenterological experiments. What happened in this year? Well, there is a development! Let us take a look at a paper published last year in Nature Clinical Practice Gastroenterology & Hepatology - a magazine belonging to the Nature publishing group. This posting is a review of the still veterinary experiments regarding the "natural orifice transluminal endoscopic surgery" (NOTES).

This time the paper is written better. The authors are medical guys who are obviously still in the euphory in front of the possibility to perform "operations" as endoscopists. Though they started thinking about things like indications, complications and techniques.
For me the interest in NOTES-publications remain still in the question about the indication and the risks of this experiment. Therefore I don't want to discuss the other parts of the paper. Also, I will compare the transluminal with the laparoscopic approach only and not with the open surgery, because the laparoscopy is what NOTES competes with.

Already in the introduction the authors remind us about the reaction of the German Surgical Society to the report of the first laparoscopic cholecystectomy. The message is not ambiguous - the initial difficulties are expected and we discuss them. As a main advantage of NOTES the "scarless" approach is discussed. But for the first time I read a meaningful NOTES-idea:

The transluminal approach could be particularly important for morbidly obese patients and others at high risk for standard surgery.

In the cases where the subcutaneous way is so long that it represents a significant risk for postoperative infection, the transluminal approach could be a real alternative. Having experience with several hundreds of laparoscopic operations, I saw only few postoperative infections of a laparoscopic wound. But having a transluminal alternative in morbidly obese patients is something I could appreciate, as long as the complications are acceptable. The authors of the paper claim to debate "various potential benefits of this novel technique" but besides the good idea regarding obese patients and the "scarless surgery", they don't. They even focused the whole idea this way:

The entire premise of transluminal surgery is based on the potential advantages associated with scarless access to the peritoneal cavity.

Exactly! Good point at the target!

So what else besides "postoperative hernias, adhesions and abdominal wall pain"?
The euphoria brings the following:

If the degree of immunosuppression correlates with the extent of abdominal wall trauma, then the choice of abdominal access could affect immunologic outcome.

But the authors are fair enough to write:

The effect of NOTES on the immune system is currently unknown.

Let me share with you, my valuable reader, my thoughts about these concerns.

Incisional hernias
This could be an issue in the open surgery but let us be honest: as a surgeon, how many incisional hernias did you see after laparoscopy? In 10 years working as a resident, fellow and then an attending surgeon and having seen several thousands of laparoscopically operated patients, I saw 2 (two!) postoperative hernias after laparoscopy. Both of them were in obese patients.

The extent of the adhesions correlate with the dimension of the intraabdominal surgery and not necessarily with the length of the cutaneous incision. If you are a gastroenterologist and do not understand the reason, please ask the next surgeon to explain this to you. (Don't get me wrong - there are a lot of things we, the surgeons, don't understand and you, medical guys, could explain.)

Abdominal wall pain
In my experience I didn't have the feeling that there is a big potential for improvement of the abdominal wall pain after a laparoscopy.

Immunologic reaction
This topic could be more controversial then the previous ones. We know that the immune system is compromised by surgery but it is difficult to measure this effect. Hence it would take decades to make a better conclusion about the impact of NOTES on the immune system, then we can do now on reflection.
I believe that the effect of surgery on the immune system is a physiological response to the injury and the consequent somatic stress.
The first question is if the injury of the skin, subcutaneous tissue and fascia brings more stress then the injury of the gastric (or whichever) wall. Today we know that the wall of the stomach and intestine (incl. appendix) play significant role in building the intact immune system. It remains unclear if the injury of an "immunologic organ" causes stronger immune suppression then the skin incision, which is physically a bigger wound in the common case.
The second question considers the immune response to the potential complications. Every surgeon has to do with wound infections and we all know that they are a real concern in elderly or immunosuppressed patients. But as unhappy a postoperative wound infection may be, the problems regarding an intraabdominal organ perforation bring incomparable changes in the situation of the immune system. Therefore, should the immune outcome be even better in the NOTES compared to the laparoscopic approach, the possible complications are so crucial in the transluminal technique, that I would accept in most cases the worse immune situation after the laparoscopic surgery in order to avoid them.

Without coming to negligible levels of postoperative complications, the transluminal surgery has definitely no future. One of the main initial problems would be the "{gastric, intestinal} wound closing insufficiency". For that reason, the development of the NOTES could significantly improve the technical facilities in closing gastric or intestine wounds, which would improve the outcome of the conventional anastomoses.

The latter idea, as well as the possible alternative approach in obese patients, are the benefits which the transluminal surgery could bring to the current situation in laparoscopic and even open surgery.