Surgery Blog for Surgeons

Transgastric endoscopy - current adventure in the surgery fashion

In the beginning of 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 may not be that of a one. Common sense doesn't need much trials. Therefore I dare to share some thoughts about a recent discussions concerning minimizing the "Minimally Invasive Surgery".

There is a paper in a recent issue of Endoscopy [Official Organ of the European Society of Gastrointestinal Endoscopy (E.S.G.E.) and Affiliated Societies], 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? Dr. 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 listed for this method in the paper of Dr. Fritscher-Ravens. However I could think of some disadvantages which were 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 stuff in, seriously enough. Considering the problems occurring with the stitches of a bowel wall as complications of a bigger surgery, the unsolicited creating of 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 correct angles for the trokars ("triangulation"). Whatever comes regarding new devices, one can forget the freely choosable angle in a transgastic operation... just my 2 cents.
  • Third: the time needed for performing a transgastric operation would be inevitably 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 justify 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 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 based on common sense, I don't need any trials to know that you would perform transgastric operations, well knowing that you would accept a higher mortality, which may never fall back to the one of the current approaches. You would then have unpleasant conversations with former patients in the hell.

And all of this is for the sake of preventing skin scars?
Go ahead and make me laugh! People say laughing is healthy. :)