New cases explore surgery without scars
More than 150 natural orifice procedures performed
(Editor's note: This month's issue includes the first part of a two-part series on natural orifice surgery. In this issue, we give an overview of the current status of the surgery. In next month's issue, we explore patient selection, physician skills, and tools in development.)
Surgeons at University of California San Diego Medical Center recently removed a diseased appendix through the mouth. This is another first in a series of firsts for natural orifice surgery.
Because natural orifice procedures still are considered to be in the research stage, with only about 150 performed so far throughout the country, they are performed on humans in very controlled study cases, says Christopher J. Gostout, MD, FASGE, professor of medicine and director of endoscopic research and development at the Mayo Clinic in Rochester, MN.
Thus far, surgeons have used the natural orifice approach to remove gallbladders, uteruses, and appendixes through natural orifices, such as the mouth, rectum, and vagina. They have used flexible endoscopes and specialized surgical instruments.
The first gallbladder to be removed through the vagina in the United States was performed by Marc Bessler, MD, a surgeon at New York Presbyterian Hospital at Columbia University in New York City. "Because this is a completely new approach, only one in every four or five patients agrees to this approach," he says. "There is a certain 'yuck' factor that I had not anticipated."
A significant benefit for patients who do select this approach are recovering and returning to work more quickly, says Bessler. There is less pain — even no pain for most patients — so there is no need for pain medication that restricts a patient's ability to return to normal activity, he adds. Laparoscopic gallbladder patients typically go home the day of surgery.
"In [natural orifice surgery], no muscles are cut, so patients don't have the same restrictions on physical activity such as lifting following a procedure," Bessler says. However, they have a recovery period of several days and a period of time during which they need to restrict activity, he says.
Natural orifice surgery procedures typically require less anesthesia, which will enable surgeons to possibly move more procedures to the outpatient setting, says Gostout. "The potential for a shift in the location of [natural orifice surgery] operations and modification of anesthesia needs may have a significant impact on the economics of patient care," he says.
Currently, the vast majority of natural orifice procedures are performed under protocol with the oversight of the facility's Institutional Review Board, says Gostout. Because of this status, the facilities are not reimbursed by insurance companies, which are viewing the surgery as experimental, he explains.
Representatives from Gostout's facility are beginning to educate insurers on the benefits of natural orifice surgery, and they are initiating efforts to eventually obtain codes for the procedures, says Gostout.
"It will take years, but we foresee that [natural orifice surgery] will become mainstream once procedures are tested and proven to be beneficial for the patient and economically feasible for the physician and facility," he says.
Surgeons at University of California San Diego Medical Center recently removed a diseased appendix through the mouth. This is another first in a series of firsts for natural orifice surgery.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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