Surgical Innovations

Take NOTES

New surgical technique and technology may reduce the invasiveness of laparoscopic surgeries.

Today about 75% of abdominal operations at NewYork-Presbyterian Hospital/Columbia University Medical Center are performed with minimally invasive techniques. Yet physicians and researchers are working to make these procedures even less invasive by gaining access through a natural orifice, thereby avoiding the need for incisions in the abdomen.

Natural Orifice Translumenal Endoscopic Surgery, or NOTES, is a new method of performing minimally invasive surgery through the mouth, anus, or vagina. Trans means "across," and lumen refers to the space of an organ. Still in the investigational phase, NOTES has been successful in animal studies of gall bladder removal (cholecystectomy), appendectomy, tubal ligation, and other abdominal operations.

Researchers at the center hope that NOTES will afford patients an even faster recovery and less pain than today’s laparoscopic operations. "This may be as significant a leap forward in reducing invasiveness as the transition from open to laparoscopic surgery was," says Marc Bessler, MD, Director of Laparoscopic Surgery. Dr. Bessler, along with a team including Dennis Fowler, MD, Director, Minimal Access Surgery Center, and Peter Stevens, MD, has been aggressively conducting animal studies at NewYork-Presbyterian/Columbia toward the ultimate goal of doing operations without any external incisions or scarring.

Surgeons in India have removed the appendix in a handful of patients through a scope inserted through the mouth, into the stomach, and across an incision in the stomach wall. The absence of nerves in these organs allows for a virtually pain-free recovery, but it is very difficult to achieve a perfect closure of incisions in the stomach, and leaks can cause serious complications. For this reason, although a range of operations could eventually be performed through the colon or mouth, the first natural orifice operations in people will likely be transvaginal removal of the gall bladder. At this time, transvaginal access poses the lowest risk of infection: "Nothing leaks into the belly as it could from the stomach,"Dr. Bessler explains. In time, transvaginal access could potentially be used to remove the appendix, the ovaries, tissue from the liver, or any mass inside the abdomen.

Many gynecologists nationwide are already performing hysterectomy and tubal ligation transvaginally. In these operations, a tiny incision is made high in the vaginal wall, flexible endoscopic instruments are inserted, and the gall bladder or appendix can easily be removed. After surgery, the small vaginal incision heals and patients have no external scars.

Potential challenges to the adoption of NOTES include internal leakage (from imperfect suturing of the internal incision), infection, need for enhanced suturing and visualization techniques, and others. In addition, NOTES will require specialized new training because the technique and visualization differ from those used in laparoscopic surgery today.

In a parallel and complementary project, Dr. Fowler, with funding from the National Institutes of Health and in collaboration with colleagues from the Department of Computer Science at Columbia University, has developed new devices that are likely to help meet some of the technological challenges. Providing three-dimensional images and tools for surgery, these devices can be remotely controlled through joystick or voice commands, or they can be programmed to move autonomously within a patient’s body. "The goal of this is to further reduce the invasiveness of the surgery for the benefit of the patient," says Dr. Fowler.

Dr. Bessler represents the center in the Natural Orifice Surgery Consortium for Advancement and Research (NOSCAR), a national think tank working to solve the current challenges to translumenal surgery. "This is a new and exciting future," says Dr. Bessler. In addition to the transvaginal approach, the team is investigating access through the mouth for minimally invasive procedures for gastroesophageal reflux and weight loss. They have applied for approval by the Institutional Review Board (IRB) to perform transvaginal gall bladder removal, and expect to begin offering this option to eligible women in late fall 2006.