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Editorial March 2008

NOTES Invades Gynecology: Just Because We Can, Does Not Mean We Should

Arnold P. Advincula, MD

The technology surrounding laparoscopy and other minimal access techniques is constantly improving in order to achieve the goals of reduced pain, tissue damage, and length of post-operative recovery. Minimally invasive surgery has undergone an evolution from open, to laparoscopic, to no-scar surgery; the next phase appears to be NOTES – Natural Orifice Transluminal Endoscopic Surgery. The driving concept behind this new and experimental surgical approach is a controlled perforation of the lumen of a healthy hollow viscus (such as the stomach or colon) with a flexible endoscope in order to gain access to the peritoneal cavity through a natural orifice.

First reports of this surgical approach date back to 2004, when Anthony Kalloo and his colleagues described entering the abdomen of a porcine model through the stomach and performing peritoneoscopy and a liver biopsy.1 The same year, physicians in India reported the first appendectomy in a human performed with no external incisions: Drs Reddy and Rao removed a patient’s appendix by using a flexible endoscope passed across the wall of the stomach.2

Although these early reports denote an exciting paradigm shift in surgical access to the abdomen, several concerns arise. The most significant is how to obtain secure closure of the wall of the hollow viscus that is traversed in order to gain access to the peritoneal cavity. A leak from the stomach or colon could lead to devastating complications. Currently, there are no proven techniques for ensuring the secure closure of the stomach or colon during a transluminal endoscopic approach. As a result of these concerns, the transvaginal route has become an area of focus.

In March 2007, Marc Bessler and his colleagues at Columbia University Medical Center performed the first human laparoscopically-assisted transvaginal cholecystectomy.3 The patient was a 66-year-old woman with intermittent biliary colic and gallstones. Total operative time was 3.5 hours with no complications, and the patient was discharged the next day. One month later, in Strasbourg, France, Professor Marescaux and his colleagues performed the first NOTES cholecystectomy using a transvaginal approach in a 30-year-old woman with symptomatic cholelithiasis.4 The procedure was performed using a standard double channel video flexible gastroscope and standard endoscopic instruments. At no stage of the procedure was there a need for laparoscopic assistance, and no complications occurred.

I was initially impressed upon hearing these two cases of transvaginal cholecystectomy, but once the gynecologic surgeon in me emerged, my reaction quickly turned into suspicion. I began questioning the safety of such an approach: what about the patient with the unrecognized pelvic mass or adhesions secondary to pelvic inflammatory disease; or, better yet, what about the patient with asymptomatic stage IV endometriosis who has the obliterated posterior cul-de-sac? I am not sure if our general surgery and gastroenterology colleagues are ready to manage these various scenarios.

As gynecologists, we have all encountered these situations in our daily practice. Will the quest to minimize the invasiveness of a traditional laparoscopic cholecystectomy result in a rectovaginal fistula and convert a minimally invasive procedure to a maximally invasive one? Will a woman’s reproductive potential be compromised as a result of undergoing a NOTES procedure? These are all very important issues that will need to be addressed as natural orifice endoscopic transvaginal procedures evolve. Bottom line, this type of natural orifice surgery should be handled by the true pioneers of vaginal surgery: gynecological surgeons. I support progress, but in the end, just because we can perform transvaginal cholecystectomy, does not always mean we should.

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Arnold P. Advincula, MD, Associate Editor

References

1. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004;60(1): 114-117.
2. Rao GV, Reddy DN. Transgastric appendectomy in humans. Presented at: World Congress of Gastroenterology; September 2006; Montreal, Canada.
3. Bessler M, Stevens PD, Milone L, Parikh M, Fowler D. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc. 2007; 66(6):1243-1245.
4. Marescaux J, Dallemagne B, Perretta S, Mutter D, Wattiez A, Coumaros D. Operation Anubis (transvaginal cholecystectomy). Presented at: Japanese Congress of Surgery; April 2007; Osaka, Japan.