The mere mention of transvaginal
surgery was enough to send several of Dr Marc Bessler's
female patients running for cover. But at long last
the director of laparoscopic surgery at the New York
Presbyterian/Columbia University Medical Center and
his team found a willing patient. The 66-year-old woman
agreed to have her gallbladder removed vaginally; the
operation was successfully performed March 21.
The procedure used a new technique,
Natural Orifice Translumenal Endoscopic Surgery (NOTES),
which goes through natural openings in the body, such
as the mouth, rectum or vagina, to access the abdominal
cavity. The vagina is particularly attractive, says
Dr Bessler, as far as endo-friendly orifices go. "Women
are better built than men for NOTES," he says. "Because
the vagina offers a more sterile environment than the
rectum or the mouth. As an access route, it's one of
the safest and least prone to infections."
WHAT'S
IN IT FOR HER
Aesthetically speaking, NOTES has its appeal. No more
big abdominal incisions and scars, or the pain and infection
risk associated with them. Gone too is the lengthy recovery
period. Dr Bessler's patient was out of the hospital
the next day. "In the future, this will be a day procedure
and the patient can go back to work in a day or two,"
says Dr Bessler.
There are risks, however. The possibility
of vaginal drainage and bleeding was a concern, but
Dr Bessler and his team dealt with that by using a needle
to puncture the wall of the vagina, instead of making
large incisions. For women in their reproductive years,
the potential for infertility and dyspareunia (pain
during intercourse) is another issue. "If scarring forms
in the area, either condition is possible," Dr Bessler
admits. "But I can find about 5,000 cases of transvaginal
removal of organs and only two reported incidents of
dyspareunia, and the incidence of infertility is known
to be minimal in this type of operation."
"The risks are no greater than
any other laparoscopic surgery," agrees Dr Guylaine
Lefebvre, gynecological surgeon at Toronto's St-Michael's
Hospital. "However, women have to wait longer before
having sex," she adds.
DAY
OF THE JACKAL
While some women may squirm at the idea, others are
more receptive. "They did another transvaginal gallbladder
removal in France," Dr Bessler points out. In a game
of medical one-upmanship, the French doctors accomplished
the surgery entirely free of external abdominal incisions
(the New York team had to make three small ones). They
even gave theirs a name: Anubis, for the jackal-headed
Egyptian god who uses long instruments to embalm the
dead.
The French team, led by Dr Jacques
Marescaux, Chief of Digestive and Endocrine Surgery
at the University of Strasbourg, were able to minimize
any risk of spillage from the gallbladder by enclosing
it in a protective bag before removing it. The only
external evidence left on the patient's body was a tiny
spot on her abdomen where a needle was inserted to inflate
the abdominal cavity. The 30-year old patient resumed
her regular life two days after the operation.
SURGERY'S
FUTURE
Dr Bessler presented the procedure at the annual meeting
of American Gastrointestinal Endoscopic Surgeons on
April 22. "Nobody threw rocks at me," he jokes. "Though
a few people raised questions about potential negative
consequences."
Although she has some reservations
about the advantages of the transvaginal route, Dr Lefebvre
is impressed. "I think it reflects a continuous exploration
of surgery through minimally invasive methods."
Dr Bessler is also optimistic.
"Fourteen years ago when we started doing laparascopic
surgery, people said larger operations weren't going
to be feasible and now we do them routinely. With time,
it'll be the same for this type of operation."
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