An Appendectomy Through the Mouth

By DARRYN BENNETT

E-MAIL STORY

Monday, Aug. 25, 2008 | Jeff Scholz, a 42-year-old former Marine, became the first patient in the country to have his appendix removed through his mouth after he was rushed to the University of California, San Diego Medical Center emergency room in March.

San Diego surgeons are at the forefront of the most minimally invasive surgery technique to date. Formally known as "natural orifice translumenal surgery," or NOTES, the nascent technique eliminates scars almost altogether by removing diseased organs, such as an appendix, through a patient's mouth, vagina or rectum. Generally, just one incision is made through internal tissue, which is far less sensitive and heals much more quickly than external wounds that result from conventional operations.

Dr. Mark Talamini (left) and Dr. Santiago Horgan (center) conduct natural-orifice surgery, a nascent technique that proponents say leaves virtually no scars. Courtesy Photo

When Scholz arrived at the hospital he was complaining about severe stomach pain, but doctors told him he had an inflamed appendix that needed to be removed. He was offered a choice between laparoscopic surgery, a technique that involves inserting tiny scalpels and a camera through several inches-long incisions in the abdomen, and natural orifice surgery. He chose the latter.

To perform the operation, doctors passed surgical instruments -- a small needle scope -- and a tiny camera through Scholz's mouth and down his throat to his stomach, and put a camera through a one-fifth of an inch opening in his navel to help guide surgery. A small cut was made in the stomach wall so the surgeons could reach the appendix and remove it via mouth.

"Basically, there's a tube put into the stomach that pokes the organ, grabs it and pulls it up then out," said Jackie Carr, a spokeswoman for the medical center.

Scholz ended up with a slightly sore throat, but said the pain was extremely minimal.

"A day after surgery, I have little pain, a two on a scale of 1-to-10," he said in a hospital release at the time.

Top UCSD surgeons hope the technique, still in the experimental phase, will eventually transform the operating room by doing away with scarring, pain and lengthy recovery times -- but first they'll have to persuade more patients to give it a try.

"People do have qualms about it," said Dr. Mark Talamini, chairman of surgery at the UCSD Medical Center. "The concept [of operating through orifices] is, well, foreign."

Talamini and Dr. Santiago Horgan, director of minimally invasive surgery at UCSD, were the first to perform the natural-orifices surgery in the United States. With 13 of the experimental operations now under their belts, they said early results appear promising; patients, such as Scholz, have reported minimal pain, almost no scarring and have been able to leave the hospital the day of the surgery.

Also, they said, once the technique is perfected, it would allow options that open surgery can't, such as slicing out tiny cancers or operating on obese patients without having to cut through layers of fat. From a financial perspective, some procedures could begin to be done on an outpatient basis, saving billions of health care dollars.

But there are skeptics. Most of the procedures have been gallbladder removals, which are typically performed laparoscopically and are already virtually scarless and painless. Based on that, a team of surgeons at Brigham and Women's Hospital in Boston have said the benefits of natural-orifice surgery may not outweigh the potential complications of the experimental technique, namely the risk of internal leakage and infection.

Even proponents of the technique acknowledge that more training and better instruments are needed before it can be widely employed. Doctors are still using laparoscopic surgical tools which aren't as flexible as needed for meticulous internal maneuvers.

Making sure hospitals are reimbursed adequately could be problematic too if insurers can't be persuaded to pay more for natural-orifices operations, which often take longer than conventional surgeries.

The emerging technique also has an image problem to overcome before it can become standard practice. Surgeons at several hospitals in the country that have started to offer the surgery have reported having trouble recruiting patients because of a "knee-jerk" rejection to the idea, but in a recent survey of UCSD undergraduates, conducted by Horgan and Talamini, the majority of female respondents said they would choose to have their gallbladder removed through their vagina rather than undergo traditional surgery. They cited the benefits of less pain, no scarring and shorter recovery time in their decision.

And, as with most new medical procedures, as more of the surgeries are successfully performed and people become more familiar with it, acceptance may grow. In 1999, for example, gallbladders were only removed in open surgery. Less than a decade later in 2008, 98 percent are removed laparoscopically, according to UCSD.

Soon after Scholz's operation, Horgan and Talamini performed a transvaginal surgery on a 24-year-old patient. Surgical tools and a small camera were passed through a small incision in the wall of the vagina to the appendix, and the appendix was removed via the same route.

The operation didn't require surgeons to make painful cuts through abdominal muscle, which causes about 5 percent of patients to develop hernias later. It took about 50 minutes, roughly 20 minutes longer than a standard appendectomy, and the patient reported almost no pain two days later, according to the hospital's report.

So far, several surgical teams have removed appendixes, kidneys and gall bladders and performed partial hysterectomies through natural orifices. UCSD surgeons said they hope to perform more complicated gastrointestinal operations in the future.

Please contact Darryn Bennett directly at darryn.bennett@voiceofsandiego.org with your thoughts, ideas, personal stories or tips. Or set the tone of the debate with a letter to the editor.