Natural Orifice Surgery: No Scars

Surgery Without External Cuts Called 'Next Greatest Surgical Evolution'

Reviewed by Louise Chang, MD on September 18, 2007
From the WebMD Archives

Sept. 17, 2007 - French doctors who report removing a woman's gallbladder through her vagina say such "no-scar surgery" may be the wave of the future.

At least two U.S. women -- one at New York Presbyterian Hospital and another at the University of California San Diego Medical Center -- have undergone similar surgeries.

Doctors who advocate the technique call it "natural orifice transluminal endoscopic surgery" or NOTES. "Natural orifice" here means the vagina, the anus, or the mouth. "Transluminal" means surgeons insert surgical tools (endoscopic tools) through the body's natural openings. And the "surgery" part means doctors still have to cut through to the inside of the body and to operate on diseased organs.

The idea is to eliminate big incisions -- and surgical scars -- and to speed recovery after surgery.

Jacques Marescaux, MD, and colleagues at Louis Pasteur University in Strasbourg, France, appear to have been the first to perform NOTES surgery without backup from the laparoscopic instruments used for conventional minimally invasive surgery.

"With its invisible mending and tremendous potential for improving patient care and well-being, NOTES might represent the next greatest surgical evolution," Marescaux and colleagues suggest.

The surgeons report details of the operation in the September issue of Archives of Surgery.

Fast Recovery After Natural Orifice Surgery

Marescaux and colleagues performed the NOTES gallbladder removal on a 30-year-old woman with gallstones. The surgeons used endoscopic tools inserted through the woman's vagina during general anesthesia.

To reach the gallbladder, the surgeons made a small incision at the rear of the woman's vagina. The only external incision was a tiny cut in the woman's abdomen to insert a needle scope (the cut was also used to inflate the abdominal cavity with gas and to aid in removal of the gallbladder). The gallbladder was removed through the vagina.

On the evening after surgery, the woman felt well enough to go home. Because she was their first NOTES patient, her doctors kept her overnight and she left the hospital the next morning. Ten days later, the woman had resumed full activity with no discomfort, discharge, or bleeding.

Doctors developing the NOTES technique say similar operations could be done by mouth. However, this would mean making a cut in the stomach or gut to get to internal organs. Research continues on the best way to make sure these cuts can be closed without risk of leakage.

A group of surgeons has formed the Natural Orifice Surgery Consortium for Assessment and Research -- NOSCAR -- to promote NOTES research and responsible use of the technique. The group hopes to develop better techniques and better medical tools for NOTES surgeries.

NOTES vs. Laparoscopy

The NOSCAR group obviously is promoting the "no scar" aspect of NOTES. But current minimally invasive laparoscopic surgical techniques already leave no lasting scar, says John G. Hunter, MD, professor and chairman of surgery at Oregon Health & Science University in Portland.

"Having had laparoscopic surgery myself, and as a laparoscopic surgeon, I can tell you there are no scars within six months to a year of the operation," Hunter tells WebMD. "To suggest laparoscopy is scarring and NOTES isn't is not accurate."

Hunter also questions whether recovery time is truly longer with minimally invasive surgery than for NOTES.

Hunter's editorial comments accompany the Marescaux report in the Archives of Surgery.

"The benefits of NOTES are not earthshaking and the risks are real," he writes. "Marescaux and colleagues. You have (again) put man on the moon. Now we need to figure out if there is any reason to populate this new plane."

Hunter is all too aware of how this makes him sound. As a young surgeon advocating minimally invasive surgery, he remembers being told by older surgeons that he was wasting his time.


"They said laparoscopy would never fly -- and they were completely wrong," he remembers.

While Hunter doesn't think that NOTES will end up being the best way to perform gallbladder operations, he does see ways the technique could, in the future, improve a number of surgical procedures.

"There is a lot of great opportunity here," he says. "I don't see NOTES as revolutionary. It might be incrementally better for some things. It is evolution rather than revolution at this point."

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SOURCES: Marescaux, J. Archives of Surgery, September 2007; vol 142: pp 823-827. Hunter, J.G. Archives of Surgery, September 2007; vol 142: pp 826-827. John G. Hunter, MD, professor and chairman of surgery, Oregon Health & Science University, Portland.

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