You Want To Take My What Out Of My Where? Hospitals Experiment With Orifice Surgery

Imagine a major surgery that leaves no scar, causes little pain, heals quickly and lets you get back to regular activities in just a few days. Research into exactly that is being funded by a Boston health care nonprofit called CIMIT that is headed by Dr. John Parrish. He said the goal is to give doctors access to what's inside your body, without cutting the outside of the body.

"It's access through a natural orifice," Parrish said. "So you don't need to make even a small incision in the chest or the abdomen, and you use the mouth or the vagina or the anus as an entry site, and then there's no scar."

There is no scar because the surgery is done through the existing orifice. Flexible cameras and other medical devices are inserted into the orifice so surgeons can do their work without cutting through flesh. Human clinical trials are happening at a handful of hospitals around the country, including in Boston.

Dr. Parrish says natural orifice surgery could be used to take out organs, remove cancers, repair defects, perform biopsies and do other surgeries. "Entering the chest or the stomach by way of the esophagus, correcting hernias and a variety of other gastroenterologic procedures," he listed off.

If all this orifice talk makes you squeamish, Dr. Parrish understands. He says when people even hear about natural orifice surgery, their reaction is often something like this: "You want to take my what out of my where?"

But a surgeon at Massachusetts General Hospital, Dr. David Rattner, believes if natural orifice surgery proves as safe and successful as he thinks it could be for certain procedures, it would be well worth getting over that psychological aversion.

"If I told you that you could go back to work tomorrow after having your gallbladder out and you'd feel fine, as opposed to having a tried-and-true method that would keep you out anywhere from a week to six weeks, would you take a small amount of risk for that or not?" Dr. Rattner asked.

Just last month, Dr. Rattner removed a woman's gallbladder through her vagina. The procedure was part of a clinical trial to test the safety and effectiveness of natural orifice surgery. The patient did not want to be interviewed for privacy reasons. But Dr. Rattner says the woman recovered more quickly than many of his patients who have had the surgery done a more conventional way.

"She was up and moving around pretty much right away," Rattner said. "And by the fourth day, she was not taking really any pain medicine and was taking care of her kids and going to a barbecue and a party over the weekend, and she was pretty happy."

That kind of outcome might make natural orifice surgery seem like a no-brainer. But there is a catch. Some types of natural orifice surgery require cutting through an internal organ, such as the stomach. If you want to remove, for example, the appendix through the mouth, you have to puncture the stomach to get to the appendix. And some doctors think a healthy organ should never be intentionally damaged.

Especially the stomach. "If you make a hole in your stomach and you fail to close it," Dr. Rattner said, "then all the acid and digestive juice leaks out and you get peritonitis and you die in 24 hours unless it's treated."

That is too great a gamble for Dr. Michael Zinner. He is chief of surgery at Brigham and Women's Hospital, and he thinks natural orifice surgery will have limited application. That is in part because existing body openings are not a very clean setting for surgery.

"If you go through the stomach or the rectum or the vagina to enter the sterile field of the inside of the abdomen, it's a little bit to me like dragging sterile instruments through a sewer on your way to cleaning it up," Dr. Zinner said.

Zinner also said advanced surgical techniques similar to natural orifice surgery already exist. Surgeons routinely go through the belly button or make tiny holes in the abdomen, for example, to take out gallbladders and ovarian cysts, remove prostates, tie fallopian tubes and do hysterectomies.

At Brigham and Women's, Dr. Chris Thompson looks like he is playing a video game. He stands over a patient who is under general anesthesia and has a three-foot-long tube snaked down her throat. He watches a computer screen while he holds a long-handled device that is attached to the other end of that tube. Every few seconds there is a loud snap.

Dr. Thompson is using a flexible suturing device to perform weight loss surgery on this patient. He is making her stomach smaller so she will not each as much. Each time he pulls a trigger on the device he is holding, a stitch plunges into the patient's stomach. The other end of the stitch dangles out of her mouth.

Weight loss surgery used to mean cutting through the abdomen. But using natural orifice surgery, Dr. Thompson has put the suturing device into this woman's stomach through her mouth.

"Virtually bloodless," he says. "Look at our containers here. It's just a little dribble, if any blood comes out at all, which is nice."

Dr. Thompson expected this patient to wake up pain-free. Other than a sore throat, that was the experience of Christine Baker. She is a Massachusetts woman who had the same weight-loss surgery last year because she wanted a short recovery time.

"I have children, I have three greyhounds, I have a home that I have to keep up," Baker said. "I couldn't imagine being down for, I mean, upwards of three months. It just isn't feasible."

Unlike other types of natural orifice surgery, Baker's procedure did not involve removing an organ, or harming a healthy organ to get to an unhealthy one. But Baker said she would not rule out that kind of operation.

"I would tell anybody: Get past it. Get past it," she said. "Don't even think about where they're pulling it out of or what they're pulling out of you, because tomorrow you can go back to your life and not be down and out for however long it takes for you to get well."

Like any surgical procedure, natural orifice surgery does come with some risk of complications. So to make sure it is done safely and effectively, doctors will need new kinds of medical devices and extensive training. Surgeons say in coming years they will figure out which types of natural orifice surgery are worth doing, and which ones are too dangerous. Because for some patients, a little pain and a small scar could be the better choice.