Well, Time magazine has decided to bring national exposure to the "NOTES Revolution". In San Diego last month, Drs. Horgan and Talamini removed an appendix (hopefully inflammed) from a healthy 24 year old female via her vagina. For those who haven't heard, Natural Orifice Transendoscopic Surgery (NOTES)is the "next big thing" in general surgery, or so we're told by the innovators. Instead of three ghastly quarter inch incisions on the abdominal wall, surgeons are now exploring the utility of slicing open a woman's vagina for access to the abdominal cavity. Call me crazy but I'm a little skeptical. It sounds so appealing to have "incisionless surgery" but new techniques have to justify that they are as safe as the previous standard of care, improve outcomes, and are justifiable on a cost basis.
Let's look at the typical laparoscopic appendectomy. I make a half inch incision deep on the downslope of your navel. I make a quarter inch incision in your left lower quadrant and another quarter inch incision above the pubic bone (usually in the area covered with pubic hair). Post operatively, I usually have a hard time finding the suprapubic incision (once shaved hair grows back) and the incision by the navel is often obscured by the folds of your belly button. Cosmetically, the result is impressive. Young women have never complained. Parents of children who have it done this way are amazed. So you have to ask yourself: how much better can we get? And are women really going to be excited about having knives flaying open their vaginas? In the article, the patient raves about having minimal pain on post-op day#1 (1-2 on a scale of 10). Well, guess what? My patients will make the same claim for routine, uncomplicated laparoscopic appendecomy. Most return to work in less than five days.
The whole thing strikes me as absurd. This country struggles enough with containment of health care costs. Currently, laparoscopy affords patients the ability to undergo outpatient surgery for conditions such as cholecystitis and appendicitis with minimal morbidity and quick return to normal activity. The cost of hospitals purchasing the equipment required for NOTES, along with the costs of teaching thousands of surgeons how to do it is just mind boggling. If we're going to go down that road, there damn well better be a good reason. And I don't think "women prefer incisionless surgery for cosmetic reasons" is a valid answer.
Laparoscopy revolutionized surgery because, well, it revolutionized the way patients tolerated and recovered from open procedures. An open cholecystectomy would mandate 3-5 days of hospitalization. Plus increased pain. Plus a higher risk of wound complications and hernias. Laparoscopic appendectomy has essentially removed wound infection from the equation, even in perforated cases. Laparoscopic colon resections are reducing hospitalization and post op pain requirements. These are measurable, quantifiable variables. How measurable is something qualitative like "I don't want any scars"? I just don't see the universalization of this procedure happening anytime soon, given our current health care economic climate. It's fine if the really smart doctors at places like Mass General and Mayo Clinic and the like want to work at it and develop expertise, but at some point it should become obvious that the mere "ability to do something" is not justifiable grounds for restructuring how surgical diseases are cured. Take a baseball analogy. Your shortstop is Hanley Ramirez of the Marlins. He bats .300, hits homers, and steals a lot of bases. One of the top two or three SS in the game. But you decide you want someone better. You want Jose Reyes. Maybe he steals a few more bases, score a couple more runs, but overall, his stats are equal to Ramirez. But you want him. You like that he plays for the Mets. You like his "passion" for the game. The problem is, you have to pay twice as much for Jose Reyes. For a guy who gives you essentially the same output as the guy you already have. To get him you have to pay other guys on the team less and sacrifice talent in other spots, like pitching and defense. The advocates for NOTES are like the guy who will trade Hanley Ramirez for a more expensive Jose Reyes. It's crazy. You don't get to the World Series making deals like that. And we won't arrive at a more equitable distribution of health care dollars if we make the big move to NOTES over the next ten years.....