The Natural Orifice Consortium

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Or more completely, the Natural Orifice Consortium for Assessment and Research, a group dedicated to investigating and exploring ways to perform surgery through natural orifices, such as the vagina, anus/rectum, and about any other opening nature provides:

Using patients’ natural openings (the mouth, vagina or rectum) as entry points to the body is perhaps the intuitive next step to laparoscopic surgery…

The group’s official acronym is NOSCAR–yes, that there is a gratuitous “S” to make the clever “no scar.” When I read the word “Consortium,” I can’t help but think of some underground, covert organization–guys in dark suits, meeting in secret places, speaking in the language of riddles and subterfuge. About orifices, of course, because you can’t talk about that stuff in the open, it’s gotta be in secret. Can you imagine the higher-ups of this “Consortium” going out for a dinner, paying with some black Amex where the business name is embossed on the card? Maybe there’s even a sphincter watermark that needs to be checked for authenticity… OK, I’m blaming my Lortab this late at night, I apologize…back to the real story at hand. (The truth is out there…)

If we were talking a huge fish-gutting midline incision, perhaps going through one of someone’s tender bits and saving days and days in the hospital and weeks of recovery would be a tradeoff. But the article above (which is from Time BTW–there might be something more scholarly out there, but alas, I don’t have those resources anymore) is talking about a simple appendectomy. An appefrickindectomy!!! Why am I shocked? Because even when comparing “open” vs. laparascopic, we’re talking a 2″ or so incision in the RLQ via the external oblique muscle (surgeons, please correct my newbie knowledge here) or a couple of similar/smaller incisions for the lap technique. How on God’s green earth is cutting open some poor women’s hoo-ha a better surgical choice? I mean maybe–MAYBE–said female works as a swimsuit/lingerie model, but even then, if that’s her professional job, she’ll have professional makeup artists to cover the tiny-ass scars.

But wait, there’s more:

Surgeons Santiago Horgan and Mark Talamini made a small incision in the wall of the patient’s vagina, through which they passed surgical tools and a small camera to the appendix, removing the organ through the same incision. Surgeons also made a small cut in the bottom of the patient’s bellybutton and inserted another camera through it to help guide surgery. The procedure took 50 minutes from start to finish, 20 minutes longer than a standard laparoscopic appendectomy.

Wha?! So they made an umbilical incision anyway, just like lap, so this magically wards off the evil spectre of herniation…how? And almost doubling surgical time is ALWAYS a plus…good going guys! (Note that an open appy is probably 15 minutes for someone who wants to book it out of there (maybe less–never been at a clocked speed test case), tripling the time.

But let’s now turn to that first quote and change the patient to a man. Say a young, otherwise healthy male presents to an ER with an acute abdomen, rebound tenderness, McBurney’s sign, the works. Cocksure eager surgeon dude comes and offers the poor guy a “minimally invasive” option–going through his ass. Last I checked, having a trocar sticking out one’s ass as all these scissors, cautery, etc. get shoved in en route to the appendix (is this in a right decubitus or a jackknife position here, anyway?) is about as invasive as you get.

Yes, the total instrument travel distance in this case is pretty short, and if there’s no serious shit going on, it probably is technically a more direct approach than going through layers of muscle, fascia, etc. Again, I appeal the the surgeons to educate me on basic surgical points here, but isn’t an immediate entry into the peritoneum via the GI lumen–and specifically the rectum of all places–just presenting a contamination problem right away? Yes, there will be abx irrigation, but going through the gut lumen for starters just seems wrong from an aseptic technique POV. Dunno. The whole thing is whack, which is my whole point, so there.

  • By Sid Schwab, April 10, 2008 @ 12:22 pm

    I agree. It’s a world gone mad.

    I wrote about it a while back, too, here.

    It was also reported the other day that some surgeons in San Diego (I think it was) did an appy via gastroscope, thus turning a twenty minute operation into a three hour one, with god knows how much more cost. But they did say the patient was doing situps in four days, as opposed to the usual…. four!!!! (They didn’t say that part; it’s just that it happens to be true.)

  • By Celeste, April 11, 2008 @ 12:42 pm

    There are surgeons who do pudendal nerve decompression surgery through the vagina (up near the cervix) so as to avoid going in through the gluteus. From what I’ve seen on our forum, the patients with the “less invasive” surgery don’t get as good of results (speed of relief or degree of relief). This route spares the sacrobuterous ligament, however in some patients the ST ligament is what is causing the very painful nerve compression. To do it this way on male patients means creating an incision in the perineum; I think by that point “less invasive” isn’t on the table anymore.

  • By Dragonfly, April 14, 2008 @ 5:10 am

    How on earth are they going to sterilise that one? No amount of betadine……
    I want the incisions in my abdomen thanks, doc. Stay away from lady town….

  • By Calli Arcale, April 28, 2008 @ 9:24 pm

    That just sounds nuts to me. I mean, women suffer all kinds of complications from the tears and assorted other things that can occur during childbirth. (Which, of course, is natural and thus totally good and wonderful . . . right?) Why would anyone *intentionally* cut the vagina unless there was a damned good reason why it was better than another route?

    Yeah, there’ll be fewer visible scars, but I gotta wonder why not one single article on this subject has ever even mentioned the possibility of sexual dysfunction. I find it hard to believe that nothing could go wrong in that department.

  • By Tsin, May 20, 2008 @ 4:08 pm

    Mexico did a pure Transvaginal Natural Orifice Cholecystectomy . The diference is that the previous reported cases used a small abdominal port . But the Group of Dr. Fausto Davil. Poza Rica, Veracruz . Mexico. Did a pure NOTES . April 2008

  • By Karl, June 2, 2008 @ 7:26 pm

    I think the general logic is that these laparoscopic procedures,
    regardless of the site of approach, or how bizarre, reduce days
    of hospitalization which is often the case save in the instance
    of post-op infection or in the surgical nightmare case where
    someone slices up a ureter or some regional vessel, in which
    case, its bye bye laparascope hello exploratory laparatomy.

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