Saturday, April 26, 2008

Sour NOTES - a really, really stupid idea in surgery

At right, a picture of NOTES done "olde school" for a tooth extraction.

I'm not so far out of doing a few thousand abdominal procedures during my general surgery training that I don't still feel fluent in GI surgery. As I'm still boarded in General Surgery in addition to Plastic Surgery, I get a lot of trade journals sent to me on endoscopy, laparoscopy, etc... Occasionally, something I'll read about makes my eyebrow raise as I don't BOTOX yet :) The concept of NOTES surgery is one of those things.

Take an operation that is typically performed safely in less then 30 minutes with minimal pain or morbidity and turn it into one that last 3 hours, introduces unnecessary risk, and has no conceivable advantage. What do they call that at the University of California San Diego (UCSD)? They call it progress (!!!!!)

Welcome to the concept of NOTES "Natural Orifices" surgery (see here for a primer) where intrabdominal surgeries are performed by making a hole thru the stomach, anus, or vagina to work thru versus making several 3-5mm perforations in the abdominal wall with laparoscopic techniques. While ingenuity & creativity is always to be applauded in surgery, at some point you have to do an honest assessment of the risks, benefits, & outcome.

The surgeon in this WebMD article celebrating the first NOTES appendectomy in the United States at UCSD seems to have his intellectual blinders on when discussing this procedure.

Dr. Santiago Horgan, chief of minimally invasive surgery at UCSD, says “We’ve proven this approach works. We’ve seen the impact on patient care and on outcome: less pain, quicker recovery, improved cosmetics.”

So let me get this straight: The absence of three nearly invisible 3-5mm scars, with no advantage in length of stay, with the addition of a hole in your rectum, vagina, or stomach (which all can leak), with significantly prolonged surgery adding cost, increased nausea, and increased risks of deep vein thrombosis (DVT) is somehow supposed to be an improvement? This is a technique that needs to be put back in a holding pattern indefinitely where safe procedures exist until you can come up with some compelling rationale for doing them. If I was sitting on a hospital's Internal Review Board (IRB) looking at this I'm not sure I could give an endorsement for this.

In fairness, some of these same arguments were made when laparoscopic surgery first appeared in the late 1980's and it's now the preferred technique for many procedures. You have my permission to throw this post in my face in 2015 if everything is NOTES and laparoscopic equipment is gathering dust somewhere. I like my odds however!



Jeffrey Frentzen said...

The criticisms about NOTES are not limited to your blog, Rob. As I point out in PSP's blog entry of April 29 -- which references your blog entry on the subject -- other online pundits have taken offense at the NOTES technique (Surgeonsblog and Mexico Medical Student provide compelling arguments).
Best wishes,
Jeff Frentzen
Editor, PSP

Natali said...

Wow that is an interesting article, keep up the good work