A patient asks her doctor for gallbladder surgery, but wants no incision, no scar and relatively little pain. It's quite a request, but on May 20 David Rattner, MD, chief of General Surgery at the Massachusetts General Hospital Digestive Healthcare Center, performed New England's first natural orifice surgery - completely incision free.
This exciting, new procedure is called NOTES (natural orifice translumenal endoscopic surgery) and involves placing a gastroscope through the vagina up to the gallbladder. Using flexible instruments, surgeons extract a patient's gallbladder through a natural orifice, the vagina. They observed the procedure by using a mini laparoscope. The patient, a young woman in her 30s, fully recovered within days of her surgery.
"We're in a very early phase of development right now, but what we’re doing is proving it is very safe to do natural orifice surgery," says Rattner.
Dr. Rattner's research lab at the Digestive Healthcare Center is demonstrating that surgery through the body's natural orifices - the mouth, anus or vagina - is an effective and safe way to reach the abdominal, pelvic or thoracic cavities. It is a major breakthrough in minimally invasive surgery, and only five centers in the United States offer this innovative technique to patients.
Future NOTES procedures could involve entering the mouth or rectum of a male or female to get to the stomach. Rattner envisions the next step is to take out the colon through a male's rectum to avoid abdominal incisions.
"It's less painful and has a faster recovery time than the alternative surgical procedure. This is because there are no pain fibers in the internal organs that you penetrate," explains Rattner.
Pulling in multiple specialists from Mass General
Performing the NOTES procedure requires the collective expertise of several Digestive Healthcare Center specialists. The team, led by Dr. Rattner, includes a gastroenterologist, gynecologist, general surgeon and colorectal surgeon who all work together on different aspects of the surgery. Samantha Pulliam, MD, a gynecologist at Mass General, was pulled in to operate on the vagina.
"Vaginal surgery is a common approach for woman. In many ways it's not a new natural orifice through which to operate," says Pulliam. "We're familiar with it in a unique way, whereas we don't have as much history with other natural orifices."
In 2006 Dr. Rattner began pursuing minimally invasive surgery by writing the guidelines for NOTES. Since then, he cofounded and became President of NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research), an organization of laparoscopic surgeons and interventional gastroenterologists who explore ways to perform surgery without external scars. NOSCAR has raised over four million dollars to support NOTES.
"When we first started seeing early videos of the procedure, everyone got interested. It captivates both the gastroenterology community and the surgical community," says Rattner.
About 150 NOTES procedures have been performed in the United States, but Mass General is the only institution involved on the East Coast. Largely supported by the Center for Integration of Medicine & Innovative Technology, several hospitals, including Mass General, were awarded 2.1 million over three years to advance the surgery.
It takes unconventional thought to make NOTES a reality for patients. And Dr. Rattner is exactly the type of free thinker to push the boundaries of minimally invasive surgery. "Even if other people said we couldn't do it, I still wanted to get involved. I wanted to try something others said we couldn't do," remarks Rattner.