Surgeon hones scar-free operation technique

This article has been corrected. You may view this article’s correction here.

Appendectomies — removal of the appendix — usually require the surgeon to make a 2- to 3-inch-long incision in the patient’s stomach. Recent advances in medical technology, developed by Yale School of Medicine surgeon Kurt Roberts, allow for a virtually pain-free removal of the organ — through the patient’s vagina. Staff reporter Florence Dethy investigates.

Late this fall, a Yale professor became the first surgeon in the United States to remove a patient’s appendix without leaving a single mark.

The surgeon, Kurt Roberts, an assistant professor of surgery gastroenterology at the Yale School of Medicine, removed a 20-year old woman’s appendix via a small incision in her vagina, an operation typically performed with three abdominal incisions. The procedure is part of an ongoing one- to two-year study launched in August to investigate the feasibility and safety of transvaginal appendectomies, as well as their effects on patients’ quality of life.

“This is a new approach to removing an organ, which means there is not even a pinprick on the abdominal wall,” Robert Udelsmann, surgeon in chief at Yale-New Haven Hospital, said in an interview with the News. “I call it ‘invisible incision surgery.’ ”

In fact, since the surgery did not touch the patient’s abdominal wall, she was able to leave the hospital virtually pain-free — and without even a scratch to indicate she had just undergone surgery.

“Surgeons who do these minimally invasive surgeries are like magicians,” Udelsmann said.

Indeed, since he performed the procedure, Roberts said several surgeons at the hospital have asked to observe his technique in the operating room. But he added that not everyone is convinced that the new procedure’s benefits outweigh its risks.

“Some people say ‘It’s fantastic, and you are advancing medicine,’ ” he said. “Others are more concerned.” He added that, among the latter, there was an inertia against trying something new.

Roberts first became interested in trying such a surgery after seeing a video of the first human transgastric appendectomy in August 2005. Soon after, he began imagining ways to push the envelope of minimally invasive surgery. He did not just want to emulate what he had seen, but to improve upon it.

“I thought that’s what the future brings,” Roberts said of the procedure. “If you don’t have to make any incisions, there is no violation of the abdominal wall, and there is no pain.”

For Roberts, the appeal of the procedure lay in the fact that the patient would have minimal pain, no scars on her belly and a return to regular activities in no time. Indeed, Roberts’ patient was able to leave the hospital the day after her surgery. The next day, she simply popped a Tylenol and was back to her normal routine, whereas patients are advised to avoid strenuous activity for four to six weeks after a typical appendectomy.

Though the transgastric procedure had used the stomach as the point of entry, Roberts preferred a vaginal entrance because it would decrease the likelihood of the patient developing post-operative complications.

But approaching the surgery, one of the key issues he needed to resolve was how to deal with the reduction in surgical maneuverability, considering that he wanted to use only a single incision to enter the body. (Typically, a surgeon uses three.)

The surgery was the culmination of a three-year long process during which Roberts investigated and developed the technical skills needed for the procedure.

After performing 13 abdominal appendectomies using one incision through the belly button and attending clinics around the country on the topic of laparoscopic surgery, he became comfortable with maneuvering the necessary instruments within a single surgical opening. By July 2007, he said he felt he could successfully transition from an abdominal to a vaginal entrance — and at that point, confident that he could perform the “invisible surgery.”

Yet, even after acquiring the go-ahead from YSM’s Human Investigations Committee to proceed with the operation on suitable, fully informed and consenting subjects in July, it was almost three months before a patient gave him permission to execute the never-before-done procedure.

Most patients, when asked if they wanted to undergo the new operation, expressed interest, Roberts said. But none of them wanted to go first.

Finally one said yes: a 20-year-old female affected with acute appendicitis.

Having performed the surgery once, Roberts said he looks forward to telling future patients about it and hopes they will participate in his study. Despite the surgery’s success, however, he acknowledged that change sometimes comes slowly and that the technique might not become widely used.

“The surgery is new, unknown, has not been done before,” he said. “People sometimes, depending on where they are in their life, are afraid of new things.”

Considering possible arguments against the surgery, Roberts joked that if his patient were ever incapacitated and in need of an abdominal operation, a surgeon might attempt to remove or operate on an appendix that was no longer there — as she would lack the tell-tale scarring on her stomach.

Confirming Roberts’ suspicions, several female students interviewed said that, while they would be interested in such a procedure, they were concerned that it had only been done once.

“I think I would be interested if it had been performed on hundreds and hundreds of patients,” Elena Hoffnagle ’11 said. She added that a laparoscopic appendectomy did not seem like a complicated or severe enough procedure to make the additional risk of an experimental procedure worth it.

Looking forward, Roberts said the next step is to apply the transvaginal technique to the removal of gallbladders and to tubal ligations — the cutting and sealing of the Fallopian tubes.

Comments

  • OBserver

    Dr. Roberts is to be commended on his development of a novel procedure, but isn't it unfortunate that he chooses to characterize anyone who doesn't think his new idea is the greatest thing since sliced bread as having "an inertia against trying something new?"

    Couldn't he merely admit that some have reservations about a procedure that carries perhaps unnecessary risks for the reproductive organs, without the personal attack?
    My guess is the good doctor is as arrogant as he is skilled, and that has the potential for unfortunate results.

  • Anonymous

    great article. how does he enter through the vagina though? it is through the birth canal itself? because the birth canal leads to the uterus… and I'm guessing you would not want to tamper with that.

    interesting read nonetheless.

  • Dr. Backdoor

    I'm waiting for the trans-rectal. Hold on appendix hoooold on.

  • Anonymous

    I'd imagine that one of the biggest risks is infection control, as I would guess that it is much more difficult to sterilize the vagina and maintain the sterile field there (it's moist, has pockets and a nearby cervix) than it would be to do so on a dry, smooth belly. Complications at the site of incision, such as infection, could then threaten the reproductive organs.

    As long as patients are fully informed, however, the benefit of getting right back to work pain-free could certainly outweigh this risk.

    Btw, I'm sure that an incision is made through the wall of the vagina - nothing is passed into the uterus or through the cervix. The key is to get through the outer muscle layer of the body which is full of nerves and thus causes pain and is also directly injured by the surgery, preventing full use of the muscle until it heals.

  • Anonymous

    I've been the proud owner of a vagina for some time, and I would be extremely wary of having sharp things up in there.

    First of all, has this actually been pain free? I would be really shocked, as I tend to think of my vagina as much more sensitive than my abdomen. How has recovery been? Have the patients been able to have normal sex lives? How long do they have to wait before they can have sex again, and is it the same/better/worse than it was before? Can this be done any time, or does one have to be in the right place in one's menstrual cycle? What if one's hymen is present and one would like to keep it that way?

    So many concerns that the article didn't address…

  • Anonymous

    woahhh coool!

  • Trumbull 08

    #5 :"I've been the proud owner of a vagina for some time, and I would be extremely wary of having sharp things up in there."

    I definitely spat out after reading that comment - you owe me a new monitor. Nicely put though.

  • anonymous

    Transvaginal endoscopic appendectomies were done since 1998 under the name of Culdolaparoscopy.