New Haven Independent

The 20-year-old patient was left with no external holes, cuts, sutures or staples.
Instead, Dr. Kurt E. Roberts and colleagues extracted the woman’s infected appendix through her vagina, without making any other incisions for cameras, retractors or other instruments.

“This is ground-breaking. It’s the first operation of its kind in this country,” Roberts said Friday.

A handful of similar procedures have been performed in Europe, he said. Due to privacy laws, the hospital did not identify the patient, a local woman.

Roberts is at the forefront of a new surgical field called natural orifice transluminal endoscopic surgery, or NOTES. Rather than cut through muscles to reach internal organs, NOTES takes advantage of the mouth and vagina.

Instruments are guided into these natural openings, eliminating scarring and hastening recovery. Women naturally seem more suited to incisionless surgery than men, because women have a birth canal, and it is difficult for men to envision a similar type of procedure through the bladder via the penis, Roberts said.
The anus is not an attractive option because it is brimming with fecal matter and bacteria. The vagina’s normal acidity also tends to keep bacteria at bay.

Roberts said he plans to start performing incisionless gall bladder removal in women in about two months.

Dr. Robert Udelsman, chief of surgery at the Yale School of Medicine, said “invisible incision” is the next wave in minimally invasive surgery. “There may be wide applications for the removal of other organs, including the gall bladder, ovaries and fallopian tubes. Unfortunately there is not a comparable approach for men,” he said.

Previously, Roberts and others, have removed appendixes and gall bladders through the vagina and belly button, but these procedures all required extra holes for instruments.

Still, a few very small scars are better than a six-inch fleshy reminder of sutures.
Another advantage accessing the abdominal cavity through the vagina is that the base of the organ has relatively few pain receptors, Roberts said.

The surgeons inflated the woman’s abdominal cavity with carbon dioxide to provide a clearer surgical field. They then inserted a trochar, or cannula, through the back of the vagina and toward the inflamed appendix.

The tube did not impinge on the uterus and will have no effect on potential future births.

A small camera, a retractor, grasper, and stapler were fed through the conduit. The appendix was pulled into the trochar before it was severed, to prevent the spilling of infectious liquids into the abdomen.

Roberts said the operation, from start to finish, lasted 59 minutes, which is about as long as the conventional surgery.

“It was done on Sunday, she was discharged on Tuesday. She said she took one Tylenol,” Roberts said.

The U.S. population has a 7 percent life-time risk of appendicitis.
Local hospitals perform hundreds of appendectomies a year.