BALTIMORE, Feb. 4 -- "Surgeons here removed a donor's kidney through an incision in her vagina, a first for the burgeoning field known as translumenal natural orifice endoscopic surgery (NOTES). Diseased kidneys have been removed in transvaginal procedures, said Mohamad E. Allaf, M.D., director of minimally invasive surgery at Johns Hopkins University, who performed the extraction on Jan 29. But, he said, the healthy kidney extraction took the approach to a new level.
'In contrast to removing diseased kidneys, this procedure has to deliver a perfect kidney since it will be used by the recipient,' he said in a statement released by Johns Hopkins.
The donor was a 48-year-old Maryland woman who gave the kidney to her niece.
Robert Montgomery, M.D., head of transplant surgery at Hopkins, said the procedure took some three and a half hours, comparable to a conventional laparoscopic extraction.
The surgery was not fully a NOTES procedure because tools and endoscopic cameras were passed through three small laparascopic incisions in the donor's abdomen. One was made in her navel, so she will have two visible scars.
But the Hopkins doctors pointed out that the transvaginal procedure would spare her the five- to six-inch abdominal scar that would result from traditional healthy-kidney removal surgery.
Other surgical teams have performed NOTES and NOTES-like procedures through the nose, mouth, and rectum as well as the vagina.
Appendectomies and cholecystectomies, as well as kidney removals, have been performed using a natural orifice approach.
Last summer, what was believed to be the first full NOTES procedure in the U.S. was performed at Columbia University in New York. Marc Bessler, M.D., led a transvaginal cholecystectomy in July that used no external incisions.
Some surgeons have questioned the choice of the vagina as a NOTES route, pointing out that the experience and skills gained from such procedures can't be used on half the population.
Lee Swanstrom, M.D., of the Oregon Clinic in Portland and a pioneer of NOTES, said transvaginal surgeries can interfere with sex, sometimes causing pain. 'My feeling is that the transvaginal route is useful for the time being,' he said. 'But in the long run it will probably be reserved for GYN procedures.' In his most recent NOTES surgeries, Dr. Swanstrom said he's used gastric access. He added that insurance companies have resisted paying for NOTES procedures, claiming they are experimental.
And, in fact, most NOTES procedures in the U.S. have been conducted under clinical trial protocols. The reimbursement issue has kept him from performing more than a handful of NOTES procedures, he said. Other surgeons contacted by MedPage Today reported similar problems. None had performed more than a half-dozen NOTES surgeries. Surgeons in Brazil and India, on the other hand, have reported doing hundreds of NOTES surgeries."
Article by John Gever, Senior Editor, MedPage Today
Published: February 04, 2009