Surgery Without the Slicing

Going in through existing orifices is good for patients and device makers, less so for doctors and hospitals
Former Marine Scholz had his appendix removed through his mouth Brad Swonetz/Redux

Editor's note: For a CBS Evening News report on minimally invasive surgery that was made in collaboration with BusinessWeek, go to:

On Mar. 11 Jeff Scholz, a 42-year-old former U.S. Marine, developed severe abdominal pain. It wasn't as bad as the gunshot wound to the leg he suffered while in the service, but it kept him doubled over for most of the night. At the insistence of his fiancée, he went to the emergency room at the University of California at San Diego med center the next morning, where he learned his appendix was inflamed and had to come out. That's how Scholz, the owner of a wholesale clothing company, ended up making medical history. He's the first patient in the U.S. to have his appendix removed through his mouth.

This revolutionary procedure is labeled scarless surgery because it requires very little external cutting. Rather than making an incision three to five inches long in his abdomen, doctors passed flexible surgical instruments and a tiny camera through Scholz's mouth and down his throat to his stomach, and inserted a camera through a tiny opening in his navel. A small incision was made in the stomach wall so the surgeons could reach and remove the appendix. They then sutured the stomach and withdrew the gear.

Scholz ended up with a slightly sore throat but no other pain. Rather than spending days in the hospital, "I walked out on my own the next day," he says. "A few days later I was doing push-ups and eating pizza." Encouraged by the success of Scholz's operation, the same surgical team next removed a woman's appendix through her vagina.

Scarless surgery has the potential to transform the operating room, even more so than the "minimally invasive" laparoscopic techniques introduced some 20 years ago. Laparoscopy—also known as keyhole surgery—involves inserting tiny scalpels and cameras called laparoscopes through small cuts in the abdomen or elsewhere. The scarless version eliminates those skin cuts almost altogether. Scarless surgery was first tried four years ago in India and South America, and in the past two years it has been performed more than 60 times around the world.

The champions of scarless surgery hail it as the dawn of a new age in medicine. "I was skeptical three to four years ago, but I'm getting religion," says Dr. David Rattner, chief of general surgery at Massachusetts General Hospital in Boston. "It really could work."

It could also create a major new market. Makers of medical devices (BusinessWeek, 3/31/08) are spending millions to develop appropriate surgical instruments, and surveys have found that patients aren't put off by the "ick factor" of an organ coming out of their mouths if it means a faster recovery. But before scarless surgery is widely adopted, there's a need for training programs and better instruments. Surgeons must also persuade insurers to reimburse them adequately for an operation that can take far longer than conventional surgery.


Scarless surgery is formally known as natural orifice translumenal endosurgery (NOTES), and refers to operations done through the mouth, vagina, rectum, or urethra. Typically, the only incisions are through the stomach, which has few nerve endings. Patients can expect far less pain, a much lower risk of infection, and a hospital stay of a day or less. "This is a new way of thinking," says Dr. Mark Talamini, one of the surgeons on the San Diego team that operated on Scholz. "In our studies it's remarkable how quickly the stomach heals."

Surgeons studying scarless surgery say that once perfected, it should allow them to remove diseased tissue they simply can't get at with open surgery. Tiny cancers too small to justify open surgery could be sliced out. Doctors could operate on obese patients without having to cut through layers of fat. Many procedures could move to an outpatient setting, saving the health-care system billions of dollars.

Surgeons can be a conservative lot, however. Winning them over to scarless surgery is likely to take years, judging from the long, slow adoption of minimally invasive techniques. Although gallbladder removals and acid reflux repairs are almost all done laparoscopically these days, only 15% of hysterectomies are minimally invasive, and 25% of hernia repairs.

The problem boils down to cost—not for the patient, but for the doctor. Minimally invasive operations can take twice as long as standard surgery, and doing the same procedure without any outer incisions will slow the process further. But insurers pay the same amount for an operation no matter how long it takes. Shorter recoveries also mean lost revenue for hospitals. As noted in one Israeli study of the costs and benefits of minimally invasive surgery: "Hospitals have no economic incentive to adopt the laparoscopic technology as benefits occur only in society."

Customer demand could change all that. A small patient survey by Dr. Nathaniel Soper, an expert on minimally invasive surgery at Northwestern Memorial Hospital in Chicago, found that the majority would choose a scarless approach if assured the procedure was safe.

Instrument manufacturers are eager to develop safer tools. Ethicon Endo-Surgery, a Johnson & Johnson (JNJ) unit and the leader in the $15 billion market for minimally invasive instruments, is donating money to surgical societies to advance research into scarless procedures and funding further development in-house. There are also startups such as Austin (Tex.)-based Apollo Endosurgery, which grew out of a scarless surgery collaboration among surgeons at several different hospitals. Says Apollo CEO Dennis McWilliams: "The venture capital community is very interested in NOTES because it sees a multibillion-dollar market that is finally opening to competition."

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