How is the new NOTES procedure done?
You make a six-inch incision in the back of the vaginal wall and insert one flexible tube that contains four channels through which you insert surgical instruments and cameras. Then you dissect upwards toward the kidney, which is located midway up the back. Dissecting means you are using scissors to open up layers of tissue, called fascial planes, to get to the kidney. Separating these layers of tissue feels like peeling away layers of cotton candy. Once you get to the kidney, you identify blood vessels supplying it with blood, put clips on the vessels so they don't bleed, and cut them free from the kidney. (The clips are actually left in the body after the surgery.) To remove the organ, doctors might use the "Roth Net" retrieval net, which is like a collapsible butterfly net. You thread the Roth Net through the tube, which opens up on the other side and "catches" the kidney like a net capturing a butterfly. Then kidney is pulled through the vaginal incision.
[Instead of using the Roth Net, the Hopkins team actually used a sterile plastic bag to extract the kidney, according to Allaf. The bag is similar to the Roth Net in that it slides through a narrow tube, opens at the end and captures the kidney.]
Is this procedure safer than traditional surgery?
With any surgery there are always certain risks, such as infection or excessive bleeding. It's not yet clear whether the risks are lower for NOTES. There are no clinical trials that I know of comparing this technology with any other.
Is the recovery time shorter?
Yes. With laparoscopy the recovery time is about one to two days. With these NOTES procedures it could potentially become an overnight procedure (meaning you have the surgery one day, and go home the next).
Why does it take longer and require reconstructive surgery for women to recover from hysterectomies (removal of the uterus and sometimes the ovaries and fallopian tubes through the vagina) than from this procedure?
Part of the uterus is connected to the vaginal wall. The uterus actually anchors the vaginal wall, which in turn anchors the bladder and rectum. So when you pull out the uterus, you are ripping the vaginal wall. One the other hand, when you pull out the kidney, you're not removing any architectural support of the vaginal wall, bladder and rectum.
What are some of the drawbacks of NOTES?
If we're not careful and don't close things as well as we ought to, infection and bleeding could become an issue. We don't have excellent tools or a lot of experience yet on closing some of these incisions.
Is this procedure more expensive and time-consuming than standard surgery?
The answer to both of those questions is: yes—right now. But once you have the right tools, it's not going to be. As more doctors become familiar with this procedure and they have more precise tools, it will ultimately be less expensive than it is now.
In 10 years, do you expect that this procedure will become the norm?
I think it's going to be the next wave. The majority of organ removals will probably occur through orifices.