PITTSBURGH – A 4-year-old boy lay on an operating table here a few weeks ago with a tumor that had eaten into his brain and the base of his skull. Standard surgery would involve cutting open his face, leaving an ugly scar and hindering his facial growth as he matured.
But doctors at the University of Pittsburgh Medical Center knew a way to avoid those devastating consequences. They removed much of the tumor through the boy's nose.
Since then, doctors in New York and in France have announced they removed gall bladders through the vaginas of two women. And doctors in India say they have performed appendectomies through the mouth.
It's a startling concept and a little unpleasant to contemplate. But researchers are exploring new ways to do surgery using slender instruments through the body's natural openings, avoiding cutting through the skin and muscle.
Many questions remain about that approach. But doctors say it holds the promise of providing a faster recovery with less pain and no visible scars. And in the brain, it can avoid a need for manipulating tissue that could disturb brain and eye function.
For abdominal surgeries, going through the mouth, vagina or rectum would avoid the need to cut through sensitive tissues. And deep inside the body, where tissue doesn't feel lasting pain, the procedures themselves might be less traumatic.
Some abdominal surgeries like bowel operations can require patients to spend a week or more recovering at home. With the natural-opening surgery, the theoretical hope is that "they really can go back to work the next day," said Dr. David Rattner of Massachusetts General Hospital.
"It would be like going to the dentist and getting a root canal," Rattner said. "It's not trivial, but it also isn't disabling."
Sometimes doctors even pass up one natural body opening for another. On the same day they treated the 4-year-old, doctors in Pittsburgh operated on neck vertebrae of an elderly man through his nose. Usually, this operation would have been done through the mouth.
But going through the nose meant the patient could start eating right away rather than waiting a few days. And he avoided the risks of a feeding tube and a surgical hole in his throat to help him breathe, said neurosurgeon Dr. Amin Kassam.
Doctors at the medical center first reached the spine through the nose just two years ago, he said.
They have even removed brain tumors the size of baseballs through the nose, nibbling at them and withdrawing pieces the size of popcorn kernels.
However, entry through the nose isn't feasible for brain tumors in some locations. That's why doctors had to remove the rest of the 4-year-old's tumor another way, by going through the side of his skull. They used an incision designed to hide behind his hairline.
The key to operating through body openings is specialized slender instruments that can be inserted into the natural channels, along with devices that provide light and a video camera lens at the site of the surgery. Doctors watch their progress on video screens as they manipulate the surgical instruments.
Sound familiar? It's much like laparoscopic surgery, which revolutionized the operating room more than 15 years ago. For many operations, long incisions have been replaced with three or four holes, each maybe a quarter-inch to a half-inch wide. That has vastly reduced pain and recovery time.
The natural-opening approach holds the promise of going a step beyond that by eliminating the need for those punctures.
"Getting rid of them completely is going to be not an evolutionary step, but a revolutionary step," said Dr. Marc Bessler of New York-Presbyterian Hospital/Columbia University Medical Center.
He led the surgery in New York that detached and removed a woman's gall bladder through her vagina. The team also inserted laparoscopic instruments into two small incisions in her abdomen, using one instrument to hold tissue out of the way.
A week after that surgery was announced, a French doctor said his team had removed a woman's gall bladder through her vagina without any abdominal incisions. Instead, the team pierced her abdomen with a needle about a tenth of an inch wide. The needle was equipped with a video camera system and also allowed doctors to inflate the abdomen to create a working space.
The surgery, performed April 2 on a 30-year-old woman at University Hospital of Strasbourg, was led by Dr. Jacques Marescaux of the Institute for Research into Cancer of the Digestive System in Strasbourg. In a written statement, Marescaux said the procedure left no abdominal scar.
Meanwhile, surgeons have shown increasing interest in removing brain tumors through the nose over the last five years or so, noted Dr. Gail Rosseau, chief of surgery at the Neurologic-Orthopedic Institute of Chicago.
"This is the dawn of this phase of neurosurgery," said Rosseau, a spokeswoman for the American Association of Neurological Surgeons. "This is exciting, it's new and it may well be better for our patients. In fact, we hope it will be. But it does raise questions."
Cancers can come back if they're not completely removed, she noted. It's too soon to tell whether attacking tumors through the nose leads to a higher rate of cancer recurrence than going through the skull, she said. Concerns like the risk of meningitis from spinal fluid leakage also have to be addressed.
Today, most surgeons would go through the skull to remove baseball-sized tumors, she said, "but a decade from now? I don't know."
As for abdominal surgery, a few procedures have been done in people, but nearly all the research so far has been in animals. There are still plenty of questions and barriers to overcome.
For example, Rattner said, new tools must be developed to perform this kind of surgery. And while it makes sense that people would recover faster from natural-opening surgery than laparoscopic procedures, that hasn't been proven yet, Rattner said.
Then there's the basic question of just what abdominal procedures make sense for a natural-opening approach. For women, Bessler believes the gall bladder and appendix will be among those that will be removed through the vagina.
Rattner questions whether a natural-opening approach for removing those organs offers enough of an improvement over laparoscopy — which can get a patient back to work in four to seven days — to make it worthwhile.
He sees more potential for procedures that replace surgeries that can keep a person out of work for weeks, like removing a kidney, adrenal gland or a portion of the intestine. Or doing obesity surgery.
"It's not going to replace laparoscopic surgery, but it's going to have a niche somewhere," Rattner said. "We're trying to figure out where that niche is going to be."