Remember when a laparoscopic cholecystectomy was considered state of the art? Surgeons could offer patients an operation through "keyhole" incisions that used to require an enormous subcostal cut that put a patient out of commission for months at a time. The anesthetic plan also became easier to manage. No longer did we have to worry as much about prolonged operative time, intraoperative hemorrhage, pulmonary insufficiency, or postoperative pain and splinting.
Along those lines, researchers are developing new procedures that practically remove any visible skin incisions. The following list is by no means comprehensive. Some of the procedures sound exotic, if not bizarre. But they all have one common goal, and that is to minimize the morbidity and mortality of patients. One day patients may be treated without any incisions at all just like in Star Trek.
1. The TOGA procedure is a transoral gastroplasty that aims to replace the standard laparoscopic gastric bypass. Even though the laparoscopic procedure only requires six or seven tiny incisions, patients still complain about incisional pain afterwards. A gastric bypass also introduces the complications of increasing the intraabdominal pressure on morbidly obese patients who already have pulmonary compromise. TOGA is done completely endoscopically through the mouth. The hope is that there is less pain and less pulmonary complications which could eventually make it an outpatient procedure.
2. Transgastric appendectomy is performed by making several small incisions through the stomach. A pneumoperitoneum is produced to help visualize the appendix way down in the right lower quadrant of the abdomen. In this study the patients were allowed to eat and drink as soon as they woke up from anesthesia.
3. Transvaginal cholecystecomy is the next evolution of laparoscopic cholecystectomy. Surgeons used standard laparoscopic equipment to take out the gall bladder through vaginal incisions. The only skin incision required was for the varess needle to access the abdominal cavity to create the pneumoperitoneum.
4. Transcolonic cholecystectomy sounds even more far-fetched than the last procedure. This one is still in the animal experimentation stage. The idea of introducing equipment into the peritoneal cavity that has gone through the colon mucosa doesn't sound attractive. Is it really possible to sterilize the colon no matter how many Betadine enemas are given?
5. Transaxillary thyroidectomy was first introduced in South Korea but is now getting some attention here in the West. A da Vinci robot is used to assist the surgeon guide his instruments from the armit all the way to the neck. This procedure actually sounds very scary. As anybody who has ever attempted a central line placement or regional anesthesia will tell you, the axillary and periclavicular regions are fraught with peril. The risks of tension pneumothorax, brachial plexus injury, and arterial and venous lacerations would keep me from surfing the net during the entire procedure. That is just too much stress for this anesthesiologist.
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