Vaginal approach to gallbladder removal

Or removal of the appendix through the mouth?


I finished my residency training in 1993, and was privileged to witness some of the first "laparoscopic" gallbladder removals on one of my rotations with some private surgeons. After 5 years or so of observing and assisting with the old technique that required a 7 to 10 inch incision at the right upper abdomen and months of recovery, I was used to patients lying very still and needing encouragement to breathe after the surgery. I nearly fell apart myself when, just an hour after we removed her gallbladder, one of my patients sat up in bed. I've never moved faster than I did that time, trying to catch her before she tore her wound or fell out of bed when the pain hit!

My first reaction to this story was one of alarm about possible harm due to trying a new, risky maneuver, just because it's surgically possible.

I wasn't sure how much of my distaste was a woman's reaction to invasion through the vagina. After I read the description of the appendectomy through the mouth, I decided that it's a true caution about the risk of such a route.


The biggest problem with recovery from surgery is the trauma to the tissues surrounding the surgical site, especially the muscles that are cut and sewn.

I finished my residency training in 1993, and was privileged to witness some of the first "laparoscopic" gallbladder removals on one of my rotations with some private surgeons. After 5 years or so of observing and assisting with the old technique that required a 7 to 10 inch incision at the right upper abdomen and months of recovery, I was used to patients lying very still and needing encouragement to breathe after the surgery. I nearly fell apart myself when, just an hour after we removed her gallbladder, one of my patients sat up in bed. I've never moved faster than I did that time, trying to catch her before she tore her wound!

The new technique allowed for us to remove the gallbladder - and later, the appendix (and other stuff) - by making 3 or 4 cuts, all less than an inch and using instruments and a camera that allowed remote or video-guided surgery. Without all that cut skin and all those layers of muscle, patients got better, faster.

It's almost routine to perform hysterectomies through the vagina these days. But let's face it, in this case, everything's right there. The surgeon just has to watch for the blood vessels, the bladder and the rectum, and virtually no muscles have to be cut, at all.

Either of these operations would require muscles and "surface" tissues to be cut, and each require that the surgeons' instruments pass other organs. There's also the problem of making the surgical field sterile and maintaining infection control.

With removal of the gallbladder, there is also the risk to the liver, and especially, the common bile duct from the liver to the intestines. For that matter, an oral approach to the appendix would require reaching past the lungs, the diaphragm, the liver and the intestines, unless the instruments can be passed through the esophagus and stomach. (How would you intubate this patient, protect her lungs, or handle the leaks of acid from the stomach into the abdominal cavity?

The surgeons quoted in the New York Times article are proponents of "no scar" surgery.

I'm a little concerned about the way they "read":

Dr. Bessler said his patient agreed to the procedure (two others had declined) because he told her he thought it would have advantages for her, and she accepted his judgment. She was the first in a study that is to include 100 women who need gallbladder surgery, appendectomies or biopsies taken from inside the abdomen. All the procedures will be done through the vagina.

Dr. Dennis Fowler, another surgeon who participated in the operation, said the team began experimenting on women because “incisions in the vagina have been used for a variety of procedures for decades, and proved safe with no long-term consequences.”
. . .
The operation took about three hours, twice as long as the usual laparoscopic surgery, but it was the team’s first operation on a human, and the time should decrease with practice, Dr. Bessler said. Also because it was the first time, to be on the safe side, the doctors did make three small openings in the abdomen for surgical tools. But their ultimate goal is to perform the operation entirely through the vagina.