Avoiding scars

Dr. Yoav Mintz. Photo: Bethsabée Süssmann
By Roland S. Süssmann
Do you know NOTES? It is a new technique, Natural Orifice Transluminal Endoscopic Surgery, which is a true revolution in the field of operating methods. Few people have heard of it, even less have benefited from it and even fewer still surgeons know how to carry out this intervention. It was at the impressive hospital and university complex of Hadassah Ein Karem in Jerusalem that we met Dr. Yoav Mintz, a leading expert in minimal invasive surgery and one of the groundbreakers of NOTES, which has been available for a short time at this hospital after it was approved in July 2008 by the Israeli Ministry of Health.

Before telling us about this new operating technique, we would like to get to know you a bit better. Who are you and what is your medical and surgical experience to date?

My family has lived in Jerusalem for ten generations, and my three children are the eleventh. My father was a diplomat and we traveled a lot. I have lived in Ethiopia and Uruguay, but I did all my medical studies in Hadassah here in Jerusalem, where I also completed my internship. I did my specialty in surgery at Hadassah, and as part of a Hadassah program spent a year at Mount Sinai Hospital in New York. I returned here and have carried out a large number of minimally invasive surgical operations. I am fascinated by the subject and wanted to go into it as deeply as possibly and to discover new possibilities. So I left for UCSD (University of California, San Diego) to work for two years with the world leaders in robot-assisted surgery and minimally invasive surgery, including Dr. Mark Adams Talamini. He is the President of SAGES (Society of American Gastrointestinal and Endoscopic Surgeons), the body that defines all conduct in respect of gastro-intestinal surgery. In parallel I worked with Dr. Santiago Horgan, President of MIRA (the Minimally Invasive Surgery Association), the international association of robot-assisted surgery. I have thus had the privilege of working hand in hand for years with these two world leaders in the two respective fields. While I was there they gave me the job and the challenge of putting the finishing touches to NOTES.

What is it exactly?

Before replying I have to say a few words about laparoscopy or minimally invasive surgery. When for example you have to remove a gall bladder, instead of opening up the entire abdomen we make a few small incisions through which we introduce the instruments needed for this operation. The result is less suffering and fewer complications (for example wound infections, hernias, hematoma etc), the patient is mobile and he or she can get up a few hours after the operation and quickly go home, usually the next day. There are also less pulmonary complications, people are able to breathe in without abdominal pains, and there are still more advantages. In fact, when we moved over from open surgery to laparoscopy about 25 years ago, it was a real revolution, which is still with us.
We are now at the threshold of a new revolution in this field whose full name is NOTES (Natural Orifice Transluminal Endoscopic Surgery). As you know, access to the abdominal cavity is required for a wide range of operations as well as simply for diagnoses. Depending upon the requirements, this is done either by endoscopy or laparoscopy. NOTES is a technique by which we enter with an instrument through the mouth into the stomach, then leave the stomach by making a small incision into the abdomen, proceeding for example to an ablation of the gall bladder. Then we take the vesicle out through the mouth and close up the stomach incision. No scares, no pain. In women we go through the vagina, which is a surer route than through the mouth. In fact, the incision we make in the stomach has to be sutured using an endoscope, whereas in the vagina we make just a small hole that we can easily close. For the time being these operations are carried out under full anesthetic, but we hope that that within a few years we will be to them under partial anesthetic.

What are the risks and the disadvantages?

As with everything that is in a manner of speaking experimental, we still do not know all the risks and cannot yet evaluate them. What we already know is that we are eliminating all the dangers of complications that exist in open surgery and laparoscopy, part of which I have already mentioned. One of the risks is certainly that making an incision in the stomach that could be badly sutured, causing seepage. That is why we are always working to improve the instruments used in suturing an incision in the stomach.

You speak of the natural orifices. To avoid going through the stomach, would it be possible to go through a person’s anus?

That is in fact a possibility, however, the anus carries more bacteria and is very difficult to asepticize. We are thinking of carrying out transanal interventions, but at the surgical level this is not yet been fully developed. We are also working on the total sterilization of the anus.

What type of operations can you carry out today using this system?

I will mention the two interventions we can carry out here at Hadassah, gall bladder, which affects annually one million patients in the USA, and appendicitis, which also affects a large number of people. Other interventions are presently at the experimental stage. Obviously, our patients will have a choice, and after we have provided them with all the explanations they will have to sign a consent form. In any case, this operation cannot be done as an emergency, but only when properly scheduled.

Are there other medical centers where NOTES is already practiced?

Very few, in fact. There are four hospitals in America, of which one is of course UCSD, where I still work, two in New York, Columbia Hospital and the New York Presbyterian Hospital, and Johns Hopkins Hospital in Baltimore. There are several centers in South America, but cooperation there is quite difficult and we do not know what exactly is happening; there is one in India, where we also have no control, and there are a few in Europe, one of which is in Strasbourg. To date, all of them have carried out one or two interventions of this type. At UCSD we have carried out 23 operations, the largest number using NOTES, which means we have the largest experience in the USA and Europe. For the time being, ten surgeons in the world know this technique.

This new operating technique clearly requires new instruments, which opens up a new area in surgical instruments. Where and how are these instruments developed?

Actually, enormous sums are being invested in the research, development and production of new instruments. Everyone believes that NOTES is the new revolution and each is trying to obtain patents for the most effective instruments. Every company making laparoscopy instruments, endoscopes and anything involving gastro-intestinal surgery, has R&D funds. Such is the case with Ethicon Endo-Surgery Inc., a subsidiary of Johnson and Johnson, which has a virtual monopoly on laparoscopy instruments, Tyco and Olympus. Some of these companies work with us directly; we explain what are the requirements and they use our services to do field-testing. There are of course Israeli companies with which we cooperate regularly and that are also active in this field of research.

Are you already teaching NOTES in the medical schools in Israel?

No, I teach it at UCSD, but not to medical students. These classes are only open to highly experienced laparoscopy surgeons, because it is the type of surgery that requires a very large amount of know-how. In Israel I am the only one, together with my team, that at the moment is carrying out this type of operation. By the way, I have had enormous difficulties obtaining approval from the Israel Ministry of Health. I got it in San Diego, where, despite everything, it was a major innovation. I thought with the American approval in hand, things would be easier here, but that was not to be. It took me three months to convince the hospital and six more for the ministry.

You developed NOTES. How did you have this idea?

In fact, the first idea in this direction was advanced by Anthony Kalu of Johns Hopkins in 2004. When I came to UCSD in 2005, Dr. Talamini told me I ought to see whether we could develop this idea of transgastric surgery. He put at my disposal a laboratory, instruments, prototype instruments, operating rooms etc, and within a year we had developed the technique. I must say that since I had all the funds, time and resources I needed, I was able to work very fast. I must say that the subject fascinates me. All this only came about at the end of 2005, when I was really ahead and much more advanced that Johns Hopkins. In 2007 we carried out our first operation on a patient.

How did you get him to accept the idea of going in for entirely novel surgery?

Following two years in the US, I returned to Israel with my family. In parallel with the approvals we had obtained for NOTES in San Diego, we had also got them at the university of Buenos Aires. So I went to Argentina, where I carried out the first four operations. However, there I did not have to convince the patients. That was the job of the Argentinian doctors. In San Diego, our second case was a secretary in the surgical department of UCSD, who knew all the ins and outs of this intervention. It was she who wanted it, especially in order to avoid having a scar. She knew she would be getting the best surgeons. The first patient was a man who had a certain pride in being the first one. An American television team came to make a short report about him.

As you practice NOTES you must discover new problems and new advantages. Can you give us a few examples?

We discovered the importance of the cosmetic aspect of this operation. People do not want scars and of course to suffer as little as possible. We thought that when someone was sick that the main thing was to get rid of the sickness and that the esthetic angle was secondary. Yet that is definitely not the case. On account of the various advantages I have enumerated, we have noted that people are prepared to take the risk of innovation. Further, up till now we have not encountered postoperative complications that could have had consequences and there is hardly any pain in recovery. Another very important aspect is that patients can return home quickly, which means that they can go back to work fast, since there is less hospitalization time. In a nutshell, our system offers a whole range of economic advantages. As for negative aspects, for the time being we have not discovered any new ones, but we will know more in a year when we will have had more experience and perspective. I am very much aware that we are at the stage where we still have to demonstrate that NOTES really is more advantageous for the patient than laparoscopy. As far as costs go, the two operative systems cost the same.

In many scientific areas Israel is today a world leader. Is this also true in your area?

We offer here several specializations that cannot be obtained elsewhere, for example NOTES. As far as laparoscopy goes, today we have excellent surgeons in Israel and we have decided to set up in Hadassah a scholarship for Israeli surgeons, and also possibly for foreign doctors. For Israelis this is very important, since it is always difficult to move families to another country, to take the children out of school for a year etc. Until now the best specialization for minimally invasive surgery has been in the USA, but from now on we can offer it here.
There are two other areas in which I am professionally active, of which the most important is robot-assisted surgery. This is in fact a type of laparoscopy, however, it is no longer the surgeon’s hand that is operating on the patient, but rather instruments controlled from a computerized console with a joystick that the surgeon guides as he follows the operation on the control monitor. This facilitates more precise surgery, since the computer and robot arm are able to make more supple movement than a human arm can. This can be easily seen by looking at a robotic production line. The robots have been developed in the US and Europe, but until now this type of surgery did not exist in Israel. Our first robot is on the way and should be installed within two months. This will allow us to carry out radical prostatectomy, some operations on the intestines and the liver, and others. At the beginning I shall be the only one to do it in Israel and I will of course be called upon to train people.
The second thing I also do is Single Trocar Surgery, through the umbilicus. It is the same technique as NOTES, but instead of going through the mouth or the vagina, I make a single incision (as against the four needed in laparoscopy) in the umbilicus, through which I pass an endoscope and then remove a gall bladder or appendix. Here too, no scar is visible.
I would like to finish off by saying that we are moving forward with very small steps at a time and very responsibly. I have the advantage of a laboratory kitted out with very modern equipment, which facilitates carrying out my experiments on animals. We are equipped to carry out practically every operation there is, including transplants. In the university section of Hadassah we have a farm of pigs, goats, mice, chimpanzees and other animals. You should be aware that our experiments are highly regulated and our primary concern is avoiding causing suffering to the animal. Within our operating room – laboratory we also give courses in laparoscopy, including to doctors from throughout the country and the areas controlled by the Palestinian Authority. Having said which, it has to be acknowledged that to carry out my first operation, I had to operate on about one hundred pigs (the anatomy of whose abdomen resembles that of humans) and about fifteen human corpses.
To conclude, I would say there can be no doubt that the great surgical revolution of tomorrow is underway and Hadassah will become one of the most important centers in the world for NOTES.