Todd McCarty, MD, FACS, of the Lakewood Weight Loss & Wellness Clinic in Dallas, performed the first natural orifice bariatric surgery in November. This minimally invasive procedure involves entering the abdominal cavity through natural openings — in this case, the vagina — instead of through incisions in the abdominal wall. This reduces pain, recovery time and complications.
Dr. McCarty performed gastric sleeve surgery on a female patient on a Thursday. The patient returned home the next day, went Christmas shopping over the weekend and returned to work on Monday. She reported no abdominal pain and minimal vaginal discomfort.
"With more experience, we'll be able to do the majority, if not all of the [bariatric] procedures, through the vaginal port," Dr. McCarty says.
He is no newcomer to minimally invasive surgery. Dr. McCarty was among the first to perform many advanced laparoscopic operations, including surgery of the stomach, esophagus, spleen and liver. He was also heavily involved in the transition from open to laparoscopic bariatric surgery. Dr. McCarty offers seven points on minimally invasive and natural orifice bariatric surgery.
1. Using natural orifice entry reduces pain and infection. The first benefit to this method of surgery is a reduction in pain, Dr. McCarty says.
"The reality is that even with laparoscopy with five or six incisions in the abdominal muscle, you risk hernias and infection," he says. "It's more painful for the patients."
There's also a reduced risk of infection because the remnant stomach is not pulled out through an exterior incision.
2. The trans-vaginal approach made the most sense for bariatric procedures. Natural orifice surgery has been gaining popularity in recent years, and there are many approaches, including oral, trans-rectal, trans-vaginal and going thought the bladder. Because 75-80 percent of bariatric patients are female, Dr. McCarty says the trans-vaginal approach made the most sense.
Dr. McCarty read about other procedures being done through vaginal ports and was worried about sexual function post-surgery. When published studies confirmed that women reported no loss of sexual function after such surgery, he thought "the stage was set."
A few months ago, he read a published report of colorectal surgeons removing a colon through an incision in the vagina right next to the cervix. He also read report of trans-vaginal appendectomies.
"If you can take a colon out, why can't you put a band in," he says.
3. Practice makes perfect. Before performing the surgery, Dr. McCarty practiced using surgical simulators and live animal labs until he became comfortable with the approach including instrumentation such as the forceps to hold the tissue and the more complex suturing instruments.
"You really have to be comfortable with doing single incision laparoscopic cases," he says. "Most of what you're doing is through a single port in the vaginal wall."
4. The procedure itself was without complications. Dr. McCarty chose to have an OB/GYN participate in the surgery. The procedure itself, though technically challenging, went well. A small camera was inserted through the belly button so the surgeons could visualize the inside of the perionatal cavity, and an incision was made through the vagina and peritoneum, the membrane that forms the lining of the abdominal cavity.
"The surgery itself was technically challenging because of the anatomy of the pelvis," Dr. McCarty says. "As opposed to doing surgery on things close to the pelvis, you have to go up and over the pelvis and back down to the stomach. That took a little bit of trial and error just to figure out how to best use the instruments available."
The surgery took two hours, and the patient was up and walking around later that day.
5. Patient selection is important. One of the most important things to consider when performing a surgery with an innovative approach is patient selection. For trans-vaginal bariatric surgery, Dr. McCarty recommends a patient with a BMI of 30-40, less than 50 years old, no previous pelvis surgery and a clear understanding of the benefits and the risks of the procedure.
"With new procedures, you can't predict adverse outcomes," he says. "The patient has to be insightful enough to understand the potential benefit of an innovative and new approach."
A patient's anatomy also plays an important role when dealing with natural openings. Women who have given vaginal birth are preferable as childbirth widens the pelvis and makes access a little easier. Although his first patient had not given birth, her anatomy was "still very favorable."
Dr. McCarty says he would be reluctant to operate on patients who are taller than average because the length of the instruments becomes an issue. To combat this, companies such as Covidien and Ethicon are producing longer instruments, he says.
6. There is still some resistance from older surgeons. As a general rule, some older surgeons are still putting up resistance toward less invasive bariatric surgery, Dr. McCarty says.
"To a certain extent, there is still a resistance to making this kind of surgery comfortable and easier for patients," he says. "It's a balance between the technical difficulty versus the risk to the patient population that can be higher risk than normal. That's something that always makes older bariatric surgeons a little bit nervous."
However, many younger surgeons — who are more comfortable with laparoscopic techniques — are starting to reduce the length of hospital stay for these procedures by implementing less invasive techniques.
7. Bariatric procedures and increasingly moving in the ASC setting. Despite the resistance from some, bariatric surgeries are gradually moving to an outpatient or day-surgery setting.
"Over the last seven or eight years, there's been a broad acceptance of laparoscopic bariatric surgery," he says. "It's transferring from an inpatient procedure to an outpatient or a day surgery. In the past, it's been most lap bands, but I think there's a lot of improvement, and the vast majority of these cases can be done in an ASC setting."
Dr. McCarty says the majority of insurance companies are now recommending that lap band surgery be done in the outpatient or day-surgery setting. That recommendation has been supported by the American Society for Metabolic and Bariatric Surgery.
Related Articles on Bariatric Surgery:
Bariatric Surgery Department at Lafayette General Medical Center Designated Bariatric Surgery Center of Excellence
Study: Bariatric Surgery Not as Effective for Diabetes Remission as Previously Thought
Dr. Edward H. Livingston: BMI Inadequate Indicator for Bariatric Surgery
Dr. McCarty performed gastric sleeve surgery on a female patient on a Thursday. The patient returned home the next day, went Christmas shopping over the weekend and returned to work on Monday. She reported no abdominal pain and minimal vaginal discomfort.
"With more experience, we'll be able to do the majority, if not all of the [bariatric] procedures, through the vaginal port," Dr. McCarty says.
He is no newcomer to minimally invasive surgery. Dr. McCarty was among the first to perform many advanced laparoscopic operations, including surgery of the stomach, esophagus, spleen and liver. He was also heavily involved in the transition from open to laparoscopic bariatric surgery. Dr. McCarty offers seven points on minimally invasive and natural orifice bariatric surgery.
1. Using natural orifice entry reduces pain and infection. The first benefit to this method of surgery is a reduction in pain, Dr. McCarty says.
"The reality is that even with laparoscopy with five or six incisions in the abdominal muscle, you risk hernias and infection," he says. "It's more painful for the patients."
There's also a reduced risk of infection because the remnant stomach is not pulled out through an exterior incision.
2. The trans-vaginal approach made the most sense for bariatric procedures. Natural orifice surgery has been gaining popularity in recent years, and there are many approaches, including oral, trans-rectal, trans-vaginal and going thought the bladder. Because 75-80 percent of bariatric patients are female, Dr. McCarty says the trans-vaginal approach made the most sense.
Dr. McCarty read about other procedures being done through vaginal ports and was worried about sexual function post-surgery. When published studies confirmed that women reported no loss of sexual function after such surgery, he thought "the stage was set."
A few months ago, he read a published report of colorectal surgeons removing a colon through an incision in the vagina right next to the cervix. He also read report of trans-vaginal appendectomies.
"If you can take a colon out, why can't you put a band in," he says.
3. Practice makes perfect. Before performing the surgery, Dr. McCarty practiced using surgical simulators and live animal labs until he became comfortable with the approach including instrumentation such as the forceps to hold the tissue and the more complex suturing instruments.
"You really have to be comfortable with doing single incision laparoscopic cases," he says. "Most of what you're doing is through a single port in the vaginal wall."
4. The procedure itself was without complications. Dr. McCarty chose to have an OB/GYN participate in the surgery. The procedure itself, though technically challenging, went well. A small camera was inserted through the belly button so the surgeons could visualize the inside of the perionatal cavity, and an incision was made through the vagina and peritoneum, the membrane that forms the lining of the abdominal cavity.
"The surgery itself was technically challenging because of the anatomy of the pelvis," Dr. McCarty says. "As opposed to doing surgery on things close to the pelvis, you have to go up and over the pelvis and back down to the stomach. That took a little bit of trial and error just to figure out how to best use the instruments available."
The surgery took two hours, and the patient was up and walking around later that day.
5. Patient selection is important. One of the most important things to consider when performing a surgery with an innovative approach is patient selection. For trans-vaginal bariatric surgery, Dr. McCarty recommends a patient with a BMI of 30-40, less than 50 years old, no previous pelvis surgery and a clear understanding of the benefits and the risks of the procedure.
"With new procedures, you can't predict adverse outcomes," he says. "The patient has to be insightful enough to understand the potential benefit of an innovative and new approach."
A patient's anatomy also plays an important role when dealing with natural openings. Women who have given vaginal birth are preferable as childbirth widens the pelvis and makes access a little easier. Although his first patient had not given birth, her anatomy was "still very favorable."
Dr. McCarty says he would be reluctant to operate on patients who are taller than average because the length of the instruments becomes an issue. To combat this, companies such as Covidien and Ethicon are producing longer instruments, he says.
6. There is still some resistance from older surgeons. As a general rule, some older surgeons are still putting up resistance toward less invasive bariatric surgery, Dr. McCarty says.
"To a certain extent, there is still a resistance to making this kind of surgery comfortable and easier for patients," he says. "It's a balance between the technical difficulty versus the risk to the patient population that can be higher risk than normal. That's something that always makes older bariatric surgeons a little bit nervous."
However, many younger surgeons — who are more comfortable with laparoscopic techniques — are starting to reduce the length of hospital stay for these procedures by implementing less invasive techniques.
7. Bariatric procedures and increasingly moving in the ASC setting. Despite the resistance from some, bariatric surgeries are gradually moving to an outpatient or day-surgery setting.
"Over the last seven or eight years, there's been a broad acceptance of laparoscopic bariatric surgery," he says. "It's transferring from an inpatient procedure to an outpatient or a day surgery. In the past, it's been most lap bands, but I think there's a lot of improvement, and the vast majority of these cases can be done in an ASC setting."
Dr. McCarty says the majority of insurance companies are now recommending that lap band surgery be done in the outpatient or day-surgery setting. That recommendation has been supported by the American Society for Metabolic and Bariatric Surgery.
Related Articles on Bariatric Surgery:
Bariatric Surgery Department at Lafayette General Medical Center Designated Bariatric Surgery Center of Excellence
Study: Bariatric Surgery Not as Effective for Diabetes Remission as Previously Thought
Dr. Edward H. Livingston: BMI Inadequate Indicator for Bariatric Surgery