Natural orifice surgery used for GERD, gastric bypass

Dr. Kelvin Higa, known for his expertise in minimally invasive and bariatric weight-loss surgery, has begun performing natural orifice or “scarless” abdominal operations.

Dr. Higa, a UCSF Fresno clinical professor of surgery, practices at Fresno Heart & Surgical Hospital and at Clovis Community Medical Center, rated for the second year in a row as the best place in California for bariatric surgery. He explains that Natural Orifice Transluminal Endoscopic Surgery, or NOTES, is the next phase of minimally invasive surgery.

 “As we made surgery less and less invasive, as we made the incision smaller and smaller, the benefits have been astounding,” said Dr. Higa, president of the American Society for Metabolic & Bariatric Surgery

“So with natural orifice it’s one step further. It’s actually doing an operation without an incision altogether – at  least visible incisions – using natural orifices such as the mouth, the rectum, the vagina in order to get access to things like the appendix, the gall bladder and the stomach.”

The scarless operation is performed with an endoscope, a long, flexible, sterile tube normally used to diagnose problems by inserting tiny cameras into the digestive system. In natural orifice surgery, the endoscope is used to thread a video camera and surgical instruments into the abdominal cavity to make an internal incision in the stomach or colon to get to other organs.

The concept has been around for a long time, Dr. Higa said, but surgeons had to wait for the development of electronics, smaller cameras, better video resolution and remotely operated surgical equipment to do the operation safely. “It’s been waiting for the technology to catch up with the ideas,” he explained.

“Natural orifice surgery right now is in its infancy,” Dr. Higa said. “It’s not ready for prime time for many of the operations, but there are some procedures that we can affect today with FDA-approved devices, that we’re performing in our center.”

Since November, Dr. Higa has used the technique successfully to re-do gastric bypass surgery and to reduce reflux or GERD (gastroesophageal reflux disease). He said only a handful of hospitals nationally are performing such surgeries.

Proponents of NOTES say the technique should revolutionize surgery just as laparoscopy did in the 1980s when surgeons shifted from completely opening up the abdominal cavity for operations such as gall bladder removal to just using a few tiny incisions to insert a camera and surgical instruments. Dr. Higa said this next wave of surgery is exciting.

“If there’s no incision, no scar, it’s safer, and certainly more appealing to a lot of patients,” Dr. Higa said. And while natural orifice surgery is still very new, physicians are also finding that is has great potential. Patients will need less anesthesia during such operations, and are likely to have shorter hospital stays and avoid infections possible with external incisions.

This story was reported by Erin Kennedy. She can be reached at