Appendix Removed via Patient's Mouth

from WebMD — a health information Web site for patients

Salynn Boyles

March 21, 2008 — Last week Jeff Scholz of San Diego became the first person in the U.S. to have his
appendix removed through his mouth.

Other than what he describes as a very mild sore throat, the 40-year-old former Marine says he felt very little
pain after the surgery and was back to normal within a few days.

"They told me to take it easy, but I feel great," he told WebMD Tuesday afternoon -- six days after having his
diseased appendix removed in a procedure known as Natural Orifice Transluminal Endoscopic Surgery
(NOTES).

"Two days ago I started to do sit-ups again, and I ended up working a 10-hour day yesterday."

Appendectomy via Mouth

Surgeons at the University of California San Diego's Center for the Future of Surgery performed the highly
experimental operation, which involved guiding surgical instruments through the mouth, down the esophagus,
and into the stomach with a tube-like device known as a flexible endoscope.

Once inside the stomach, a small incision was made into the stomach wall to allow access to the appendix.

These days most appendectomies are performed laparoscopically, which is much less invasive than traditional
surgery but still requires cuts through the abdomen wall.

The NOTES procedure is even less invasive than laparoscopic appendectomy, lead surgeon Santiago Horgan,
MD, said in a news statement.

"Only one small incision to insert a small camera in the belly button was required to complete the surgery vs.
three incisions required for a laparoscopic procedure," he says.

Scholz's surgery went off without a hitch, and the University of California, San Diego (UCSD) surgical team
hopes to perform one more appendectomy through the mouth soon.

Safety Concerns Remain

If all goes well, the two initial surgeries will be followed by a pilot study of the procedure, UCSD department of
surgery chairman Mark A. Talamini, MD, tells WebMD.

Talamini is also president elect of the Society of American Gastrointestinal and Endoscopic Surgeons.
"These are the first baby steps to look at this type of surgery to see if it is feasible, and to see if it is a
potentially better way to approach appendix removal," he says.

The procedure has also been used to remove diseased gallbladders, with endoscopes inserted through the
mouth or the vagina.

"The paradigm shift here may be that the stomach or vagina may heal better than the skin and [connective
tissue] do," Talamini says. "We aren't ready to say that this is the case, but it is worth investigating."

The concern about going through the wall of the stomach is that stomach juices could leak out if the hole is not
properly closed, exposing the patient to potentially life-threatening complication.

Because of this potential risk, researchers are proceeding with extreme caution, Talamini says.

"We are working to develop the technique and the tools to do this procedure in the most foolproof way
possible," he says.

SOURCES:
News release, University of California, San Diego, Center for the Future of Surgery.
Mark A. Talamini, MD professor and chair of the department of surgery, University of California San Diego
Medical Center; president elect, Society of American Gastrointestinal and Endoscopic Surgeons.
Santiago Horgan, MD, professor and director, University of California, Center for the Future of Surgery.
Jeff Scholz, appendectomy patient.