At the Cleveland Clinic, surgeons pioneered single-incision kidney removal. They have also used SILS to harvest kidneys from kidney donors for transplantation and hope this method will encourage more people to donate. "The goal here is not only cosmetic," said Dr. Jihad Kaouk, a urologist there. "The goal here is the overall wellness of the patient."
He knows that the idea of taking a kidney - or any other organ - out through the navel may seem like an unnecessary advance. But he said there has been great demand from other surgeons to learn how to perform the procedure, including a class in May that drew 350 instead of the 100 expected.
"There are skeptics, yes," he said. "It comes from a lack of long-term data. We don't have it so far because it's a young procedure."
Not everyone has even bought into laparoscopy yet, Allaf said. While 90 percent of the kidneys removed at Hopkins are done laparoscopically, he said, the figure is more like 30 percent nationally.
Park said the University of Maryland has no plans to move to single-incision surgery for now. He isn't convinced that there is a benefit to it - except perhaps as a marketing tool for hospitals to lure patients concerned about their appearance. As it is, he said, the pain and complications associated with the small ports he uses in a gallbladder surgery are minimal. And the scars are pretty small.
"If you want the battle of the nice-looking tummies, I can line up a bunch of slides of nice-looking tummies" from the standard laparoscopic surgery, Park said. "The single port stuff - it's low-hanging fruit, and it maybe helps us feel like we're doing something new. I have yet to be convinced it's worth the struggle."
When surgeons moved away from open surgery, Park said, they lost having a full range of motion with their hands, elbows and wrists as they worked. Moving to a single port means the loss of even more control and fine motor movement, he said, something he worries will hurt patients.
Allaf said he believes SILS will be seen as an improvement. So far, he said, patients use fewer painkillers and return to work faster. "If you can do something with one hole and do it just as good as with more, then why not?" he said.
He likened the advance to upgrading your television set. You can watch a television program on an old grainy black-and-white set and still laugh at the jokes, he said. Still, many people opt for the 50-inch, full-color plasma screen with surround sound.
Allaf, though, isn't satisfied with single-port surgery. When it comes to kidney cancer, he said, regardless of how many large or small cuts are made, the procedure remains basically the same as it was 100 years ago: Surgeons remove the diseased kidney.
He and his colleagues want future improvements in kidney cancer treatment to be even more meaningful to patients by eliminating the need for any surgery. They are working on ways to freeze the cancer without removing the kidney, as well as looking at using ultrasound and electricity to kill tumors - all without increasing recurrence rates.
A short walk from Allaf's office is the one belonging to Dr. Anthony N. Kalloo, director of gastroenterology and hepatology at Hopkins. Kalloo has been working for years to develop what he and his fellow doctors are calling NOTES (natural orifice transluminal endoscopic surgery) in which organs are removed through patients' existing orifices - the vagina being the most popular so far.
"What if you took this one step further," he said. "Instead of having small incisions, having no incisions."
When he first talked about it, he was told it was malpractice. "You're going to kill patients," critics said.
This type of procedure has probably been done about 300 times, Kalloo said, mostly outside the United States. Gallbladders, kidneys, appendixes have been taken out, mostly by cutting a hole in the vagina wall and then sewing it back up once the organ is out.
The surgeries have not been pure NOTES - they have been assisted by a camera inserted into a small incision in the belly button. The experimental procedure, he said, is still one to two years away from mainstream use.
The idea, for now, makes doctors nervous. Said Allaf: "NOTES scares me." He and others worry about the complications that could come with making holes in the bowel or in the vaginal wall to remove organs that can be easily taken out laparoscopically.
At Anne Arundel Medical Center, Massoglia wraps up her third gallbladder surgery of the morning - two single-incision operations and one using four ports. She is still figuring out which patients make the best candidates for her new technique. She has started with thinner patients, whose anatomies tend to make surgeries less difficult, and has slowly offered it to more.
What she is doing still startles some of her colleagues. She tells of one patient - a 21-year-old bartender with a belly button ring - whose scar was essentially invisible soon after Massoglia removed her gallbladder.
When the woman went to see her primary care physician, Massoglia said, "he didn't believe that she'd had it done."
A cut too small to see
With latest in minimally invasive surgeries, doctors debate whether less is more
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