Kidney donations occur every day, but most do not come out through the vagina. The case of a 48 year old woman whose donated kidney was retrieved through her vagina has made headlines, and rightly so. This is the future: natural orifice surgery.

So says NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research) a collaborative of specialist surgeons. Conveniently, the acronym conveys the principle benefit of the surgery, no scar. In reality, there is a scar, but it is located internally. A kidney or appendix can be removed through the vagina. A gallbladder can be removed through the stomach and pulled out the esophagus. And that’s just the beginning. This represents a real paradigm shift in surgery.

Back in the Dark Ages, when I went to medical school, having surgery meant a substantial surgical incision. The kidney was removed through a large incision in the flank; the gallbladder came out through a large incision curving from the right upper abdomen toward the back; even the appendix, small as it is, required a 3-4 inch incision in the right lower abdomen. Since the skin incision is the most painful part of surgery, most surgical procedures required days or weeks of recovery, and substantial amounts of pain medication in the immediate post operative period.

All that changed with the introduction of the laparoscope, whose use was pioneered by gynecologists. The laparoscope (also known by the umbrella term of endoscope) was originally nothing more than a long tube with an eye piece and a light source. The laparoscope could be introduced into the abdominal cavity through a one inch incision located immediately below the navel. It provides a nearly complete view of the abdomen and pelvis. With the addition of a manipulating rod, introduced through a half inch incision in the lower abdomen, various types of simple surgery could be performed.

The laparoscope was a tremendous boon to gynecology patients. Many different gynecological problems present with similar symptoms. Since the treatment is very different, it is imperative to tell them apart. While all three results in severe lower abdominal pain, the treatment for a ruptured tubal pregnancy is emergency gynecologic surgery, the treatment for appendicitis is general surgery, and the treatment for a severe pelvic infection is no surgery at all. Sometimes other symptoms made one diagnosis far more likely than the others, but all too often, the wrong treatment was implemented initially, or actual surgery was required to look into the pelvis and see what was going on. In the case of pelvic infection, the surgery turned out to be unnecessary in retrospect.

The laparoscope changed all that. Now if there was any doubt, the patient could have laparoscopy. The doctor could look into the pelvis directly to make the correct diagnosis and the woman was left with a tiny incision small enough to be covered by a bandaid. It wasn’t long before gynecologists discovered that they could do far more than look. With the advent of special instruments, a ruptured tubal pregnancy or an appendix could be removed. Fallopian tubes could be easily tied by laparoscope, and ovarian cysts, or an entire ovary could be removed using the scope. And in every case, the patient had far less pain (usually managed with Tylenol or ibuprofen), and a very quick recovery. Patients went home the very same day as their surgery, with only one or more bandaids providing evidence that any surgery had occurred.

During my internship, gynecologists were actively encouraging surgeons to embrace the technology. Initially they did not have much success. I distinctly remember the Chief of Surgery predicting that “real” surgeons would never operate through a scope. He was spectacularly wrong. Within a few years, most appendectomies were being performed through the scope, and surgeons extended the technology in amazing ways. Now gallbladders and kidneys are routinely removed using the laparoscope. One thing did not change, however. Laparoscopy continued to require little incisions in the abdomen through which the scope and the instruments were inserted. And in the case where something large like a kidney was removed, a separate, larger incision was required to pull the organ out. That increased the pain and the recovery time.

Natural orifice surgery is a logical extension of laparoscopy and its benefits. In natural orifice surgery, the laparoscope or the instruments are introduced through a tiny incision in a natural orifice. So, for example, in a “no scar” appendectomy, the scope is still inserted below the navel, but the instruments go in and the appendix comes out through an incision in the upper vagina. Now instead of 2 or 3 small abdominal scars, an appendectomy leaves one small abdominal scar, and one larger, unseen scar in the upper vagina.

An even greater benefit is that removal of organs like the kidney, that used to require a 2-3 inch incision to get the kidney out of the body, can be done with a similar incision in the upper vagina. A vaginal incision results in far less pain. Indeed the woman who just donated her kidney needed very little pain and declared that the kidney donation was far easier than having a baby, and far less painful than when she had had her gallbladder removed through a traditional incision.

As natural orifice surgery is becoming more popular, surgeons are becoming more creative. How about removing the gall bladder through a small incision in the stomach? What about abdominal surgery done through a small incision in the rectum? Some surgeons are even exploring the possibility of urinary tract surgery done through a small incision in the bladder.

To be sure, there are technical difficulties that must be overcome. For example, in the case of the donated kidney, dragging it through the bacteria filled vagina before placing it in another person raises the risk of serious infection. Yet technical problems often lead to ingenious solutions. In the case of kidney donation, the first step is to enclose the kidney in a sterile plastic bag tied at the top. When the kidney is released from its attachments, it is removed through the vagina by simply pulling out the sterile bag, kidney enclosed.

Natural orifice surgery is not for everyone, and is not appropriate for every procedure. Anyone who has internal adhesions (scarring) from previous surgery is often not a candidate for any kind of laparoscopic surgery. Natural orifice surgery, like other forms of laparoscopy, is not appropriate for cancer surgery where it is critical to explore every corner of the abdomen and pelvis to make sure there is no cancer left behind. In addition, since so few natural orifice procedures have been performed thus far, we may not have a clear idea of the risks of complications. Can stomach acid leak out of the stomach after surgery to remove the gallbladder? Will operating through an incision in the rectum carry an unacceptably high rate of infection? No one knows.

These problems, though, are technical problems, and are therefore amenable to technical solutions. Natural orifice surgery is the future of surgery. It dramatically reduces operative pain and recovery time for all patients, and by making operations like kidney donation far easier, it may lead to an increase in people willing to donate.

“No scar” surgery represents a natural evolution in surgery. The operations have stayed the same, but the incisions have been shrinking and are now being placed in hidden areas. It is still preferable to avoid surgery all together, but when that is not possible, natural orifice surgery can dramatically improve the experience.