Quality of Life Interventions from the Columbia University Department of Surgery

The Future of Surgery: No Scars in Sight

Marc Bessler, MD
Director, Minimal Access Surgery Center
Columbia University Medical Center
In affiliation with NewYork-Presbyterian Hospital

Moving beyond laparoscopic surgery's small incisions, surgeons in Columbia's
Department of Surgery are committed to improving surgical techniques even further.

The wave of the future, according to
Marc Bessler, MD, Director of the Minimal
Access Surgery Center at Columbia University Medical Center, holds the promise of
surgery that leaves no visible trace at all. Dr. Bessler and colleagues are using, testing,
and refining three new methods of performing surgery that leave no external scars on
the body.


Endolumenal surgery is performed by inserting fine instruments through a natural orifice such as the mouth.

This approach is currently being used to prevent acid reflux by inserting a tube into the mouth and esophagus and creating a valve at the point where the esophagus meets the
stomach. The procedure may provide an important alternative to medication for the 30 million Americans with chronic, progressive reflux disease.

In endolumenal weight loss surgery, surgical instrumentation is advanced through the mouth into the stomach, where it is used to staple or suture a stomach pouch from the
inside. The stomach pouch limits food intake in a similar fashion to the gastroplasty or banding procedures, but without any incisions in the abdomen or leaving a device in
place. In addition to esophageal and weight loss procedures, endolumenal surgery is being used to remove small tumors or polyps from the stomach.


Natural orifice endoscopic translumenal surgery, or NOTES, entails the use of fine instrumentation advanced through a natural orifice such as the mouth, vagina, or rectum.
In this approach, once the instrumentation is in place, an incision is made through an internal organ in order to access the abdominal cavity and perform the surgery. This
approach may be used for operations such as:

  • gallbladder removal through an incision in the vaginal wall;
  • appendix operations performed through the vaginal wall;
  • intestinal biopsies, or removal of parts of the intestine, performed with instrumentation advanced through the rectum; and
  • removal of lesions in the colon, also via the rectum.

Operations through incisions in the stomach may also be performed in the future, but this approach carries risk of leakage if the stomach incision does not heal well. The
vaginal approach does not present this risk, explains Dr. Bessler. Surgeons at Columbia have been able to ensure safety and perform the procedure with no skin incisions.


Transumbilical surgery, also called 'single incision surgery,' involves the use of one small incision in the belly button. With three or four instruments advanced through that
single incision, Dr. Bessler and colleagues can do the following
  • remove the gallbladder;
  • insert or remove adjustable gastric bands for weight loss;
  • perform sleeve gastrectomy for weight loss;
  • remove the appendix;
  • correct hernias; and
  • surgically treat gastroesophageal reflux.

As with the procedures discussed above, this approach provides a minimally invasive alternative with excellent access to the abdominal organs and little or no visible scar.

Evolution from standard laparoscopy to surgery with no external scars depends on refinement of the miniature surgical and imaging tools that surgeons use in this approach,
and the training of surgeons in the use of these new methods. At this time, select surgeons in the Department of Surgery are offering scarless procedures to patients as part of
clinical studies and limited protocols. Overall, patients are recovering very quickly and very well, reports Dr. Bessler. "Since laparoscopic surgery requires three to five
incisions, these scarless approaches will make surgery even easier for patients," he states, adding, "So far most patients have been very pleased with the results."
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