Surgical pilgrimage – The need to avoid navigation through drains, medicine or ‘medisin’: Our notes on NOTES

Abstract

Mr. G. Buess and Sir A. Cuschieri must be congratulated for initiating the debate on natural-orifice transluminal endoscopic surgery (NOTES) [1]. To do so in the absence of any dissent to NOTES is not only commendable but the fulfillment of a role befitting them. While attending the World Congress 2006, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conference 2007, and the European Association for Endoscopic Surgery (EAES) conference 2007, I heard the outlandish propositions about NOTES and wondered if I was intellectually handicapped in not appreciating them in totality. Coming from the developing world, and having a perception of my own anonymity, I could not muster the courage to speak against or question the rationale of transgastric or transcolonic procedures. This is why I felt reassured and proud of whistleblowers like Buess and Cuschieri. It is well established that health intervention should be both effective and safe [2]. Even the word ‘‘safe’’ has to be used with caution while evaluating surgical techniques [2]. Endoscopic surgery has seduced the surgeon as well as society. Its appeal has been maintained by an endeavor to ethically duplicate the wisdom of the accumulated experience of the conventional surgery era [3]. As noted by the authors [1] the surgical breach in gastrointestinal continuity is absurd, unless part of the intended surgical benefit. It is astonishingly inhumane to be even reading things like transvesical thoracoscopy [4] and wondering for the helpless poor animals being wasted, more so in such nonsurvival models. These self-professed heroes have deviated from the basic tenet of our profession: primum non nocere (first, do no harm). Many a time they flaunt supporting statistical data. While statistical support may be an important tool in scientific pursuit it cannot be a substitute for humane clinical decision-making in surgery [5]. While endoluminal procedures, as noted by the authors [1], are a legitimate progress, the nomenclature of NOTES seems a veil to cover unholy transgression of surgical ethics and human dignity. The human body is sacred, while operating, a surgeon is akin to being on holy pilgrimage and you do not navigate through drains while on a pilgrimage. The society respects us and expects a reciprocal respect. In this era of easy access to information no amount of statistical evidence will be able to stand scrutiny in the event of unforeseen complications from a gastric, colonic or vesical leak. Any such leak is a surgeon’s nightmare even in well intended and necessary procedures. To say this will not happen is being dishonest. Things can go wrong when least expected and there is a probability even for the improbable [6]. Surely times are both challenging and exciting. Case volumes and reimbursements might be decreasing [7], forcing upon us the need to be seen as innovators. The lure B. B. Agarwal Journal of International Medical Sciences Academy, New Delhi, India