No one really wants to know if taking out an inflamed appendix using an endoscope passed through the mouth, esophagus, and stomach is a safe operation. But some German surgeons have published another paper on the subject.

Their first paper, which I critiqued in 2013, was what is known as a pilot study—kind of a “let’s see if this works at all” before doing more formal research. In that one, 15 patients underwent transgastric appendectomy with five significant complications.

Undaunted, the investigators pressed on. The current paper, published ahead of print in the journal Surgery, is a nonrandomized comparison of standard 3-port laparoscopic appendectomy to hybrid transgastric appendectomy. The procedure is called “hybrid” because a small abdominal wall incision must be used to insert an instrument to facilitate visualization and ligation of the appendix.

From October 2010 to May 2013, the investigators screened 273 patients with appendicitis and after patient refusals and exclusions for various criteria, transgastric appendectomy was offered to 65 patients. Of that group, 30 agreed to undergo the NOTES procedure, and 35 opted for standard laparoscopic appendectomy.

The groups were similar in age, sex, and body mass index. The duration of surgery for the NOTES patients was 94.5 minutes compared to 69 minutes for the laparoscopic cohort, a statistically significant difference. The duration for both procedures far exceeds the norm of 20 to 40 minutes for a laparoscopic appendectomy in the US.

NOTES patients did not tolerate a regular diet until postoperative day 2 vs. day 1 for the standard patients, a statistically significant difference. Although the median length of postoperative stay after surgery was 3 days for both groups, which is typical in Europe, the paper says the NOTES patients stayed in the hospital significantly longer.

Complications occurred in three NOTES patients, two of whom required laparoscopic reoperations and one had shoulder pain. Two standard laparoscopy patients had minor complications—an unexplained rise in inflammatory marker blood tests and a wound infection. Overall, postoperative quality of life scores were similar.

The authors concluded their study showed transgastric appendectomy was feasible, but it offered no advantages to laparoscopic appendectomy.

Because there were so few subjects, the conclusion may suffer from a type II error; that is, it was too small to say there was truly no difference in any parameter.

The concept of natural orifice transluminal endoscopic surgery or NOTES was first described by Kalloo et al in 2004. Since that time, the technique has been investigated by several researchers who have shown that it is possible to remove the appendix via the stomach or through the vagina.

However, enthusiasm for it is waning. A PubMed search for “transgastric AND appendectomy” yielded 41 hits with only two original papers on the subject in the last five years. Both are from the Heidelberg group as discussed in this post.

The German NOTES registry was established in March 2008 as an outcomes database. According to a recent paper in Annals of Surgery, 36 transgastric appendectomies were done as of the end of October 2015 for an average of about 5 cases per year over that 7½ year period.

In 2014, just under 146,000 appendectomies were performed in Germany, so at 5 per year, transgastric appendectomies represent about 0.003% of all such cases

As I said when I blogged about the 2013 paper from the Heidelberg group, “Just because you can do something doesn’t mean you should.”

To that I would add, “Dieser chirurgie ist tot.” [This surgery is dead.]


Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.