upturned belly glows from within, as if red hot, while
shadows crisscross furtively beneath the skin. “There’s
your scope,” one surgeon says to another, gesturing
toward a video monitor tracking the progress of this
intra-abdominal game of hide-and-seek.
There are two scopes in this pig’s belly—one
a fixed-tube laparoscope peering in through a tiny
incision cut into the lower abdomen, the other a flexible
endoscope which has entered the animal’s body
through its open mouth and then snaked its way into
its upper abdomen.
The writhing black endoscope is operated by Sergey
Kantsevoy, one of the driving trailblazers in a radical
new idea. His journey into the peritoneal cavity is
being watched intently through Michael Marohn’s
more rigid laparoscope. The heads of both scopes, which
employ their own video probes and monitors, will momentarily
greet each other face-to-face, so to speak, without
any abdominal tissue coming between them. This will
be a rare medical moment in its own right, but not
the main reason for the attention paid by 11 other
GI colleagues who check in throughout the day. They
are waiting to hear if this procedure will achieve
a key threshold in the maddening conundrum that has
eluded them for more than five years.
For these GI surgeons, this is pig number 49 in an
accelerating quest to see if they can use the flexible
endoscope to enter the body through a natural orifice
such as the mouth and then penetrate the outer boundary
of the intestinal tissues—the gastric wall within
the abdomen. Once there, they hope to operate, withdraw
from the surgical site and—of overwhelming importance
in today’s experiment—make an airtight
seal over the hole so no bacteria can seep through.
They then will slip the scope back out without leaving
a trace that they were ever there. If their big idea
works, they believe it could usher in a new, more ideal
kind of GI surgery. Rather than slicing into a patient’s
abdomen from the outside to reach damaged organs, surgeons
would enter the body without a single cut through the
skin or muscle.
But a fundamental question remains: Beyond the obvious
cosmetic value, what’s the point?
|> SCOPE MEETS SCOPE: To observe the experiment, a laparoscopic surgeon captured live video of the endoscope’s progress. Each instrument had its own monitor—endoscopic image on the left; laparoscopic on the right.
The fact is, from the day surgeons first began cutting
into the human body to make repairs, they have struggled
with the consequences of slicing through skin and muscle
and sawing through bone to gain access to internal
organs. These large “open” operations place
a heavy burden on human systems, disrupting organs,
creating new pathways for infection and demanding long
Twenty-five years ago, a solution seemed at last to
be at hand with the introduction of the laparoscope.
This new elongated tool, guided by a camera on its
tip and images on a nearby monitor, required but a
few tiny incisions in the skin as it maneuvered toward
tissue targets. Its minimally invasive procedures made
for quicker healing times and fewer obstacles. Patients
warmed to their smaller scars.
Over the next few decades, gastroenterologists made
great headway, first with the laparoscope and later
with the new flexible endoscope. This second amazing
tool required no incisions at all. It simply entered
the body through the mouth and then cleverly wound
its way into the esophagus, stomach, intestines and
colon, where specialists became adept at examining,
snipping, rearranging, suturing and excising unwanted
Now, only one seemingly impenetrable barrier remained
for the endoscope to be able to reach every part of
a GI surgeon’s realm: Organs like the appendix,
gallbladder, liver, uterus and ovaries lie beyond the
gastric wall. Perforating that border would mean crossing
an area crawling with bacteria—an open invitation
to infecting nearby sterile organs. In laparoscopic
and open procedures, surgeons carefully maneuver around
the gastric wall to avoid such risks, but the flexible
endoscope would need to breach that wall to reach the
organs behind it. To most, that seemed like an open
invitation to a deadly case of peritonitis.
Still, by 1997, one prominent endoscopist had started
thinking seriously about tackling even this challenge.
Early that year, Tony Kalloo, a rising star in gastroenterology
who’d just become Hopkins’ director of
endoscopy, accepted an invitation to speak at an annual
meeting in San Francisco. As he ruminated about his
presentation, Kalloo began thinking out of the box.
By the time he took the podium, he had prepared an
elaborate series of slides outlining a notion by which
GI surgeons would operate without any external cutting
at all. They would enter the body through a natural
orifice and wind their way to the gastric wall, penetrate
it and manage all the sterility issues.
If laparoscopists could now take out gallbladders
and return patients to work up to three days later,
Kalloo’s thinking went, performing those same
operations with the endoscope through the body’s
natural openings would make for scar-free appendectomies,
easier gallbladder removals, smarter gastric bypasses,
smoother tubal ligations—all with even shorter
recoveries, less pain and no external scarring whatsoever.
The audience listened politely. Then a few chuckles
erupted. What was Tony Kalloo thinking?
From the video monitor for Michael Marohn’s
laparoscope, the glowing head of Sergey Kantsevoy’s
endoscope can be seen behind a diaphanous layer of
tissue. “See the bubbles?” Marohn asks
with a certain urgency. “Sergey, look at my monitor
a second. That’s your probe, right there.”
Kantsevoy’s face is a study in concentration
as his enormous gloved hands expertly manipulate a
cluster of knobs at the probe’s base to guide
its tip through the complex web of tissues. In the
darkness beyond the surgical lights, an observing surgical
fellow mimics his hand motions, like a shadow-boxer.
Then the unveiling: The head of Kantsevoy’s
squirming endoscope pops into the open just below the
lower stomach wall, naked under the spotlight of Marohn’s
video probe. Seemingly of its own accord, the endoscope’s
head pirouettes in three dimensions, unsheathing its
glistening forceps and scalpel in a boastful display
that heralds an entirely new frontier of medical
“So this is scope meets scope—laparoscopy
meets endoscopy,” Marohn says as he observes
Kantsevoy’s end-zone dance. For laparoscopic
surgeon Marohn, the arrival of this new contestant
on his traditional playing field might, at first blush,
portend a turf war. But the spirit of discovery is
contagious in its own way, and Marohn is happy to bring
his skill set to the chase. This occasion could also
capture a pivotal solution to one more obstacle in
Kalloo and his fellow researchers are all too aware
that it won’t be enough to show that they can
enter the extra-abdominal cavities and perform marvelously
sterile procedures. They must also come up with a way
to patch the hole in the transgastric wall so that
it’s airtight. There can be no leaks. The abdominal
wall is notoriously tough territory. Common sutures
and clips have proven unreliable.
This last major hurdle has dogged these surgical researchers
through hundreds of tries. Now, experimental technology
that has been assembled in a briefcase-size console
tucked just behind Kantsevoy could solve the problem.
Kantsevoy and another endoscopist test the new device
in preparation for deployment. When they maneuver the
tip of their endoscope closer to the hole they’ve
made in the gastric wall, a robotic female voice emanates
from the aluminum control box behind them: “In
The consulting bioengineer cranes his head and intones, “This
VISIONARY: Trailblazing endoscopist
Tony Kalloo first proposed the new
form of surgery.
When Tony Kalloo recruited Sergey Kantsevoy to work
with him in 1997, it was a calculated pairing. Kalloo,
who graduated from medical school in his native Trinidad
in 1979, had narrowed his interests to the specialty
of gastroenterology during residency and fellowship
training at Howard University and Georgetown. Endoscopic
surgery was just taking off during those years, and
a mentor helped him quickly master the new technology.
But for all of Kalloo’s skill with the endoscope,
he never kidded himself about whether that instrument
could handle heavy surgery: Whenever he detected a
trace of disease in an abdominal cavity beyond the
gastric wall, Kalloo always asked a trained GI surgeon
to step in.
And so, as he embarked on his bold transgastric idea,
Kalloo knew he needed a GI partner with cutting smarts.
With Kantsevoy, he would have just the man—a
hard-working Russian émigré who’d
trained in Gorky as a surgeon but migrated into gastroenterology
soon after coming to America in 1992. In 1997, when
Kantsevoy came to Hopkins in search of a GI fellowship,
he closed out his “three-minute interview” with
Tony Kalloo by making a pledge: “You will not
One of the pair’s first major hurdles came in
the form of chilly objections from an industry partner
that Kalloo had sought as a funding source. Olympus
Optical, the cautious Japanese maker of cutting-edge
endoscopic equipment, threatened to withdraw from its
relationship with Kalloo if he persisted on this “drastic” and “impossible” transgastric
course. Even after Kalloo had shared promising results
from early experiments at an international presentation
in 1999, Olympus maintained its opposition. To fund
his studies for the first years, Kalloo would rely
solely on his division’s research budget.
Medically, Kalloo’s first great obstacle was
to preserve sterility throughout the abdominal region.
Early experiments soon hit on a successful answer:
flushing the stomach with an antibiotic solution before
perforating the gastric wall. Word of that breakthrough
won a small cult of believers for the new GI approach.
Dozens in the United States and overseas joined the
Few of these early experiments in animals saw publication.
Finally, though, in 2004, Kalloo, Kantsevoy and other
key associates published a seminal study in Gastrointestinal
Endoscopy proposing endoscopic transgastric surgery
as “a new approach to diagnostic and therapeutic
Within months, Kalloo learned that a GI specialist
in India had begun experimenting with the new endoscopic
procedures on humans. The following year, that surgeon
came to an international gathering of endoscopists
and announced that he’d performed 20 successful
appendectomies and a handful of tubal ligations using
the transgastric technique—all, reportedly, with
no incidents of infection.
With momentum building, Kalloo joined a coalition
of select scientists who shared the vision. They named
their approach “natural orifice translumenal
endoscopic surgery,” or NOTES, and they dubbed
their group the Natural Orifice Surgery Consortium
for Assessment and Research, or NOSCAR. The researchers
trademarked the term and set up a Web site, www.noscar.org,
that would act as a clearinghouse for the latest developments.
Today, what stands out on the site is the fact that
Olympus has done a 180-degree turnabout: A prominent
item proclaims that the firm is offering a $500,000
grant to innovators in the field. So far, the funding
dollars have attracted 84 applications from around
And yet many prominent surgeons remain doubtful that
GI operations can ever truly be safe without external
cuts. “It’s fraught with dangers,” one
eminent member of the profession proclaimed in a recent
commentary to the BBC. “There are more dangers
going through the stomach lining than doing laparoscopy.” Another
highly regarded specialist, meanwhile, opined in the
same report: “You would have to seal up the hole
you’ve made in the stomach as you come out and
then make sure that hole doesn’t leak.”
Ah, yes: The hole, transgastric surgery’s last
“In firing range” warns the robotic voice,
as Sergey Kantsevoy homes in on the perforation he
has made into the digestive tract of pig 49. Kantsevoy
withdraws his scope and moves it closer to the perforated
tissue again, prompting the voice to repeat, “in
The bioengineering consultant standing at Kantsevoy’s
side guides him and his colleagues in the maiden deployment
of this very space-age endoscopic suturing device,
which at this moment is extending its experimental
probe. As Kantsevoy and an associate endoscopist, Samuel
Giday, delicately coordinate the approach, Kantsevoy
maneuvers the endoscope’s position. Giday, meanwhile,
manipulates the scope’s forceps and the prototype
stapling device that extends from its head. It is the
staple gun they will use to seal off the hole made
by the endoscope in the pig’s stomach.
PARTNER:Sergey Kantsevoy brought the
combined specialties of surgery and
endoscopy to the experiments.
Kantsevoy and Giday gather in a clump of the perforated
tissue, looking for a suture line. Laparoscopist Marohn
advises. “You need a bigger bite,” he says. “Take
a bigger bite.” Then, with the tissue gathered
up just so, Giday hits the stapler’s trigger.
In both video monitors, a sparkle of light flashes
across the targeted tissue. In the blink of an eye,
a series of titanium sutures has instantly deployed
across the 6-centimeter expanse of gastric tissue, “like
magic,” says Kantsevoy.
The seal looks good through the monitors, but will
The physicians deliberate as one laparoscopic master
weighs in with a voice of optimism. “This has
promise,” Mike Marohn says.
There are days when Tony Kalloo pauses and catches
his breath. Like today, amid a schedule crammed with
meetings and patient consults, when his assistant hands
him the sheets of slides from his bold presentation
in San Francisco 10 years ago. Suddenly, a curiously
boyish awe steals across his face. He raises the slides
over his head to study them, leaning back in his office
chair, drifting off into an unselfconscious silence. “For
gosh sakes,” he finally whispers, seemingly to
himself. It’s the first time he’s looked
at them in years, and they bring back memories.
“It aroused such a flood of emotion,” he
says, remembering the crowd of skeptics who challenged
his idea that GI surgery might someday start with an
endoscope being slid down a patient’s mouth.
He recalls appealing to his colleagues, “Allow
us to get this into the lab.”
Looking back now, the determined GI director becomes
philosophical about all that’s happened since
then. All the resistance to his proposal, he says,
was just part of the natural to and fro of modern science. “It’s
like running a marathon. It’s kind of painful
along the way but in the end you know you’re
going to be done.”
Ramsey Flynn is the magazine's