Transvaginal cholecystectomy, Transaxillary thyroidectomy, Transoral thyroidectomy are in vogue currently. It has been possible because of advances in instrumentation. Surgeons have exploited their skills in the application of such instruments and are advocating various endoscopic procedures. Having gone through training and imparting surgical training in medical school for nearly 40 years, made me to analyze and think the authenticity and ethical application of such procedures. The surgical procedures are aimed towards the safety first and cosmesis later. The proponents of such procedures always have highlighted the cosmetic aspects of the procedure. The surgical procedures performed should be evidence based and should pass through the standards of surgical technique. The quoted procedures only have limited series and lack multicenter trials to prove its universal acceptability.The reported series hardly mentions about ethical clearance and long term consequences. Even the surgeons are silent about training the young surgeons to tackle the complications arising out of procedures being advocated [1]. This is the status when it is being practiced in select high volume centers. What will be situation when it is being performed frequently and by a majority of surgeons who may not be well trained and skillful? Mere statements that analgesics required are less may not carry much significance since no data is available in this regard. My concerns are following:

Will it be cost effective?

1.  What will be the learning curve for trainees?
2. How the learners will gain confidence in conventional procedures?
3. What will be the long term effects of such procedures in the event of diseases like malignancy at these sites and how the surgeons,proposing the techniques will address such situation?
4. Will it not be a breach in integrity of natural parts?
5. Will it be ethical?
6. Is the most important issue for any surgical procedure is always cosmesis and pain?

Transoral thyroidectomy has issues like Mental nerve damage, long operating time, Infections, manipulation of equipment through narrow space, large area of soft tissue tear, leakage from thyroid lesions and malfunction of the muscles of expression [2].

It has been quoted with reference to trans-vaginal cholecystectomy that the limitations in the studies need scientific and educational efforts to prove the safety and efficacy. Well designed randomized control trial with large samples need to be done for a reasonable decision. Further, the data on superiority of trans-vaginal cholecystectomy over conventional laparoscopic cholecystectomy is inconsistent and needs strict evaluation including long term effect on vagina [3]. Further the procedure is skill imparting, challenging and has a increased conversion [4].

These techniques need the right surgeon for the right patient and probably cannot be universally advocated based on technical advances and industry driven rather should have an ethical and practical approach.

1. Nitta K, Ishikawa N, Kawaguchi M, Ooi A, Watanabe G. Thyroidectomy using purenatural orifice transluminal endoscopic surgery in a porcine model. Artif Organs. 2015May;39(5):441-445.
2. Yang K, Ding B, Lin C, Li W, Li X. The Novel Transvestibule Approach for EndoscopicThyroidectomy: A Case Series. SurgLaparosc EndoscPercutan Tech.2016 Feb;26(1):e25–e28.
3. Xu B, Bo Xu, Zheng WY, Ge HY, Wang LW, et al. Transvaginal cholecystectomy vsconventional laparoscopic cholecystectomy for gall bladder disease: A meta-analysis.World J Gastroenterol. 2015 May;21(17):5393–5406.
4. Kiong KL, Iyer NG, Skanthakumar T, Ng JC, Tan NC, et al. Transaxillary thyroidectomies: Acomparative learning experience of robotic vs endoscopic thyroidectomies. OtolaryngolHead Neck Surg. 2015 May;152(5):820-826.