Abdominal surgery without any scars - the speciality of Prof. Dr Dirk Bulian

Witten/Herdecke University (UW/H) has appointed PD Dr Dirk Bulian as an adjunct professor for his sustained achievements in teaching and research. Bulian is head of the "Minimally Invasive Surgery (MIS) and NOTES" department at Merheim Hospital, Witten/Herdecke University Hospital. He specialises in operations on abdominal organs such as the gallbladder, stomach and intestines - without any scars thanks to the NOTES technique. The abbreviation stands for Natural Orifice Transluminal Endoscopic Surgery. The special feature of this procedure is that natural orifices such as the mouth, anus or vagina are used to access the diseased organ. While open surgery leaves significant scars and the traditional keyhole technique leaves smaller scars - mainly due to the necessary incision for the organs or parts of organs to be removed - there is no corresponding injury to the abdominal wall with NOTES.

New surgical technique scientifically monitored

Prof Bulian was one of the first surgeons in Germany to master this technique and used it for the first time at the Cologne City Clinics in 2008. Since then, he has provided scientific support for this method, lectured on it and written numerous publications on it. "At the beginning of this new surgical technique, the focus was on whether the method would lead to better results for patients. For example, a lower risk and less pain or simply a better quality of life. Later, for example, I looked at whether NOTES also has advantages for patients who are very overweight or whether pregnancy is possible afterwards without any problems," Bulian lists some of the topics of his studies.

In collaboration with other doctors and the German Society for General and Visceral Surgery (DGAV), he established a register for these procedures from 2008 and analysed the data from it: "We wanted to critically monitor the new surgical technique and identify complications at an early stage, such as those that occurred when laparoscopic surgery was introduced in the 1980s, some of which had catastrophic consequences for patients," he explains the initiative. Using the data collected, he was able to analyse the results in a 2016 study (Bulian DR, Kaehler G, Magdeburg R, et al. Analysis of the First 217 Appendectomies of the German NOTES Registry. Ann Surg 2016.) that there is a very low risk associated with so-called image bowel resection using the NOTES technique. In 2016, he was also awarded the Felicién Steichen Prize by the German Society of Surgery (DGCH) for a comparative study he conducted in Cologne on gallbladder removal using the NOTES technique: His study showed that gallbladder removal via natural access routes resulted in just as few complications as traditional endoscopic surgery; however, the patients experienced significantly less pain and felt demonstrably better.

Current studies on corona and inguinal hernia

In addition to working on the NOTES topic, Prof Bulian and his team are supporting many studies with their experience and patient data. During the coronavirus pandemic, Cologne was one of almost 1,700 clinics from 116 countries that joined the Global Surg initiative. "Worldwide, it was found that even with smaller, plannable operations such as a hernia, poorer outcomes and even deaths occurred after recovery from COVID-19. Using the global data, a new guideline has been developed which now recommends that surgery should only be performed seven weeks after recovery from a coronavirus infection." Bulian is currently involved in a registry that deals with the treatment of the open abdomen after serious injuries and complicated inflammations in the abdominal cavity. This year, the renowned "British Journal of Surgery" published the results and honoured them with an award.

Commitment to the study of medicine in Witten

"The students in Witten are much more committed and independent than I have experienced at other universities," says Bulian about the UW/H. And he should know. And he should know: From the admission procedures for applicants to working as a tutor in Witten's typical "problem-based learning" programme, teaching in the clinical study section and the final examination in the last state examination, he actively accompanies the medical studies. "I think problem-based learning is particularly important because the students learn much earlier than usual which decisions and further diagnoses are expedient in everyday medical practice. And that they learn to work these out largely independently," he says.

Links to the studies:

• DOI: 10.1097/SLA.0000000000001742 (study on so-called appendectomies via NOTES; register analysis)
• DOI: 10.1097/SLA.0000000000000218 (Cologne study on gallbladder operations via NOTES)
• DOI: 10.1093/bjs/znad163 (Study on the treatment of the open abdomen)