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| | {{Natural orifice translumenal endoscopic surgery (NOTES)}} |
| '''For the WikiPatient page for this topic, click [[Natural orifice translumenal endoscopic surgery (NOTES) (patient information)|here]]''' | | '''For the WikiPatient page for this topic, click [[Natural orifice translumenal endoscopic surgery (NOTES) (patient information)|here]]''' |
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| '''Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org] | | '''Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:moh_sbeih@hotmail.com]Phone: 617-849-2629; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu] |
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| '''Related Key Words and Synonyms:''' Natural orifice translumenal endoscopic surgery, single incision laparoscopic surgery, minimally invasive surgery, transanal endoscopic microsurgery, Natural orifice surgery consortium for assessment and research. | | '''''Synonyms and keywords:''''' Natural orifice translumenal endoscopic surgery, Single incision laparoscopic surgery, Minimally invasive surgery, Transanal endoscopic microsurgery, Natural orifice surgery consortium for assessment and research, Society of american gastrointestinal and endoscopic surgeons. |
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) overview|Overview]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) overview|Overview]]== |
| [[Natural orifice translumenal endoscopic surgery (NOTES)]] is an experimental surgical technique whereby "scarless" abdominal operations can be performed. The surgeon accesses the peritoneal cavity or the thoracic cavity via a hollow viscus and performs diagnostic or therapeutic procedures. NOTES involves passing surgical instruments and a tiny camera through a natural orifice (mouth, urethra, anus, etc.), then the procedure can be performed through an internal incision in the stomach, vagina, bladder or colon, thus avoiding scars and external incisions through the skin, muscles, and nerves. The patients recover more quickly and experience less pain with better cosmetic results. The postoperative complications such as wound infections and hernias are significantly reduced.
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| Animal models and cadavers have been used to demonstrate the possible applications of NOTES, including abdominal cavity screening, abdominal organs biopsy, appendectomy, cholecystectomy, tubal ligation, gastrojejunostomy, partial hysterectomy, oophorectomy, colorectal resection and trans-esophageal myotomy.
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| NOTES describes going beyond the margins of a lumen (hollow organ). The word translumenal could be spelled as "transluminal". Analogies are found with nomen, foramen or abdomen which build the corresponding adjective form with an "i" (nominal, foraminal, abdominal) instead of "e".
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) historical perspective|Historical Perspective]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) historical perspective|Historical Perspective]]== |
| *In 1901, Dimitri Ott from Russia performed transvaginal inspection of the peritoneal cavity. In the same year, the first experimental laparoscopy reported by Georg Kelling (a German Surgeon), he initially used a cystoscope to insufflate and explore the abdominal cavity of a dog <ref>Litynski GS (1999) Endoscopic surgery: the history, the pioneers. World J Surg 23: 745-753</ref>.
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| *In 1940s, the first natural orifice procedure has been mentioned. Culdoscopies were performed using an endoscope passed through the recto-uterine pouch to view pelvic organs <ref>Halim I, Tavakkolizadeh A. NOTES: The next surgical revolution? Int J Surg 2008; 6: 273-276</ref>.
| | ==[[Natural orifice translumenal endoscopic surgery (NOTES) experimental evolution|Experimental Evolution]]== |
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| *[[Laparoscopic surgery]] innovation was introduced in the late 1980s, and the minimally invasive surgery started spreading worldwide in 1987, when the first laparoscopic cholecystectomy reported by Dr. Philippe Mouret Spaner (a French gynecologist) <ref>Mouret P (1991) From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery: the future perspectives. Dig Surg 8: 1124-1125</ref><ref>SJ, Warnock GL. A brief history of endoscopy, laparoscopy, and laparoscopic surgery. J Laparoendosc Adv Surg Tech A 1997; 7: 369-373 </ref>.
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| *In 1990, a multicenter team of investigators (the Apollo Group) used the term flexible transluminal endoscopy before the NOTES concept was coined <ref name="pmid17640587">{{cite journal |author=Pasricha PJ |title=NOTES: a gastroenterologist's perspective |journal=Gastrointest. Endosc. Clin. N. Am. |volume=17 |issue=3 |pages=611–6, viii–ix |year=2007 |month=July |pmid=17640587 |doi=10.1016/j.giec.2007.05.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S1052-5157(07)00037-2 |accessdate=2012-02-16}}</ref>.
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| *In 2002, Gettman et al published a transvaginal nephrectomy in a porcine model <ref>Gettman MT, Lotan Y, Napper CA, Cadeddu JA. Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model. Urology 2002; 59: 446-450</ref>.
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| *The first reported human transgastric endoscopic appendectomy was in India in 2003 by Dr. G.V. Rao and Dr. N. Reddy <ref>Rao GV, Reddy DN. Transgastric appendectomy in humans. Montreal: World Congress of Gastroenterology, 2006</ref>.
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| *NOTES was originally described in animals by researchers at Johns Hopkins University. Dr. Anthony Kalloo published the first report of a true transluminal procedure in 2004 , which was a transgastric peritoneoscopy in a porcine model <ref>Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest
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| Endosc 2004; 60: 114-117</ref><ref name="pmid15229442">{{cite journal |author=Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV |title=Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity |journal=[[Gastrointest. Endosc.]] |volume=60 |issue=1 |pages=114–7 |year=2004 |month=July |pmid=15229442 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704013094 |accessdate=2012-02-16}}</ref>.
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| *Senior leadership from the [[American Society for Gastrointestinal Endoscopy]] (ASGE) and the [[Society of American Gastrointestinal and Endoscopic Surgeons]] (SAGES) organized a working group of surgeons and gastroenterologists in 2005 to develop standards for the practice of NOTES. This group is known as the [[Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)]] <ref name="pmid16402290">{{cite journal |author=Rattner D, Kalloo A |title=ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005 |journal=Surg Endosc |volume=20 |issue=2 |pages=329–33 |year=2006 |month=February |pmid=16402290 |doi=10.1007/s00464-005-3006-0 |url=http://dx.doi.org/10.1007/s00464-005-3006-0 |accessdate=2012-02-22}}</ref><ref>[http://www.noscar.org/faq.php Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)<!-- Bot generated title -->]</ref>.
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| *The first international conference on NOTES was held in Scottsdale, Arizona March 9-11, 2006. One hundred forty physicians from 11 countries met to develop a detailed roadmap for overcoming the technical barriers of NOTES that had been identified in the original White Paper of NOSCAR.
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| *EURO-NOTES Foundation, established in 2006 in cooperation between European Asociation for Endoscopic Surgery (EAES) and the European Society of Gastrointestinal Endoscopy (ESGE) to focus on all activities regarding Natural Orifice Transluminal Endoscopic Surgery (NOTES). The first meeting was in June 23, 2006 in Berlin/Germany.
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| *Japan launched the JWNOTES (Japan Working group for NOTES) in 2007.
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| *Radical sigmoidectomy using a pure NOTES transanal approach was first described in 3 human cadavers in 2007 by Whiteford et al who used TEM as an endoscopic platform without the need for any abdominal incisions <ref name="pmid17705068">{{cite journal |author=Whiteford MH, Denk PM, Swanström LL |title=Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery |journal=Surg Endosc |volume=21 |issue=10 |pages=1870–4 |year=2007 |month=October |pmid=17705068 |doi=10.1007/s00464-007-9552-x |url=http://dx.doi.org/10.1007/s00464-007-9552-x |accessdate=2012-02-15}}</ref>.
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| *In 2007, the first transvaginal laparoscopically assisted cholecystectomy in the United States was formally operated by Marc Bessler (US team)<ref>Bessler M, Stevens PD, Milone L, Parikh M, Fowler D. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 2007; 66: 1243-1245</ref>, and the first transgastric cholecystectomy in the United States was performed by Lee Swanstrom (US team) <ref>USGImedical. (2007, Jun). USGI announces first NOTES transgastric
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| cholecystectomy procedures [Online]. Available: http://www.usgimedical.com/pr_transgastric_cholecystectomy.html</ref>, and J. Marescaux (French team) <ref>Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 2007; 142: 823-826; discussion 823-826</ref>.
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| *The first published human NOTES procedure was by Marks et al<ref>Marks JM, Ponsky JL, Pearl JP, McGee MF. PEG "Rescue": a
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| practical NOTES technique. Surg Endosc 2007; 21: 816-819</ref> who performed a transgastric rescue of a prematurely dislodge gastrostomy tube in 2007.
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| *In early March 2007, the NOTES Research Group in Rio de Janeiro/Brazil, led by Dr. Ricardo Zorron, performed the first series of transvaginal NOTES cholecystectomy in four patients, based in previous experimental studies. The first human transvaginal endoscopic cholecystectomy case was reported in 2007 <ref name="pmid17875836">{{cite journal |author=Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D |title=Surgery without scars: report of transluminal cholecystectomy in a human being |journal=Arch Surg |volume=142 |issue=9 |pages=823–6; discussion 826–7 |year=2007 |month=September |pmid=17875836 |doi=10.1001/archsurg.142.9.823 |url=http://archsurg.ama-assn.org/cgi/pmidlookup?view=long&pmid=17875836 |accessdate=2012-02-15}}</ref><ref name="pmid17892873">{{cite journal |author=Bessler M, Stevens PD, Milone L, Parikh M, Fowler D |title=Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery |journal=Gastrointest. Endosc. |volume=66 |issue=6 |pages=1243–5 |year=2007 |month=December |pmid=17892873 |doi=10.1016/j.gie.2007.08.017 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(07)02553-9 |accessdate=2012-02-15}}</ref>.
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| *In late March, 2008, Dr. Santiago Horgan became the first US surgeon to perform transgastric appendectomy and remove a patient's appendix through the mouth. He also applied the EndoSurgical Operating System (EOS) on pigs to perform the entire operation through the stomach without laparoscopic assistance or any abdominal incision <ref>Surg Endosc. 2009 July; 23(7): 1512–1518.Published online 2009 April 3. PubMed Central. doi: 10.1007/s00464-009-0428-0</ref>.
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| *In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. The surgery was called transvaginal donor kidney extraction <ref name="InfoNIAC.com">{{cite news | title=Surgeons Remove Healthy Kidney Through Vagina | url=http://www.infoniac.com/health-fitness/remove-healthy-kidney-through-vagina.html | accessdate=2009-02-03 | publisher=InfoNIAC.com}}</ref>.
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| * The first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance was performed at the Hospital Clinic in Barcelona by a team of surgeons from the Hospital Clinic in Barcelona and Massachusetts General Hospital in Boston in November 2009 (Dr. Antonio Lacy and Dr. Patricia Sylla) <ref name="pmid20186432">{{cite journal |author=Sylla P, Rattner DW, Delgado S, Lacy AM |title=NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance |journal=Surg Endosc |volume=24 |issue=5 |pages=1205–10 |year=2010 |month=May |pmid=20186432 |doi=10.1007/s00464-010-0965-6 |url=http://dx.doi.org/10.1007/s00464-010-0965-6 |accessdate=2012-02-15}}</ref>.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) advantages|Advantages Over Current Surgical Techniques]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) advantages|Advantages Over Current Surgical Techniques]]== |
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| Proponents and researchers in this field recognize the potential of this technique to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions. NOTES could be the next major paradigm shift in surgery, just as laparoscopy was the major paradigm shift during the 1980s and 1990s. Potential advantages of NOTES include <ref name="pmid17321258">{{cite journal |author=Swain P |title=A justification for NOTES--natural orifice translumenal endosurgery |journal=Gastrointest. Endosc. |volume=65 |issue=3 |pages=514–6 |year=2007 |month=March |pmid=17321258 |doi=10.1016/j.gie.2006.11.034 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(06)03252-4 |accessdate=2012-02-23}}</ref>:
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| *Faster recovery and shorter hospital stay. NOTES may cause less physiologic insult than laparoscopy or laparotomy, and there are some underway laboratory studies which try to reveal and compare the cytokine levels with NOTES in comparison to laparoscopy or laparotomy procedures. One study on animals reported that the circulating levels of cytokines (IL1, IL6, and TNF-alpha) are similar in NOTES and other approaches immediately after the surgery, but. However, in the later postoperative period, the levels of the cytokines was lower in NOTES procedures compared with the open or laparoscopic approach <ref name="pmid18291252">{{cite journal |author=McGee MF, Schomisch SJ, Marks JM, Delaney CP, Jin J, Williams C, Chak A, Matteson DT, Andrews J, Ponsky JL |title=Late phase TNF-alpha depression in natural orifice translumenal endoscopic surgery (NOTES) peritoneoscopy |journal=Surgery |volume=143 |issue=3 |pages=318–28 |year=2008 |month=March |pmid=18291252 |doi=10.1016/j.surg.2007.09.032 |url=http://linkinghub.elsevier.com/retrieve/pii/S0039-6060(07)00629-0 |accessdate=2012-02-23}}</ref>.
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| *Avoidance of the potential complications of abdominal wound infections. Wound infection is a common surgical complication, with a reprted incidence varies between 2% to 25%, depending on the type of surgery <ref>Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004 Jun 15;38(12):1706–15</ref><ref>DiPiro JT, Martindale RG, Bakst A, Vacani PF, Watson P, Miller MT. Infection in surgical patients: effects on mortality, hospitalization, and postdischarge care. Am J Health Syst Pharm 1998 Apr 15;55(8):777–81</ref>. Eliminating all skin incisions would eliminate the adverse impact of wound infection on the health care costs and patient recovery <ref>Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999 Nov;20(11):725–30</ref>.
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| *Decrease the incidence of incisional hernias and postoperative adhesions. The rates of small intestinal obstruction are lower after laparoscopic surgery compared with open surgery and will perhaps be further decreased with NOTES <ref>Duepree HJ, Senagore AJ, Delaney CP, Fazio VW. Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg 2003 Aug;197(2):177–81</ref>.
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| * Moving the equipment to the patient (portable NOTES instruments) may avoid transporting a patient to the operating room, and thus making some NOTES procedures suited for an intensive care unit.
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| *Requirements for anesthesia are relatively less than other types of surgeries. Some NOTES procedures could be performed under conscious sedation.
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| *Less immunosuppression.
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| *Better postoperative pulmonary and diaphragmatic function.
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| *Better cosmetic results with the potential for "scarless" abdominal surgery.
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| *Advantages in specific subpopulations. NOTES can be performed in morbidly obese patients, in whom traditional access to the peritoneal cavity can be difficult because of abdominal wall thickness, NOTES may provide an easy alternative in these patients.
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| *Theoretical, patients may prefer NOTES procedure over laparoscopic procedure based upon the assumption that it is scarless and less painful. Studies and surveys demonstrated that patients prefer NOTES if it is safe and effective <ref name="pmid18355816">{{cite journal |author=Varadarajulu S, Tamhane A, Drelichman ER |title=Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy |journal=Gastrointest. Endosc. |volume=67 |issue=6 |pages=854–60 |year=2008 |month=May |pmid=18355816 |doi=10.1016/j.gie.2007.09.053 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(07)02840-4 |accessdate=2012-02-23}}</ref>.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) experimental evolution|Experimental Evolution]]==
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| The evolving concept of natural orifice translumenal endoscopic surgery (NOTES) combines the techniques of minimally invasive surgery with flexible endoscopy. In the late 1990s, a multicenter team of investigators (the Apollo Group) developed the concept of flexible transluminal endoscopy (a term used before NOTES) <ref name="pmid17640587">{{cite journal |author=Pasricha PJ |title=NOTES: a gastroenterologist's perspective |journal=Gastrointest. Endosc. Clin. N. Am. |volume=17 |issue=3 |pages=611–6, viii–ix |year=2007 |month=July |pmid=17640587 |doi=10.1016/j.giec.2007.05.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S1052-5157(07)00037-2 |accessdate=2012-02-22}}</ref>. The first published report of a true transluminal procedure in 2004 by Kalloo et al. <ref name="pmid15229442">{{cite journal |author=Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV |title=Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity |journal=[[Gastrointest. Endosc.]] |volume=60 |issue=1 |pages=114–7 |year=2004 |month=July |pmid=15229442 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704013094 |accessdate=2012-02-16}}</ref> showed the possibilities of penetrating the gastric wall and operating in animal model using a perorally introduced flexible endoscope <ref>Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004; 60: 114-117</ref>. The NOTES procedures moved quickly from a concept to human clinical trials based on many preclinical studies, these studies demonstrate that several types of NOTES operations can be performed in survival animal models and human cadavers <ref name="pmid16564875">{{cite journal |author=Merrifield BF, Wagh MS, Thompson CC |title=Peroral transgastric organ resection: a feasibility study in pigs |journal=Gastrointest. Endosc. |volume=63 |issue=4 |pages=693–7 |year=2006 |month=April |pmid=16564875 |doi=10.1016/j.gie.2005.11.043 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(05)03344-4 |accessdate=2012-02-22}}</ref><ref name="pmid17055881">{{cite journal |author=Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Deters JL, Knipschield MA, Hawes RH, Kalloo AN, Pasricha PJ, Chung S, Kantsevoy SV, Cotton PB |title=Pilot study of the porcine uterine horn as an in vivo appendicitis model for development of endoscopic transgastric appendectomy |journal=Gastrointest. Endosc. |volume=64 |issue=5 |pages=808–12 |year=2006 |month=November |pmid=17055881 |doi=10.1016/j.gie.2006.04.038 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(06)01908-0 |accessdate=2012-02-22}}</ref><ref name="pmid16432652">{{cite journal |author=Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN |title=Transgastric endoscopic splenectomy: is it possible? |journal=Surg Endosc |volume=20 |issue=3 |pages=522–5 |year=2006 |month=March |pmid=16432652 |doi=10.1007/s00464-005-0263-x |url=http://dx.doi.org/10.1007/s00464-005-0263-x |accessdate=2012-02-22}}</ref><ref name="pmid16923495">{{cite journal |author=Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC |title=Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video) |journal=Gastrointest. Endosc. |volume=64 |issue=3 |pages=428–34 |year=2006 |month=September |pmid=16923495 |doi=10.1016/j.gie.2006.06.079 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(06)02387-X |accessdate=2012-02-22}}</ref><ref name="pmid16500399">{{cite journal |author=Wagh MS, Merrifield BF, Thompson CC |title=Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model |journal=Gastrointest. Endosc. |volume=63 |issue=3 |pages=473–8 |year=2006 |month=March |pmid=16500399 |doi=10.1016/j.gie.2005.06.045 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(05)02316-3 |accessdate=2012-02-22}}</ref>. Puncturing one of the viscera to perform NOTES procedures leads to many questions regarding the infectious complications and the reliable puncture closure. Many clinical trials tried to answer these questions before proceeding to clinical (NOTES) <ref name="pmid17012148">{{cite journal |author=McGee MF, Rosen MJ, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J |title=A primer on natural orifice transluminal endoscopic surgery: building a new paradigm |journal=Surg Innov |volume=13 |issue=2 |pages=86–93 |year=2006 |month=June |pmid=17012148 |doi=10.1177/1553350606290529 |url=http://sri.sagepub.com/cgi/pmidlookup?view=long&pmid=17012148 |accessdate=2012-02-22}}</ref>.
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| NOTES surgical procedures have been expanded in the last few years to cover a wide range of complex surgical operations, using the right translumenal route, endoscopic platform and the suitable instrumentation. Endoscopic access to the abdominal cavity using transoral (transgastric) route was intensely investigated initially to perform various abdominal procedures over the last few years, these procedures include cholecystectomy <ref>P. O. Park, M. Bergstrom, K. Ikeda, et al., “Experimental studies of transgastric gallbladder surgery: Cholecystectomy and cholecystogastric anastomosis [with video],” Gastrointest Endosc, vol. 61, pp. 601-606, 2005</ref>, appendectomy, splenectomy <ref>S. V. Kantsevoy, B. Hu, S. B. Jagannath, et al., “Transgstric endoscopic splenectomy: Is it possible?” Surg Endosc, vol. 20, pp. 522-525, 2006.</ref>, ligation of fallopian tubes <ref>S. B. Jagannath, S. V. Kantsevoy, C. A. Vaughn, et al., “Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model,” Gastrointest Endosc, vol. 61, pp. 449-453, 2005</ref>, gastrojejunostomy <ref>M. Bergstrom, K. Ikeda, P. Swain, and P. O. Park, “Transgastric anastomosis by using flexible endoscopy in a porcine model [with video],” Gastrointest Endosc, vol. 63, pp. 307-312, 2006</ref>, peritoneal exploration and organ resection <ref>M. S. Wagh, B. F. Merrifield, and C. C. Thompson, “Endoscopic transgastric abdominal exploration and organ resection: intial experience in a porcine model,” Clin Gastroenterol Hepatol, vol. 3, pp. 892-896, 2005</ref>, lymphadenectomy <ref>A. Fritscher-Ravens, C. A. Mosse, K. Ikeda, and P. Swain, ”Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance,” Gastrointest Endosc, vol. 63, pp. 302-306, 2006</ref>, partial hysterectomy <ref>B. F. Merrifield, M. S. Wagh, C. and C. C. Thompson, “Peroral transgastric organ resection: A feasibility study in pigs,” Gastrointest Endosc, vol. 63, pp. 693-697, 2006</ref>, oophorectomy <ref>] M. S. Wagh, B. F. Merrifield and C. C. Thompson, “Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model,” Gastrointest Endosc, vol. 63, pp. 473-478, 2006</ref> and other abdominal procedures. Recently, alternate access routes for NOTES procedures have been investigated such as transvaginal, transesophageal, transcolonic (transanal) and transvesical/transurethral access. The most rapidly evolved experimental studies were transvaginal NOTES procedures, including cholecystectomy <ref name="pmid19474690">{{cite journal |author=Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M |title=Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique |journal=Ann. Surg. |volume=249 |issue=6 |pages=908–12 |year=2009 |month=June |pmid=19474690 |doi=10.1097/SLA.0b013e3181a802e2 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181a802e2 |accessdate=2012-02-21}}</ref><ref name="pmid18027043">{{cite journal |author=Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M |title=NOTES transvaginal cholecystectomy: preliminary clinical application |journal=Surg Endosc |volume=22 |issue=2 |pages=542–7 |year=2008 |month=February |pmid=18027043 |doi=10.1007/s00464-007-9646-5 |url=http://dx.doi.org/10.1007/s00464-007-9646-5 |accessdate=2012-02-21}}</ref>, nephrectomy and appendectomy <ref>Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2009) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES: world’s first report. Surg Endosc 23(3):668</ref>, and the first human case was described in 2007 <ref name="pmid17875836">{{cite journal |author=Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D |title=Surgery without scars: report of transluminal cholecystectomy in a human being |journal=Arch Surg |volume=142 |issue=9 |pages=823–6; discussion 826–7 |year=2007 |month=September |pmid=17875836 |doi=10.1001/archsurg.142.9.823 |url=http://archsurg.ama-assn.org/cgi/pmidlookup?view=long&pmid=17875836 |accessdate=2012-02-21}}</ref><ref name="pmid17892873">{{cite journal |author=Bessler M, Stevens PD, Milone L, Parikh M, Fowler D |title=Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery |journal=Gastrointest. Endosc. |volume=66 |issue=6 |pages=1243–5 |year=2007 |month=December |pmid=17892873 |doi=10.1016/j.gie.2007.08.017 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(07)02553-9 |accessdate=2012-02-21}}</ref>. Cholecystectomy, which is a high volume and relatively simple end organ operation, has been the focus of most early NOTES research studies. Recently, NOTES approach has been extended from the peritoneum to other body compartments, such as transesophageal approaches to the thoracic cavity (mediastinum, heart and lung) <ref name="pmid18294512">{{cite journal |author=Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Chung S, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ |title=Pilot study of transesophageal endoscopic epicardial coagulation by submucosal endoscopy with the mucosal flap safety valve technique (with videos) |journal=Gastrointest. Endosc. |volume=67 |issue=3 |pages=497–501 |year=2008 |month=March |pmid=18294512 |doi=10.1016/j.gie.2007.08.040 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(07)02651-X |accessdate=2012-02-22}}</ref><ref name="pmid17968802">{{cite journal |author=Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P |title=Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures |journal=Endoscopy |volume=39 |issue=10 |pages=870–5 |year=2007 |month=October |pmid=17968802 |doi=10.1055/s-2007-966907 |url=http://www.thieme-connect.com/DOI/DOI?10.1055/s-2007-966907 |accessdate=2012-02-22}}</ref>. Also some recent animal studies have been focused on transgastric intrauterine procedures.
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| NOTES has also inspired the development of new and novel instrumentation and innovative surgical techniques for minimally invasive and endoscopic procedures. Gergard Buess (from Germany) introduced in the 1980s the Transanal Endoscopic Microsurgery (TEM), a natural orifice procedure used for full-thickness resection of rectal tumours followed by closure of the resultant defect by a suture <ref name="pmid3971938">{{cite journal |author=Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier H |title=Endoscopic surgery in the rectum |journal=Endoscopy |volume=17 |issue=1 |pages=31–5 |year=1985 |month=January |pmid=3971938 |doi=10.1055/s-2007-1018451 |url=http://www.thieme-connect.com/DOI/DOI?10.1055/s-2007-1018451 |accessdate=2012-02-21}}</ref>. TEM fulfils most requirements for the ideal NOTES operating platform based on what was published in NOSCAR white paper. TEM provides stable base, suction, irrigation, multiple working ports, pneumoperitoneum maintainance, and the capacity to close the viscotomy <ref name="pmid18984102">{{cite journal |author=Denk PM, Swanström LL, Whiteford MH |title=Transanal endoscopic microsurgical platform for natural orifice surgery |journal=Gastrointest. Endosc. |volume=68 |issue=5 |pages=954–9 |year=2008 |month=November |pmid=18984102 |doi=10.1016/j.gie.2008.03.1115 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(08)01605-2 |accessdate=2012-02-21}}</ref><ref name="pmid15135680">{{cite journal |author=Gavagan JA, Whiteford MH, Swanstrom LL |title=Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications |journal=Am. J. Surg. |volume=187 |issue=5 |pages=630–4 |year=2004 |month=May |pmid=15135680 |doi=10.1016/j.amjsurg.2004.01.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002961004000212 |accessdate=2012-02-21}}</ref>.
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| Recently, Robotic surgery has been investigated to be applied in NOTES procedures, a miniature in vivo robot has been developed for NOTES. The robot can be advanced through the esophagus and into the peritoneal cavity. The robot may provide a stable platform for visualization and manipulation. The NOTES robot has been tested in a porcine model as well.
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| Investigators are trying to eliminate the laparoscopic component of NOTES and performing most of the NOTES procedures through the "natural orifices" only without any laparoscopic assistance or guidance.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) laboratory/clinical reports|What has been achieved so far?]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) laboratory/clinical reports|What has been achieved so far?]]== |
| *Laboratory Reports
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| *Human Cases
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) challenges and drawbacks|Current Challenges and Drawbacks to Clinical Application of NOTES]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) challenges and drawbacks|Current Challenges and Drawbacks to Clinical Application of NOTES]]== |
| *Puncturing one of the viscera to perform the surgical procedures. This needs to be assessed thoroughly regarding the presence of long term complications, higher infection rates, and the reliability of puncture closure. Methods of reliable full thickness, watertight closure for the puncture sites in different organs should be developed.
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| *Instrumentation is still inadequate to perform all types of NOTES procedures. Innovative instruments are needed for the surgeons to perform various NOTES procedures more easily.
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| *Loss of triangulation of optics and instrumentation may limit the range of motion of instruments and may obscure part of the operator field. The current version of NOTES instruments and endoscopes may precludes such triangulation in NOTES procedures <ref name="pmid15067621">{{cite journal |author=Pasricha PJ |title=The future of therapeutic endoscopy |journal=Clin. Gastroenterol. Hepatol. |volume=2 |issue=4 |pages=286–9 |year=2004 |month=April |pmid=15067621 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S1542356504000564 |accessdate=2012-02-23}}</ref>.
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| *NOTES surgeons should be highly trained to perform NOTES procedures and to be able to use flexible endoscopes professionally. They should know abdominal anatomy and surgical principles and should masterfully exhibit the ability to manage complications. Only a small fraction of gastroenterologists and surgeons will become NOTES surgeons.
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| *There are some technical difficulties for implementation of NOTES in humans. Many investigators have encountered these difficulties along with some ethical challenges <ref name="pmid20620259">{{cite journal |author=Chukwumah C, Zorron R, Marks JM, Ponsky JL |title=Current status of natural orifice translumenal endoscopic surgery (NOTES) |journal=Curr Probl Surg |volume=47 |issue=8 |pages=630–68 |year=2010 |month=August |pmid=20620259 |doi=10.1067/j.cpsurg.2010.04.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0011-3840(10)00075-4 |accessdate=2012-02-23}}</ref>.
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| *An argument can be made that single-incision laparoscopic surgery (SILS) can be more convenient than NOTES for some procedures, especially with the presence of advanced surgical technologies that could be applied in laparoscopic surgery <ref name="pmid20135180">{{cite journal |author=Curcillo PG, Wu AS, Podolsky ER, Graybeal C, Katkhouda N, Saenz A, Dunham R, Fendley S, Neff M, Copper C, Bessler M, Gumbs AA, Norton M, Iannelli A, Mason R, Moazzez A, Cohen L, Mouhlas A, Poor A |title=Single-port-access (SPA) cholecystectomy: a multi-institutional report of the first 297 cases |journal=Surg Endosc |volume=24 |issue=8 |pages=1854–60 |year=2010 |month=August |pmid=20135180 |doi=10.1007/s00464-009-0856-x |url=http://dx.doi.org/10.1007/s00464-009-0856-x |accessdate=2012-02-23}}</ref><ref>Ahmed, K, Wang, TT, Patel, VM, et, al. The role of single-incision laparaoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc 2010; Jul 10:Epub ahead of print.</ref>.
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| *Surveys showed that most women may not favor transvaginal NOTES procedures over laparoscopic approach, especially younger nulliparous women who are concerned about the sexual function <ref name="pmid20224999">{{cite journal |author=Strickland AD, Norwood MG, Behnia-Willison F, Olakkengil SA, Hewett PJ |title=Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique |journal=Surg Endosc |volume=24 |issue=10 |pages=2424–31 |year=2010 |month=October |pmid=20224999 |doi=10.1007/s00464-010-0968-3 |url=http://dx.doi.org/10.1007/s00464-010-0968-3 |accessdate=2012-02-23}}</ref>. Cultural and geographical variations may also play a roll in the decision to accept a transvaginal surgery or not.
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| *There are some technical constraints and challenges which limit the surgeon ability to perform certain procedures. For example, it may be very challenging for the surgeon to maintain spatial orientation during the NOTES procedure, and the procedure performance can be limited to a certain points of natural entry. To provide a straight access to the operating field, lower abdominal and pelvic NOTES procedures usually performed via a transgastric approach, but upper abdominal procedures and cholecystectomy usually performed via transvaginal or transcolonic approach.
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| *It is more difficult to handle complications easily with a NOTES approach because of the limited space available for the NOTES instruments. This may require conversion of the procedure to other approach (open or laparoscopic). Beside the complications of any surgical operation such as laceration, perforation and bleeding, these complications may also include injury to abdominal organs, bowel perforation or injury, biliary fistulae, biliary leaks, urinary incontinence, fecal incontinence and peritonitis. Recent studies reported that 5 to 10 percent of NOTES procedures could have complications, most of them occur in the transgastric approach <ref name="pmid20620259">{{cite journal |author=Chukwumah C, Zorron R, Marks JM, Ponsky JL |title=Current status of natural orifice translumenal endoscopic surgery (NOTES) |journal=Curr Probl Surg |volume=47 |issue=8 |pages=630–68 |year=2010 |month=August |pmid=20620259 |doi=10.1067/j.cpsurg.2010.04.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0011-3840(10)00075-4 |accessdate=2012-02-23}}</ref>.
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| *There is a higher risk for over insufflation of the peritoneal cavity in NOTES procedures which may decrease the venous return to the heart <ref name="pmid17285385">{{cite journal |author=McGee MF, Rosen MJ, Marks J, Chak A, Onders R, Faulx A, Ignagni A, Schomisch S, Ponsky J |title=A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery |journal=Surg Endosc |volume=21 |issue=4 |pages=672–6 |year=2007 |month=April |pmid=17285385 |doi=10.1007/s00464-006-9124-5 |url=http://dx.doi.org/10.1007/s00464-006-9124-5 |accessdate=2012-02-23}}</ref>. This could be prevented in laparoscopic surgery by using pressure sensors. There should be successful monitoring of intra-abdominal pressures during NOTES; and this has been applied in animal studies <ref name="pmid20620259">{{cite journal |author=Chukwumah C, Zorron R, Marks JM, Ponsky JL |title=Current status of natural orifice translumenal endoscopic surgery (NOTES) |journal=Curr Probl Surg |volume=47 |issue=8 |pages=630–68 |year=2010 |month=August |pmid=20620259 |doi=10.1067/j.cpsurg.2010.04.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0011-3840(10)00075-4 |accessdate=2012-02-23}}</ref><ref name="pmid17285385">{{cite journal |author=McGee MF, Rosen MJ, Marks J, Chak A, Onders R, Faulx A, Ignagni A, Schomisch S, Ponsky J |title=A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery |journal=Surg Endosc |volume=21 |issue=4 |pages=672–6 |year=2007 |month=April |pmid=17285385 |doi=10.1007/s00464-006-9124-5 |url=http://dx.doi.org/10.1007/s00464-006-9124-5 |accessdate=2012-02-23}}</ref>.
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| *Financial resources are required for the technological developments and NOTES implementation.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) human experience|Human Experience]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) human experience|Human Experience]]== |
| There are hundreds of human cases have been reported since the first human NOTES reported case in India in 2003 <ref>Rao GV, Reddy DN. Transgastric appendectomy in humans. Montreal: World Congress of Gastroenterology, 2006</ref>. More than 500 cases have been reported in Germany and more than 300 cases have been reported in Brazil <ref name="pmid20585238">{{cite journal |author=Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ |title=The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients |journal=Ann. Surg. |volume=252 |issue=2 |pages=263–70 |year=2010 |month=August |pmid=20585238 |doi=10.1097/SLA.0b013e3181e6240f |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181e6240f |accessdate=2012-02-27}}</ref><ref name="pmid20620259">{{cite journal |author=Chukwumah C, Zorron R, Marks JM, Ponsky JL |title=Current status of natural orifice translumenal endoscopic surgery (NOTES) |journal=Curr Probl Surg |volume=47 |issue=8 |pages=630–68 |year=2010 |month=August |pmid=20620259 |doi=10.1067/j.cpsurg.2010.04.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0011-3840(10)00075-4 |accessdate=2012-02-27}}</ref>. Many human cases have been reported in the United States and in other countries. Most of the reported cases are not purely NOTES but with laparoscopic assistance. A few number of the reported cases are pure NOTES procedures.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) potential applications|Potential Applications]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) potential applications|Potential Applications]]== |
| NOTES procedures have been performed through different natural orifices. So far, transvaginal approach is the most common and has the highest success rate for certain procedures.
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| ===Transvaginal NOTES===
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| This is the most common apprach to be used in NOTES procedures. This approach has been used for cholecystectomy, appendectomy, colon resections, abdominal wall hernia repair, and sleeve gastrectomy <ref name="pmid20620259">{{cite journal |author=Chukwumah C, Zorron R, Marks JM, Ponsky JL |title=Current status of natural orifice translumenal endoscopic surgery (NOTES) |journal=Curr Probl Surg |volume=47 |issue=8 |pages=630–68 |year=2010 |month=August |pmid=20620259 |doi=10.1067/j.cpsurg.2010.04.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0011-3840(10)00075-4 |accessdate=2012-02-27}}</ref>. Transvaginal cholecystectomy and transvaginal appendectomy have been performed in humans. Around 85% of the Notes procedures that have been reported in Germany is transvaginal cholecystectomy (the most common) <ref name="pmid20585238">{{cite journal |author=Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ |title=The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients |journal=Ann. Surg. |volume=252 |issue=2 |pages=263–70 |year=2010 |month=August |pmid=20585238 |doi=10.1097/SLA.0b013e3181e6240f |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181e6240f |accessdate=2012-02-27}}</ref>. There are many advantages for this approach which include:
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| :*The organ (Gallbladder, appendix or others) can be extracted easily outside the body through the flexible walls of the vagina even the large organs.
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| :*It is relatively easier and safer to perform the procedure through this approach. Vaginal wall closure is less complex than gastric wall closure and has less complications rate.
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| The drawback of this approach is that it can be used only in females. Also, the NOTES surgeon should have the basics of gynecological surgery before perform a transvaginal procedure. Women may present with dyspareunia and infertility after the procedure, also there is a potential risk for [[urinary tract infection]] after cannulation of the urinary bladder (required in transvaginal NOTES procedures).
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| ===Transanal/Transrectal NOTES===
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| Transanal rectosegmoid resection using transanal endoscopic microsurgery (TEM) and laparoscopic assistance has been demonstrated to be feasible and safe in a swine survival model and in human cadavers <ref name="pmid20174948">{{cite journal |author=Sylla P, Sohn DK, Cizginer S, Konuk Y, Turner BG, Gee DW, Willingham FF, Hsu M, Mino-Kenudson M, Brugge WR, Rattner DW |title=Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model |journal=Surg Endosc |volume=24 |issue=8 |pages=2022–30 |year=2010 |month=August |pmid=20174948 |doi=10.1007/s00464-010-0898-0 |url=http://dx.doi.org/10.1007/s00464-010-0898-0 |accessdate=2012-02-28}}</ref>. Currently, there are clinical trials that aim to assess the oncological safety of this approach in treating benign and malignant colorectal tumors.
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| Transanal colorectal resection procedures requires a stable platform for endolumenal and direct translumenal access to the peritoneal cavity. The first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance has been performed successfully by a team of surgeons from Barcelona and Boston in 2009 <ref name="pmid20186432">{{cite journal |author=Sylla P, Rattner DW, Delgado S, Lacy AM |title=NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance |journal=Surg Endosc |volume=24 |issue=5 |pages=1205–10 |year=2010 |month=May |pmid=20186432 |doi=10.1007/s00464-010-0965-6 |url=http://dx.doi.org/10.1007/s00464-010-0965-6 |accessdate=2012-02-28}}</ref>. The progression and substantial improvement in NOTES instrumentation may optimize this approach to be widespread applied in humans, and may ultimately permit completely NOTES transanal colorectal resection instead of abdominoperineal resection (APR), low anterior resection (LAR) and laparoscopic colorectal resection procedures.
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| ===Transgastric NOTES===
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| This NOTES approach is more sophisticated than the transvaginal one, especially in terms of gastric wall closure after extracting the organ (requires laparoscopic assistance <ref name="pmid20541750">{{cite journal |author=Nikfarjam M, McGee MF, Trunzo JA, Onders RP, Pearl JP, Poulose BK, Chak A, Ponsky JL, Marks JM |title=Transgastric natural-orifice transluminal endoscopic surgery peritoneoscopy in humans: a pilot study in efficacy and gastrotomy site selection by using a hybrid technique |journal=Gastrointest. Endosc. |volume=72 |issue=2 |pages=279–83 |year=2010 |month=August |pmid=20541750 |doi=10.1016/j.gie.2010.03.1070 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(10)01369-6 |accessdate=2012-02-27}}</ref>. Also, the complications rate is higher in this rout compared with transvaginal route. Trials in the field (on animal and cadaver models) are trying to create a new devices and techniques to simplify the stomach incision closure.
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| Appendectomy, cholecystectomy and cancer staging have been performed via this approach <ref name="pmid18614547">{{cite journal |author=Zorrón R, Soldan M, Filgueiras M, Maggioni LC, Pombo L, Oliveira AL |title=NOTES: transvaginal for cancer diagnostic staging: preliminary clinical application |journal=Surg Innov |volume=15 |issue=3 |pages=161–5 |year=2008 |month=September |pmid=18614547 |doi=10.1177/1553350608320553 |url=http://sri.sagepub.com/cgi/pmidlookup?view=long&pmid=18614547 |accessdate=2012-02-27}}</ref>. Retrieval of dislodged endoscopic gastrostomy tube via this approach has been reported as well <ref name="pmid17404790">{{cite journal |author=Marks JM, Ponsky JL, Pearl JP, McGee MF |title=PEG "Rescue": a practical NOTES technique |journal=Surg Endosc |volume=21 |issue=5 |pages=816–9 |year=2007 |month=May |pmid=17404790 |doi=10.1007/s00464-007-9361-2 |url=http://dx.doi.org/10.1007/s00464-007-9361-2 |accessdate=2012-02-27}}</ref>. however, all cases require Some degree of hybridization is required for all transgastric NOTES procedures. This approach can be used in all patients (males and females) but the extracted specimen (through the oral cavity) needs to be relatively smaller than those extracted by other routs.
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| ===Transesophageal NOTES===
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| This approach can be used for the management of achalasia (failure of relaxation of the lower esophageal sphincter that cause dysphagia). Many cases of per oral endoscopic myotomy (POEM) have been performed successfully to treat achalasia <ref name="pmid17703382">{{cite journal |author=Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ |title=Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia |journal=Endoscopy |volume=39 |issue=9 |pages=761–4 |year=2007 |month=September |pmid=17703382 |doi=10.1055/s-2007-966764 |url=http://www.thieme-connect.com/DOI/DOI?10.1055/s-2007-966764 |accessdate=2012-02-27}}</ref>.
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| ===Transurethral/Transcystic NOTES===
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) future directions|Future Directions]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) future directions|Future Directions]]== |
| Operating on intensive care unit patients may be the future progression in NOTES procedures which may offer many benefits. Transgastric placement of diaphragm pacing for weaning the ICU patients from the ventilator may lead to several potential benefits over other methods of pacing <ref name="pmid17177078">{{cite journal |author=Onders R, McGee MF, Marks J, Chak A, Schilz R, Rosen MJ, Ignagni A, Faulx A, Elmo MJ, Schomisch S, Ponsky J |title=Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients |journal=Surg Endosc |volume=21 |issue=3 |pages=475–9 |year=2007 |month=March |pmid=17177078 |doi=10.1007/s00464-006-9125-4 |url=http://dx.doi.org/10.1007/s00464-006-9125-4 |accessdate=2012-02-22}}</ref>, this procedure could be performed at the bedside.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) current technological developments|Current Technological Developments]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) current technological developments|Current Technological Developments]]== |
| The development of NOTES instruments is emerging to make these procedures feasible and to move the field forward, these instruments include platforms and many other tools <ref name="pmid18381169">{{cite journal |author=Mummadi RR, Pasricha PJ |title=The eagle or the snake: platforms for NOTES and radical endoscopic therapy |journal=Gastrointest. Endosc. Clin. N. Am. |volume=18 |issue=2 |pages=279–89; viii |year=2008 |month=April |pmid=18381169 |doi=10.1016/j.giec.2008.01.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S1052-5157(08)00006-8 |accessdate=2012-02-23}}</ref>. The preferred way to gain access to the peritoneal cavity via a a hollow viscus (lumen) is a very small incision (minimal) followed by a balloon expansion and dilatation, a tiny incision can be made using a sphincterotome or a needle knife. Overtube is usually used to permit multiple entries to the operating field and to perform complex maneuvers, but a direct insertion of the endoscope and the NOTES instruments is possible.
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| ==[[Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)|Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)]]== | | ==[[Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)|Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)]]== |
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| Senior leadership from the [[American Society for Gastrointestinal Endoscopy]] (ASGE) and the [[Society of American Gastrointestinal Endoscopic Suregons]] (SAGES) organized a working group of surgeons and gastroenterologists who met in New York City on July 22 and 23, 2005 to develop standards for the practice of this emerging technique. This group is known as the [[Natural Orifice Surgery Consortion for Assessment and Research (NOSCAR)]]. A White Paper on NOTES was released by NOSCAR simultaneously in two medical journals in May 2006 <ref name="pmid16427920">{{cite journal |author= |title=ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005 |journal=Gastrointest. Endosc. |volume=63 |issue=2 |pages=199–203 |year=2006 |month=February |pmid=16427920 |doi=10.1016/j.gie.2005.12.007 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(05)03412-7 |accessdate=2012-02-22}}</ref>. This paper identified the major areas of research needed to be addressed before NOTES can become a viable clinical application for human patient. These areas included development of a reliable closure technique for the internal incision, prevention of infection, and creation of advanced endoscopic surgical tools <ref>[http://www.noscar.org/faq.php Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)<!-- Bot generated title -->]</ref>.
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| NOSCAR tasks include the following:
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| *Produce White Papers which focus on the challenges that need thought and research.
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| *Track the groups of similar research projects that address the previous challenges.
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| *Organize the research projects, enhance collaboration and attract funding to key areas of study.
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| *To build a robust outcomes database by collecting submission of data.
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| *Foster collaborative clinical trials.
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| The White Paper on NOTES and the guidlines for participation in NOSCAR can be found in the external links below <ref>
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| D. Rattner, A. Kalloo, and the SAGES/ASGE Working Group on Natural Orifice Translumenal Endoscopic Surgery</ref>.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) conclusions|Conclusions]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) conclusions|Conclusions]]== |
| Natural orifice transluminal surgery (NOTES) is a rapidly evolving field which may shift the minimally invasive surgery world from laparoscopic and video assisted thoracic surgery to procedures that can be done via the natural body orifices without any abdominal or thoracic incisions. This may provide many advantages and lessen many surgical complications. New NOTES procedures should be experimental at the beginning, these procedures should be performed only in research labs in advanced institutions before reaching the goal of applying NOTES clinically.
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| We are on the way for routine clinical applications of NOTES by the steady progression of the field. Patient safety and the research trials that ensure this safety is paramount. Innovative instruments are needed for the surgeons and gastroenterologists to perform safe NOTES.
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| The development of such therapeutic techniques and advanced endoscopic devices will allow the endoscopists to perform various procedures more easily such as large and deep mucosal lesions resection, and taking full thickness biopsies <ref name="pmid19806084">{{cite journal |author=Jay Pasricha P, Krummel TM |title=NOTES and other emerging trends in gastrointestinal endoscopy and surgery: the change that we need and the change that is real |journal=Am. J. Gastroenterol. |volume=104 |issue=10 |pages=2384–6 |year=2009 |month=October |pmid=19806084 |doi=10.1038/ajg.2009.150 |url=http://dx.doi.org/10.1038/ajg.2009.150 |accessdate=2012-02-27}}</ref>.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) published trials|Published Trials]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) published trials|Published Trials]]== |
| *A novel endoscopic peroral transgastric approach to the peritoneal cavity was tested in a porcine model in acute and long-term survival experiments at Johns Hopkins Hospital in 2004 by Kalloo et al <ref name="pmid15229442">{{cite journal |author=Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV |title=Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity |journal=[[Gastrointest. Endosc.]] |volume=60 |issue=1 |pages=114–7 |year=2004 |month=July |pmid=15229442 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704013094 |accessdate=2012-02-16}}</ref>. He demonstrated the feasibility and safety of this approach to be an alternative to laparoscopy and laparotomy. The peritoneal cavity was examined, and a liver biopsy specimen was obtained. The gastric wall incision was closed with clips <ref name="pmid15229442">{{cite journal |author=Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV |title=Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity |journal=[[Gastrointest. Endosc.]] |volume=60 |issue=1 |pages=114–7 |year=2004 |month=July |pmid=15229442 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704013094 |accessdate=2012-02-16}}</ref>.
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| *Radical sigmoidectomy using a pure NOTES transanal approach was first described in 3 human cadavers in 2007 by Whiteford et al who used TEM as an endoscopic platform to perform the procedure without the need for any abdominal incisions <ref name="pmid17705068">{{cite journal |author=Whiteford MH, Denk PM, Swanström LL |title=Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery |journal=Surg Endosc |volume=21 |issue=10 |pages=1870–4 |year=2007 |month=October |pmid=17705068 |doi=10.1007/s00464-007-9552-x |url=http://dx.doi.org/10.1007/s00464-007-9552-x |accessdate=2012-02-15}}</ref>. This showed that NOTES sigmoid colon resection with en bloc lymphadenectomy and primary anastomosis can be performed successfully, and it is possible to complete the critical steps of a NOTES sigmoid resection, en bloc lymphadenectomy, primary anastomosis, and retrieval of an intact specimen without any incisions using transanal endoscopic microsurgery instrumentation.
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| *Completely NOTES transvaginal cholecystectomy has been reported by a team of surgeons in Philadelphia (USA). The patient was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up. Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans <ref name="pmid19474690">{{cite journal |author=Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M |title=Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique |journal=Ann. Surg. |volume=249 |issue=6 |pages=908–12 |year=2009 |month=June |pmid=19474690 |doi=10.1097/SLA.0b013e3181a802e2 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181a802e2 |accessdate=2012-02-28}}</ref><ref name="pmid17892873">{{cite journal |author=Bessler M, Stevens PD, Milone L, Parikh M, Fowler D |title=Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery |journal=Gastrointest. Endosc. |volume=66 |issue=6 |pages=1243–5 |year=2007 |month=December |pmid=17892873 |doi=10.1016/j.gie.2007.08.017 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(07)02553-9 |accessdate=2012-02-15}}</ref>.
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| *The first series of transvaginal NOTES cholecystectomy has been performed by the NOTES Research Group in Rio de Janeiro (Brazil) in 2007, based in previous experimental studies. The first human transvaginal endoscopic cholecystectomy case was reported in 2007 <ref name="pmid17875836">{{cite journal |author=Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D |title=Surgery without scars: report of transluminal cholecystectomy in a human being |journal=Arch Surg |volume=142 |issue=9 |pages=823–6; discussion 826–7 |year=2007 |month=September |pmid=17875836 |doi=10.1001/archsurg.142.9.823 |url=http://archsurg.ama-assn.org/cgi/pmidlookup?view=long&pmid=17875836 |accessdate=2012-02-15}}</ref>.
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| *Transgastric appendectomy has been performed by Dr. Santiago Horgan (University of California San Diego) in 2008. The patient's appendix was removed through the mouth. He also applied the EndoSurgical Operating System (EOS) on pigs to perform the entire operation through the stomach without laparoscopic assistance or any abdominal incision.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) videos|Videos]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) videos|Videos]]== |
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) external links|External Links]]== | | ==External Links== |
| *http://www.noscar.org/wp-content/uploads/2011/01/NOTES_White_Paper_Feb06.pdf | | *http://www.noscar.org/wp-content/uploads/2011/01/NOTES_White_Paper_Feb06.pdf |
| | *http://www.noscar.org/ |
| | *http://www.dgav.de/english/notes.html |
| | *http://www.euronotes.world.it/ |
| | *http://www.japan-medical-tourism.com/content/natural-orifice-translumenal-endoscopic-surgery-notes-japan |
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| ==References== | | ==Acknowledgments== |
| {{Reflist|2}}
| | Person who first created this page was '''Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:moh_sbeih@hotmail.com] |
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