Natural orifice translumenal endoscopic surgery (NOTES)

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Editor-In-Chief: Mohammed A. Sbeih, M.D. [1]

Related Key Words and Synonyms: Natural orifice translumenal endoscopic surgery, single incision laparoscopic surgery, minimally invasive surgery, transanal endoscopic microsurgery.

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.

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.

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 .

• 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 .

• 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) .

• In 1990, a multicenter team of investigators (the Apollo Group) used the term flexible transluminal endoscopy before the NOTES concept was coined .

• In 2002, Gettman et al published a transvaginal nephrectomy in a porcine model .

• The first reported human transgastric endoscopic appendectomy was in India in 2003 by Dr. G.V. Rao and Dr. N. Reddy .

• 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 .

• 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 2006 to develop standards for the practice of NOTES. This group is known as the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) .

• 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.

• Japan launched the JWNOTES (Japan Working group for NOTES) in 2007.

• 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 .

• In 2007, the first transvaginal NOTES were formally operated by M. Bessler (US team), LL. Swan (US team), and J. Marescaux (French team) .

• The first published human NOTES procedure was by Marks et al who performed a transgastric rescue of a prematurely dislodge gastrostomy tube in 2007.

• 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 .

• 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 .

• 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 .

• 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) .

What has been achieved so far?

• Laboratory Reports
• Human Cases

Potential Applications

• Transvaginal NOTES
• Transrectal NOTES
• Transgastric NOTES
• Transesophageal NOTES
• Transurethral/Transcystic NOTES

Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)

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. 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 .

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 . 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 .

External Links

• http://www.noscar.org/wp-content/uploads/2011/01/NOTES_White_Paper_Feb06.pdf