Natural orifice translumenal endoscopic surgery (NOTES)

Jump to navigation Jump to search

For the WikiPatient page for this topic, click here

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, Natural orifice surgery consortium for assessment and research.

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.

NOTES describes going beyond the margins of a lumen (hollow organ). Some says that the word translumenal can 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".

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 [1].
  • 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 [2].
  • 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) [3][4].
  • In 1990, a multicenter team of investigators (the Apollo Group) used the term flexible transluminal endoscopy before the NOTES concept was coined [5].
  • In 2002, Gettman et al published a transvaginal nephrectomy in a porcine model [6].
  • The first reported human transgastric endoscopic appendectomy was in India in 2003 by Dr. G.V. Rao and Dr. N. Reddy [7].
  • 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 [8][9].
  • 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.
  • 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 [11].
  • In 2007, the first transvaginal laparoscopically assisted cholecystectomy in the United States was formally operated by Marc Bessler (US team)[12], and the first transgastric cholecystectomy in the United States was performed by Lee Swanstrom (US team) [13], and J. Marescaux (French team) [14].
  • The first published human NOTES procedure was by Marks et al[15] 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 [16][17].
  • 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 [18].
  • 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 [19].
  • 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) [20].

Advantages Over Current Surgical Techniques

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:

  • 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.
  • 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 [21][22]. Eliminating all skin incisions would eliminate the adverse impact of wound infection on the health care costs and patient recovery [23].
  • 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 [24].
  • Requirements for anesthesia are relatively less than other types of surgeries.
  • Less immunosuppression.
  • Better postoperative pulmonary and diaphragmatic function.
  • Better cosmetic results with the potential for "scarless" abdominal surgery.
  • 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.

Experimental Evolution

The evolving concept of natural orifice translumenal endoscopic surgery (NOTES) combines the techniques of minimally invasive surgery with flexible endoscopy. The first published report of a true transluminal procedure in 2004 by Kalloo et al. [9] showed the possibilities of penetrating the gastric wall and operating in animal model using a perorally introduced flexible endoscope [25]. 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. 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).

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 right 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 [26], appendectomy, splenectomy [27], ligation of fallopian tubes [28], gastrojejunostomy [29], peritoneal exploration and organ resection [30], lymphadenectomy [31], partial hysterectomy [32], oophorectomy [33] and other abdominal procedures. Recently, alternate access routes for NOTES procedures have been investigated such as transvaginal, transesophageal, transcolonic (transanal) and transvesical access. The most rapidly evolved experimental studies were transvaginal NOTES procedures, including cholecystectomy [34][35], nephrectomy and appendectomy [36], and the first human case was described in 2007 [16][17]. Cholecystectomy, which is a high volume and relatively simple end organ operation, has been the focus of most early NOTES research studies.

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 [37]. 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 [38][39].

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.

What has been achieved so far?

  • Laboratory Reports
  • Human Cases

Current Challenges and Drawbacks to Clinical Application of NOTES

Human Experience

Potential Applications

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

Future Directions

Current Technological Developments

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 [40].

NOSCAR tasks include the following:

  • Produce White Papers which focus on the challenges that need thought and research.
  • Track the groups of similar research projects that address the previous challenges.
  • Organize the research projects, enhance collaboration and attract funding to key areas of study.
  • To build a robust outcomes database by collecting submission of data.
  • Foster collaborative clinical trials.

The White Paper on NOTES and the guidlines for participation in NOSCAR can be found in the external links below [41].

Conclusions

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 [9]. 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 [9].

Videos

External Links

References

  1. ↑ Litynski GS (1999) Endoscopic surgery: the history, the pioneers. World J Surg 23: 745-753
  2. ↑ Halim I, Tavakkolizadeh A. NOTES: The next surgical revolution? Int J Surg 2008; 6: 273-276
  3. ↑ Mouret P (1991) From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery: the future perspectives. Dig Surg 8: 1124-1125
  4. ↑ SJ, Warnock GL. A brief history of endoscopy, laparoscopy, and laparoscopic surgery. J Laparoendosc Adv Surg Tech A 1997; 7: 369-373
  5. ↑ Pasricha PJ (2007). "NOTES: a gastroenterologist's perspective". Gastrointest. Endosc. Clin. N. Am. 17 (3): 611–6, viii–ix. doi:10.1016/j.giec.2007.05.002. PMID 17640587. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)
  6. ↑ Gettman MT, Lotan Y, Napper CA, Cadeddu JA. Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model. Urology 2002; 59: 446-450
  7. ↑ Rao GV, Reddy DN. Transgastric appendectomy in humans. Montreal: World Congress of Gastroenterology, 2006
  8. ↑ 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
  9. ↑ 9.0 9.1 9.2 9.3 Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004). "Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity". Gastrointest. Endosc. 60 (1): 114–7. PMID 15229442. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)
  10. ↑ Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)
  11. ↑ Whiteford MH, Denk PM, Swanström LL (2007). "Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery". Surg Endosc. 21 (10): 1870–4. doi:10.1007/s00464-007-9552-x. PMID 17705068. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  12. ↑ 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
  13. ↑ USGImedical. (2007, Jun). USGI announces first NOTES transgastric cholecystectomy procedures [Online]. Available: http://www.usgimedical.com/pr_transgastric_cholecystectomy.html
  14. ↑ 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
  15. ↑ Marks JM, Ponsky JL, Pearl JP, McGee MF. PEG "Rescue": a practical NOTES technique. Surg Endosc 2007; 21: 816-819
  16. ↑ 16.0 16.1 Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007). "Surgery without scars: report of transluminal cholecystectomy in a human being". Arch Surg. 142 (9): 823–6, discussion 826–7. doi:10.1001/archsurg.142.9.823. PMID 17875836. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  17. ↑ 17.0 17.1 Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007). "Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery". Gastrointest. Endosc. 66 (6): 1243–5. doi:10.1016/j.gie.2007.08.017. PMID 17892873. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  18. ↑ Surg Endosc. 2009 July; 23(7): 1512–1518.Published online 2009 April 3. PubMed Central. doi: 10.1007/s00464-009-0428-0
  19. ↑ "Surgeons Remove Healthy Kidney Through Vagina". InfoNIAC.com. Retrieved 2009-02-03.
  20. ↑ Sylla P, Rattner DW, Delgado S, Lacy AM (2010). "NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance". Surg Endosc. 24 (5): 1205–10. doi:10.1007/s00464-010-0965-6. PMID 20186432. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  21. ↑ 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
  22. ↑ 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
  23. ↑ 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
  24. ↑ 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
  25. ↑ 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
  26. ↑ 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
  27. ↑ S. V. Kantsevoy, B. Hu, S. B. Jagannath, et al., “Transgstric endoscopic splenectomy: Is it possible?” Surg Endosc, vol. 20, pp. 522-525, 2006.
  28. ↑ 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
  29. ↑ 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
  30. ↑ 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
  31. ↑ 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
  32. ↑ 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
  33. ↑ ] 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
  34. ↑ Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M (2009). "Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique". Ann. Surg. 249 (6): 908–12. doi:10.1097/SLA.0b013e3181a802e2. PMID 19474690. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  35. ↑ Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M (2008). "NOTES transvaginal cholecystectomy: preliminary clinical application". Surg Endosc. 22 (2): 542–7. doi:10.1007/s00464-007-9646-5. PMID 18027043. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  36. ↑ 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
  37. ↑ Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier H (1985). "Endoscopic surgery in the rectum". Endoscopy. 17 (1): 31–5. doi:10.1055/s-2007-1018451. PMID 3971938. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  38. ↑ Denk PM, Swanström LL, Whiteford MH (2008). "Transanal endoscopic microsurgical platform for natural orifice surgery". Gastrointest. Endosc. 68 (5): 954–9. doi:10.1016/j.gie.2008.03.1115. PMID 18984102. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  39. ↑ Gavagan JA, Whiteford MH, Swanstrom LL (2004). "Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications". Am. J. Surg. 187 (5): 630–4. doi:10.1016/j.amjsurg.2004.01.004. PMID 15135680. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  40. ↑ Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)
  41. ↑ D. Rattner, A. Kalloo, and the SAGES/ASGE Working Group on Natural Orifice Translumenal Endoscopic Surgery

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Natural_orifice_translumenal_endoscopic_surgery_(NOTES)&oldid=634216"