Natural Orifice Translumenal Endoscopic Surgery (NOTES)

Objective: Review of the application of natural orifice translumenal endoscopic surgery (NOTES) in human studies. Summary Background Data: NOTES presents the latest promising technology that allows new access into the abdominal cavity through a natural orifice for multiple clinical applications. It has generated excitement among physicians for a potentially scar-free surgery. Being in its infancy stage, the safety and efficacy of this technology must be studied with scrutiny. Methods: A PubMed search was conducted in April 2008 for “natural orifice translumenal endoscopic surgery” and for “natural orifice transluminal endoscopic surgery.” The search was limited to articles in English and those regarding human subjects. Results: The outcomes from the published case series show a level III evidence for the use of NOTES. However, human experience with NOTES is growing. Eleven articles involving human experience with NOTES have been published in 2007 and 2008. More studies are expected as the interest in this type of surgery has only just begun. Conclusions: NOTES is a promising new technology that needs fine-tuning before it is safely applied in the clinical setting. This highlights the need for further animal and human studies in well-controlled settings followed by industry trials and case series. The excitement about this new approach should be directed toward more training and more studies before larger clinical applications can begin.     

A primer on natural orifice transluminal endoscopic surgery: building a new paradigm

Access to the abdominal cavity is required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. During NOTES, commercially available flexible video endoscopes are used to create a controlled transvisceral incision via natural orifice access to enter the peritoneal cavity. Common incision-related complications such as wound infections, incisional hernias, postoperative pain, aesthetic disdain, and adhesions could be minimized or eliminated by NOTES. NOTES has evolved from more than 2 centuries of technological innovations and continued growth in the field of surgical endoscopy. Innovative surgical endoscopists have slowly developed means to surpass the constraints of the gastrointestinal lumen by using a flexible endoscope. The future of surgical endoscopy may be the shared entity of NOTES, which further integrates endoscopy, gastroenterology, and minimally invasive and general surgery. Although the promise of NOTES is electrifying to surgeons and endoscopists, several key issues need to be characterized prior to the incorporation of NOTES into routine practice. This article reviews the status, contemporary body of literature, limitations, and potential future implications accompanying the development of NOTES.     

Total transvaginal endoscopic abdominal wall hernia repair: a NOTES survival study

Hypothesis Natural orifice transluminal endoscopic surgery (NOTES) has gained widespread interest as a potentially less invasive alternative to laparoscopic surgery or, else, an evolution as the next-generation surgery. The main objective of this study was to assess the safety of transluminal abdominal wall hernia repair for potential human application by specifically investigating the feasibility and challenges of using a transvaginal approach. Design NOTES ventral hernia repair via a transvaginal approach. Setting University Hospital (National University Health System, Singapore). Participants The study utilized five female pigs (30–40 kg) between 5 and 7 months of age, which underwent abdominal wall hernia repair using a transvaginal approach. Intervention The procedures were performed using a double-channel endoscope under general endotracheal anesthesia. A mesh was placed and fixed to the abdominal wall using standard laparoscopic and endoscopic equipment. The animals survived for 2 weeks and were then euthanized and a necropsy performed. Main outcome measures To assess the safety and feasibility of NOTES ventral hernia repair in a survival experimental model. Results All of the procedures could be safely performed using the standard equipment. At the necropsy, all meshes were well in place and mild adhesions were recorded in one animal with a small abscess in the subcutaneous area. Conclusion This novel approach seems technically challenging but feasible using equipment and accessories currently available for conventional laparoscopic and interventional endoscopy with low intra-abdominal contamination and sepsis. New procedure-specific instruments and equipment need to be developed to allow the surgeon safer access and more degrees of instrument freedom.     

经自然腔道内镜外科的发展趋势

Natural orifice translumenal endoscopic surgery(NOTES)is a surgical technique which is performed with an endoscope passed through a natural orifice,and then through an internal incision in the viscera(stomach,vagina or rectum)to perform intraabdominal operations.Since the first successful transgastric appendectomy performed by Dr.Rao and Reddy in 2004,NOTES is developing rapidly.The advantages of NOTES include no injury and scar in the body surface;lower anesthesia requirements;faster recovery and shorter hospital stays;avoidance of transabdominal wound infections.NOTES can also be applied to patients who are not suitable for open surgery and lapascopic surgery.NOTES has the potential to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions,however,the safety and efficacy of NOTES still needs to be investigated in lhe future.     

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women’s views on a new technique

Background  

Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES.     

Scarless surgery for a huge liver cyst: A case report

IntroductionSymptomatic or complicated liver cysts sometimes require surgical intervention and laparoscopic fenestration is the definitive treatment for these cysts. We performed minimally invasive surgery, hybrid natural orifice transluminal endoscopic surgery (NOTES) without scarring, for a huge liver cyst.Presentation of caseAn 82-year-old female presented with a month-long history of right upper abdominal pain. We diagnosed her condition as a huge liver cyst by morphological studies. She denied any history of abdominal trauma. Her serum CEA and CA19-9 were normal and a serum echinococcus serologic test was negative. Laparoscopic fenestration, using a hybrid NOTES procedure via a transvaginal approach, was performed for a huge liver cyst because we anticipated difficulty with an umbilical approach, such as single incision laparoscopic surgery (SILS). Her post-operative course was uneventful and she was discharged from our hospital three days after surgery. Pain killers were not required during and after hospitalization. No recurrence of the liver cyst or bulging was detected by clinical examination two years later.DiscussionA recent trend of laparoscopic procedure has been towards minimizing the number of incisions to achieve less invasiveness. This hybrid NOTES, with a small incision for abdominal access, along with vaginal access, enabled painless operation for a huge liver cyst.ConclusionWe report a huge liver cyst treated by hybrid NOTES. This approach is safe, less invasive, and may be the first choice for a huge liver cyst.     

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.     

NOTES: the hybrid technique

INTRODUCTION: Natural orifice translumenal endoscopic surgery (NOTES) has gained much interest by minimal invasive surgeons and gastroenterologists. Performing abdominal operations without any abdominal wall incisions may offer all the advantages of minimally invasive surgery (MIS) and eliminate the complications associated with these wounds. The NOTES technique is rapidly being developed, but one of the major issues involved in the procedure that has to be addressed prior to implementation is in obtaining adequate spatial orientation. OBJECTIVE: The aim of this study was to combine the standard laparoscopic vision together with the endoscopic surgery procedure in order to acquire an independent satisfactory vision source. MATERIALS AND METHODS: The hybrid technique was performed in 6 porcine animal models. Among the procedures performed were tubal ligation, liver biopsies, oophorectomy, and cholecystectomy. All procedures were performed under general anesthesia, and all animals were euthanized at the termination of the procedure. RESULTS: The laparoscopic vision offers substantial advantages over the endoscopic vision. Spatial orientation is achieved in the same manner and quality as in MIS, and furthermore, the laparoscopic vision increases the safety of the NOTES procedure. CONCLUSIONS: The hybrid technique offers a superior vision source independent to the working endoscope. It may be an interim technique for developing NOTES until a novel imaging device will be available, or serve as the final solution for acquiring an adequate vision for this approach.     

Laparo‐endoscopic single‐site surgery: preliminary advances in renal surgery

We reviewed the preliminary advances in laparo‐endoscopic single‐site surgery (LESS) as applied to renal surgery, and analyzed current publications based on animal models and human patients. We searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Keyword searches included: ‘scarless’, ‘scar free’, ‘single port/trocar/incision’, ‘intraumbilical’, and ‘transumbilical’, ‘natural orifice transluminal endoscopic surgery’ (NOTES), ‘SILS’, ‘OPUS’ and ‘LESS’. The lessons learnt from the studies using the porcine model are that further advances in instrumentation are essential to achieve optimum results, and that testing survival in animals is also necessary to further expand the NOTES and LESS techniques. Further advances in instrument technology together with increasing experience in NOTES and LESS approaches have driven the transition from porcine models to human patients. In the latter, studies show that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills, and optimal instrumentation, are available. The next step towards minimal access/minimally invasive urological surgery is NOTES and LESS. It is inevitable that LESS will be extended to involve more complex and technically demanding procedures such as laparoscopic radical prostatectomy and partial nephrectomy.     

NOTES über den transvaginalen Zugang

NOTES (?natural orifice transluminal endoscopic surgery“) has the potential to optimize minimally invasive surgery. In gynecology there is extensive experience with the transvaginal approach to the abdominal cavity. It is easy to perform, closure is safe and there is little risk of infection. Hence, this is the approach most suitable for NOTES. By means of rigid laparoscopic instruments cholecystectomy can be routinely performed. Such operations could be performed in 149 patients in our hospital and the NOTES register of the DGAV has data on more than 900 transvaginal operations.     

Natural orifice surgery applied for colorectal diseases

Clinical natural orifice surgery has been applied to abdominal surgery in recent years, mostly using transvaginal and transgastric access. Rectal and transcolonic natural orifice transluminal endoscopic surgery (NOTES) were tested in animal and cadaver models by a few research groups. Despite the potential advantages of transcolonic NOTES for colorectal diseases, it has not yet been clinically applied. The first successful series of human applications of transcolonic NOTES in the literature from the NOTES Research Group in Brazil provide new possibilities in the field in new transrectal procedures for rectal cancer and benign disease. Successful first human reports on Transcolonic NOTES potentially brings new frontiers and applications for minimally invasive surgery. The treatment of colorectal diseases through flexible Perirectal NOTES Access is a promising new approach alongside existing laparoscopic and open surgery to improve patient care.     

ESD和隧道技术经口内镜下肌切开术(POEM)

经自然腔道内镜手术(NOTES)是指经人体自然腔道的内镜手术,近年来,NOTES技术已成为目前消化内镜微创技术发展的主要方向之一。然而目前在这一领域,临床的努力方向和研究的重点已经转移到制造病理性腔壁内和邻近腔壁的新的微创入路方法上,包括了更多常规介入性内镜诊疗操作。近来,有学者提出了新NOTES这一概念,其核心内容为经人体自然腔道,使用内镜进行手术,以取得病理组织、切除病变或解决梗阻、狭窄等问题,并不局限于进入腹腔。如消化内镜领域的经口内镜肌切开术(POEM)、黏膜下隧道内镜切除术(STER)、经口幽门肌切开术(POP)、内镜黏膜下剥离术(ESD)、内镜下全层切除术(EFTR)等,被称作new NOTES或near NOTES。其中POEM作为一项较新的NOTES技术,自2010年出现以来发展较为迅速,以黏膜下隧道技术和肌切开术为其基本技术,在新NOTES中应用较为广泛,治疗效果较确切,在贲门失弛症手术治疗上已可作为一线治疗的选择。本文就目前POEM的发展进行综述。     

Natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation in a porcine model

OBJECTIVE

To present our laboratory experience with natural orifice translumenal endoscopic surgery (NOTES) renal cryoablation.

MATERIALS AND METHODS

In two female farm pigs, we performed four procedures of NOTES renal cryoablation. In each pig, NOTES was performed through a transgastric approach and a transvaginal approach for each kidney, respectively. The pig was placed in the flank position and pneumoperitoneum obtained using a transabdominal Veress needle. In the first pig, we started with the left kidney with a transgastric approach: a dual‐channel video gastroscope (Olympus, Tokyo, Japan) was used, the stomach wall was punctured using a needle‐knife, a guidewire was passed into the abdominal cavity and the access dilated using a controlled radial expansion balloon. The bowel was mobilized medially and the Gerota’s fascia overlying the upper pole was dissected. Under direct endoscopic vision, a cryoablation probe was introduced percutaneously into the anterior upper pole of the kidney. The pig was then flipped to the right flank position and a transvaginal approach was used: the gastroscope was introduced through the posterior fornix of the vagina. For the second pig, we performed initially a transgastric right‐side cryoablation then a transvaginal left‐side cryoablation as described for the first pig.

RESULTS

All four procedures were performed successfully, with no intraoperative complications. No additional laparoscopic ports or open conversions were necessary. The vision of the kidney and the ice‐ball was adequate for all cases. The mean operative duration was 83 min. Stomach closure was tested watertight, and there were no abdominal or pelvic injuries found at autopsy.

CONCLUSIONS

NOTES can provide adequate minimal surgical dissection for safe and effective percutaneous renal cryoablation under direct videoscopic monitoring at kidney locations otherwise not accessible percutaneously. Both transgastric and transvaginal approaches can be used effectively for renal cryoablation providing a minimally invasive scar‐less surgery.     

Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients

Background  

Laparoscopic surgery has dramatically improved surgical care of patients reducing postoperative pain, wound infection rate, hospital stay, inability to work, risk of hernia, and cosmetic result. Natural orifice transluminal endoscopic surgery (NOTES) is even less traumatic to the abdominal wall and might further improve minimal invasive surgery of patients, but might also increase surgical risk when used by a transgastric or transcolonic approach with flexible endoscopes. Therefore we decided to use a transvaginal approach using rigid laparoscopic instruments for cholecystectomies.     

Population perception of surgical safety and body image trauma: a plea for scarless surgery?

Background  

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated.     

Transvesical endoscopic peritoneoscopy: Intra-abdominal scarless surgery for urologic applications

For many abdominal procedures, advantages such as minimal scarring, reduced pain, and faster recovery have made laparoscopy the favored approach over traditional open surgery. The most recent minimally invasive approach is natural orifice transluminal endoscopic surgery (NOTES), which limits morbidity because this surgery does not require incision. This article reviews the history, development, and current and future applications of NOTES in the field of urology.     

Natural orifice surgery (NOTES) and biliary disease, is there a role?

Background  Natural orifice translumenal endoscopic surgery (NOTES) is a term coined by a joint group of surgeons and gastroenterologists organized by Society for American Gastrointestinal Endoscopic Surgeons (SAGES) and American Society of Gastroenterologists (ASGE) to describe the fusion of minimally invasive surgery and interventional endoscopy. Methods  Current literature and compiled personal experience in NOTES was reviewed to provide an expert opinion on the role of NOTES in HPB surgery. Results  The majority of experience obtained to date has been in animal models. The few human cases and clinical trials that have been performed show excellent promising outcomes with minimal morbidity. Discussion  The merger of interventional endoscopy and minimally invasive surgery is a natural progression as we continually push the envelope of minimally invasive surgery. Endoscopic retrograde cholangiopancreatography, biliary stents and endoscopic ultrasonography have forever changed treatment algorithms in HPB surgery. Advancement of minimally invasive surgery to include the liver resections, pancreatic resections and pseudocyst management has improved morbidity and become the standard of care in many cases. Continued development of natural orifice techniques may further alter the approaches to the biliary tract, liver and pancreas.     

Natural orifice translumenal endoscopic surgery (NOTES): dissection for the critical view of safety during transcolonic cholecystectomy

Background  Natural orifice translumenal endoscopic surgery (NOTES), an emerging field in minimally invasive surgery, is driving the development of new technology and techniques. The NOTES approach has several proposed benefits including potentially decreased abdominal pain, wound infections, and hernia formation [1–4]. Cholecystectomy is one of the most commonly performed NOTES procedures to date [5–7]. To perform a safe cholecystectomy and reduce potential bile duct injuries, the cystic duct and artery must first be identified. Establishing this critical view of safety before ligation and division has been shown to reduce bile duct injuries associated with laparoscopic cholecystectomy [8]. This video shows that the critical view of safety can be attained with endoscopic dissection. Methods  In the porcine model, transcolonic peritoneal access is gained using an endoscopic needleknife and balloon dilator. Once orientation is established, the gallbladder is retracted using percutaneous T-tags. The cystic duct and artery bundle are identified and then meticulously dissected using endoscopic graspers, hook cautery, biopsy forceps, and scissors. The individual cystic duct and artery are isolated and identified, establishing the critical view of safety. Endoscopic clip ligation and division are then performed, and the gallbladder is dissected free. Conclusions  Dissection of the critical view of safety can be performed in a completely endoscopic fashion using appropriate instrumentation. By achieving this critical view, the incidence of biliary injury during NOTES should be minimal and similar to the incidence of biliary injury during laparoscopic surgery. While completing this procedure, we identified several remaining technical limitations and deficiencies. Endoscopic retraction of tissue still is challenging with currently available instrumentation. Hemostatic endoscopic clips are not currently available for cystic artery and duct ligation. With the development of such instruments, cholecystectomy and other NOTES procedures will become technically more feasible. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Can Gastric Irrigation Prevent Infection During NOTES Mesh Placement?

Background  Natural orifice transluminal endoscopic surgery (NOTES) ventral hernia repair could avoid abdominal wall incisions. The infectious risk for mesh placement is of concern. We compared NOTES with laparoscopic mesh placement. Methods  Thirty-seven swine were randomized to abdominal wall polypropylene mesh placement via NOTES or laparoscopy or NOTES control. All animals received antibiotics and gastric irrigation; the laparoscopy group also received preoperative acid suppression. In the NOTES mesh group, the 2-cm² polypropylene mesh was placed using a transgastric transportation device and clipped to the anterior abdominal wall. The control animals underwent endoscopy (no gastrotomy) followed by laparoscopic mesh placement or NOTES only without mesh placement. Necropsy was performed at 14 days. Results  One NOTES mesh placement was incomplete (endoscope failure). All mesh animals survived to 14 days. At necropsy, significantly more mesh infections were noted in the NOTES mesh versus laparoscopy group (4:11 vs 0:14; p = 0.03). Gastric irrigation reduced the bacterial load significantly in all groups (p < 0.001). Infection was independent of gastric bacterial load. No difference between acid suppressed and non-suppressed animals was seen. Conclusion  The mesh placement via NOTES is technically feasible but has a high infection rate despite irrigation. Sterile conduits are needed to enable NOTES-type hernia repair with mesh. Presented at the 49th annual meeting of the Society for Surgery of the Alimentary Tract, May 21, 2008, San Diego, CA.