经自然腔道内镜手术研究进展

经自然腔道内镜手术（NOTES）利用人体自然开口和管腔，通过内镜进人体腔进行内镜手术。在动物模型上经胃、结肠、阴道、甚至膀胱，食管等腔道进入腹腔、纵隔，已经成功施行腹腔探查、肝脏活检、胃肠吻合、阑尾切除、胆囊切除、输卵管结扎、子宫部分切除、肾切除、脾脏切除、胰腺尾部切除、纵隔探查等手术：最近有成功应用于临床的报道。虽设备及技术逐渐完善，但还有许多问题有待解决，如：入路途径和切口闭合等问题。随着技术和观念的进步，经自然腔道内镜手术有望再次革新傲创外科手术。     

Surgery insight: natural orifice transluminal endoscopic surgery--an analysis of work to date

Traditional flexible endoscopy has been limited to the confines of the gastrointestinal lumen; however, recent developments involving transluminal access to intra-abdominal structures hold the potential to revolutionize flexible endoscopy. Over the past few years various studies have detailed techniques that intentionally breach the lumen and provide endoscopic access to the peritoneal cavity for diagnostic and therapeutic procedures. Unlike standard surgical approaches, which require incisions to be made in the abdominal wall, natural orifice transluminal endoscopic surgery (NOTES) avoids the need for abdominal incisions and can offer specific advantages to select patient populations. Animal models have been used to demonstrate the possible applications of NOTES, including transgastric peritoneoscopy, tubal ligation, gastrojejunostomy, partial hysterectomy, oophorectomy, and transcolonic exploration, liver biopsy and cholecystectomy. In this Review, we highlight important advances in NOTES since it was first described and analyze the hazards and potential benefits associated with this innovative approach.     

经自然腔道内镜手术

在过去的几年中,内镜领域出现了一种新型介入操作-经自然腔道内镜手术(natural orifice transluminal endoscopic surgery,NOTES),这一创新的内镜操作是经由自然腔道(口腔、肛门、阴道等)进入腹腔进行各种诊断和治疗.同时,也可经由自然腔道进入胸腔等其他体腔进行内镜手术. 与传统的剖腹手术不同,经自然腔道内镜手术避免了腹壁的切口,并且能够给患者带来特殊的好处. 尽管仍有许多难点需要突破,经自然腔道内镜手术这一无疤痕,安全的微创手术方式必将快速发展. 本文就该项新型手术方式的发展历史,实验研究,临床应用及前景等作一综述.     

经自然腔道内镜外科学(NOTES)研究进展

经自然腔道内镜外科学(natural orifice transluminal endoscopic surgery,NOTES)概念自提出以来,受到内镜医师和腹腔镜医师的广泛关注,成为微创技术领域研究和争论的焦点。国内外NOTES实验研究已经证实了NOTES的安全性、可行性及有效性,有关NOTES临床应用的研究也大量发表。同时,有关NOTES操作平台、器械研发和临床应用的报道也不断增多。本文就目前NOTES临床应用进展和相关的操作平台、器械的研发及应用情况进行概述。     

Current developments in natural orifices transluminal endoscopic surgery: an evidence-based review

Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access,safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in ...     

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.     

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra‐abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra‐abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES‐related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES‐related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.     

Colorectal natural orifice transluminal endoscopic surgery (NOTES) and transvaginal/transrectal specimen extraction

Advancements in minimally invasive surgery have both revolutionized laparoscopy and set the stage for the advancement of endoscopic surgery to the forefront of modern medicine. Natural orifice transluminal endoscopic surgery (NOTES) has now become a subject of great interest to surgeons worldwide who wish to reduce the morbidity associated with abdominal operations. However, the application of NOTES to colorectal surgery has thus far been limited due to the complex dissection, anastomosis and specimen extraction typically required when operating on the large bowel. For this reason, laparoscopic-assisted natural orifice surgery has been the means by which most surgeons have begun to incorporate natural orifice surgery into their established practices. Transanal endoscopic surgery, transvaginal-assisted laparoscopy and transrectal specimen extraction are all emerging techniques that may be currently employed, in a hybrid manner, with traditionally accepted laparoscopic operations in order to transition toward less invasive surgery and even pure NOTES. To this end, the vagina appears to be the most practical and widely used site of specimen extraction and adjunct access site for laparoscopic hybrid operations. An accompanying video demonstrates the authors’ preferred technique for transvaginal and transrectal specimen extraction.     

Natural Orifice Translumenal Endoscopic Surgery (NOTES) in urology

The concept of endoscopic surgery performed through natural orifices - Natural Orifice Translumenal Endoscopic Surgery (NOTES) - represents one of the most exciting ideas recently introduced in surgery. The use of natural orifice as a transluminal access to the peritoneal cavity has been shown to be effective and reproducible. After the introduction of the transgastric access (2004), the adaptation of the well-known transvaginal access, looking for ideal and more suitable entrance has led to the development of the transcolonic and transvescical ports. To date, the NOTES technique showed its full potential in experimental models, so as to allow the completion of most of the standard procedures performed in laparoscopic technique and thus opening the door to a new era, considered as "3rd generation surgery". However, only few experiences have been translated to humans and this concept is still at an early stage of experimental development. Many efforts are still needed to establish the standardization and validation of the techniques, the verification of safety and effectiveness. ?This article intends to photograph the actual role of NOTES, reviewing its history, analyzing the potential benefits and drawbacks, browsing and comparing the different transluminal routes, describing the equipment and platforms currently available, and finally to point out the state of the art of NOTES in the urological field.     

A self-approximating transluminal access technique for potential use in NOTES: an ex vivo porcine model (with video)

BACKGROUND: NOTES (natural orifice transluminal endoscopic surgery) is an area of active research in experimental endoscopy and has the potential to significantly advance the field of minimally invasive surgery. Several investigators have illustrated the need for a transluminal access technique that is safe, reliable, and reproducible. Currently used methods directly cut through the organ wall into the peritoneum; however, rare difficulty in closing the defect with negative outcomes have been described. OBJECTIVE: To evaluate an alternative method for transluminal access. DESIGN: An ex vivo, experimental endoscopy study. SETTING: Penn State Hershey Medical Center, Animal Research Laboratories. METHODS: By using ex vivo porcine esophagus, stomach, and colon, a submucosal tunnel was created as a means of physically separating the lumen from the peritoneum during transluminal access. Postprocedure leak testing was performed, and all procedures were video recorded. RESULTS: Results of the self-approximating transluminal access technique (STAT) in porcine esophagus and stomach demonstrated the technical feasibility of this approach. The STAT was not felt to be feasible in the porcine colon. LIMITATIONS: This investigation was a limited, ex vivo pilot study and will require further testing in an adequate number of live animals. CONCLUSIONS: The STAT is technically feasible in porcine esophagus and stomach, and may have advantages over currently used techniques.     

Critical analysis of hot topics in NOTES

Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.     

经自然腔道内镜腹腔探查术不同人路与技术差异的动物实验研究

目的探讨经自然腔道内镜腹腔探查术中经胃、经结肠、经脐3种人路可行性,并对单纯经自然孔道内镜腹腔探查术和复合经自然孔道内镜腹腔探查术的利弊进行评价。方法选取2只家猪动物模型,分别行单纯经自然孔道内镜腹腔探查术与复合经自然孔道内镜腹腔探查术。每只猪均依次采用经胃、经结肠、经脐3种入路进行腹腔探查,记录每种人路的检查完成情况,术后尸解观察腹腔脏器损伤情况及造口闭合程度,对比单纯经自然孔道内镜腹腔探查术与复合经自然孔道内镜腹腔探查术的术中反应情况以及操作的难易程度。结果2只家猪术中生命体征均稳定,术后尸解均未见造口周围脏器损伤。经胃探查与经结肠探查均存在一定盲区,且闭合胃壁造口难于闭合结肠造口。经脐探查与腹腔镜技术相似。在安全造口、稳定气腹、充分探查方面,复合经自然孔道内镜腹腔探查术优于单纯经自然孔道内镜腹腔探查术。结论经自然孔道内镜腹腔探查术中经胃、经结肠、经脐3种人路在技术上均具有可行性,在使用现有内镜器械的条件下复合自然孔道内镜腹腔探查术优于单纯自然孔道内镜腹腔探查术。     

经自然腔道内镜手术的实验研究进展

近年,内镜领域出现了一种新型介入诊疗技术——经自然腔道内镜手术(NOTES),这一革新的内镜技术是经由自然腔道(胃、直肠、阴道等)进入体腔进行各种诊断和治疗。与传统外科手术不同,NOTES避免了腹壁切口,能够给特定患者带来特殊的益处。作为一项新技术,前期实验研究是必须的,可用以评价新技术的安全性、可行性、有效性,为新技术的临床应用提供必要的经验。本文就NOTES的实验研究进展作一综述。     

Natural orifice transluminal endoscopic surgery for the antireflux process in children

The successful deployment of therapeutic delivery systems with natural orifice transluminal endoscopic surgery (NOTES)-like techniques relies on a combination of technology that must be appropriate, and in children that includes size-specific, close team harmony with surgeons and endoscopists working hand in hand, absence of introduction of infection and other complications, and efficacy that is as good as the conventional approaches. Increasingly, cost will become a factor, and the higher cost of the NOTES-type techniques could be balanced by the potential for shorter stays as inpatients. Already the antireflux transoral incisionless fundoplication procedure has gained some acceptance in the United States, and it remains to be seen if it becomes commonplace in pediatrics. How long it will take for other techniques such as NOTES cholecystectomy, appendectomy, bowel resection, etc., to be adopted in a similar fashion will depend on the ongoing studies that are bearing fruit every year, and also on technological developments such as the so-called NOTES “toolbox.” These are interesting times for pediatric gastrointestinal endoscopy     

Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video)

BACKGROUND: The ability to access the abdominal cavity though a direct (modified-PEG type) gastric incision to perform natural orifice transluminal endoscopic surgery (NOTES) has been demonstrated in the literature. However, the optimal technique to access the abdomen remains unknown. OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of a transgastric approach to the abdominal cavity through an extended submucosal tunnel. DESIGN: Animal feasibility study. INTERVENTIONS: Transgastric endoscopic peritoneoscopy was performed in 7 anesthetized swine, including 2 acute and 5 survival animals. After the creation of a 10-cm to 12-cm tunnel in the gastric submucosal plane, the peritoneal cavity was accessed by needle-knife puncture through the gastric wall near the greater curvature. The peritoneal cavity was examined before the gastric mucosal incision was closed with endoclips. Survival animals were euthanized two weeks after the procedure, and a necropsy was performed. RESULTS: The abdominal cavity was successfully entered without complication in all 7 animals. The mucosal incisions were able to be closed by endoscopy. In the survival experiments, all animals recovered and gained weight. Two animals experienced clinically unapparent infectious complications. LIMITATIONS: Small sample size. CONCLUSIONS: A peroral transgastric approach to the abdominal cavity through an extended submucosal tunnel is technically feasible and allows safe abdominal access and reliable closure with currently available technology. It has potential benefits as an alternative to direct transgastric access for NOTES procedures.     

Technische Aspekte der NOTES-Sigmaresektion

Natural orifice transluminal endoscopic surgery (NOTES) is gaining increasing momentum in colorectal surgery as a hybrid technique for transvaginal and transrectal specimen retrieval. The major technical challenge is the anastomosis which can be prepared extracorporeally (transvaginal) or can be constructed totally intracorporeally (transvaginal or transrectal). These innovative techniques allow further reduction of access trauma.     

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full‐thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full‐thickness resection. Several closure techniques, including over‐the‐scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.     

Natural orifice transluminal endoscopic surgery: Where are we going?

The foundation for natural orifice transluminal endoscopic surgery(NOTES) is to access the peritoneal and other body cavities through the wall of the alimentary tract via natural orifices,with the goal of performing procedures within the peritoneum and other cavities,without the need to make incisions in the abdominal wall.We have made great progress in the field of NOTES since the publication of the White Paper in 2006.There are still major fundamental goals as outlined by the Society of American Gastroint...     

Moderne endoskopische Verschlusstechniken

The concept of scarless, endoscpic, intraperitoneal surgery (?Natural Orifice Translumenal Endoscopic Surgery”, NOTES) has gained widespread attention in recent years and has led to an enormous variety of new devices and techniques for flexible endoscopy. As NOTES depends on a safe and reliable closure for transvisceral access, the development of novel endoscopic closure devices has been a major area of interest and research. Many of these new devices are also ideally suited for closing gastrointestinal perforations and several new techniques have recently been introduced for clinical use.     

NOTES and endoscopic pancreatic necrosectomy for the GI endoscopist

Endoscopists seek to conduct more aggressive surgical procedures that surpass the limitations of existing endoscopic procedures. Endoscopic pancreatic necrosectomy and natural orifice transluminal endoscopic surgery (NOTES) are typical examples of this new trend; both are performed through the gastrointestinal wall without a skin incision. Endoscopic necrosectomy is effective for managing organized pancreatic necrosis and abscesses. The necrotic tissues are removed endoscopically by directly entering the cavity of the organized pancreatic necrosis. NOTES is a possible advance over surgical intervention, as it is a less invasive, more cosmetic, and effective procedure. There are various approaches, including the esophagus, stomach, colon, and vagina; Various procedures are possible using NOTES, such as cholecystectomy, appendectomy, full-thickness stomach resection, splenectomy, gastrointestinal (GI) anastomosis, and peritoneoscopy. The requirements for NOTES include high proficiency in endoscopic techniques, including knowledge of various devices, anatomy, and surgical procedures. Since most GI endoscopists have no surgical background, to increase the usage of NOTES, GI endoscopists should form and lead teams that include various specialists. We believe that endoscopic necrosectomy and NOTES represent a major shift in the treatment paradigm because physicians can treat beyond the gastrointestinal wall and endoscopic procedures will replace surgical treatment.