Natural Orifice Translumenal Endoscopic Surgery (NOTES): What are We Getting Into?

1Division of Gastroenterology; 2School of Computing, Department of Mechanical and Materials Engineering, Department of Surgery, Hotel Dieu Hospital, Kingston, Ontario Correspondence: Dr Lawrence C Hookey, Queen's University, Division of Gastroenterology, Hotel Dieu Hospital, 166 Brock Street, Kingston, Ontario K7L 5G2. Telephone 613-544-3310, fax 613-544-3114, e-mail hookeyl@hdh.kari.net WHAT IS NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY? For most gastroenterologists, one of the first rules of endoscopy is to diligently avoid perforation of the gastrointestinal lumen. While this principle remains true in the majority of cases, therapeutic crossing of the gastric or duodenal lumen is now accepted for pancreatic pseudocyst drainage and percutaneous gastrostomy tube placement. Endoscopic ultrasound-guided fine needle aspiration of abnormalities in the abdomen and mediastinum has further pushed this barrier. Natural orifice translumenal endoscopic surgery (NOTES), first described in 2004 (1), extends the concept of extraluminal endoscopic intervention to another level. The technique begins with the creation of an opening in a natural lumen (most often gastric, although colonic, vesical, vaginal and uterine approaches have been described) using either electrosurgical incision or needle puncture followed by balloon dilation. An endoscope is then passed through the opening, with pneumoperitoneum provided through the endoscope. Procedures such as cholecystectomy and oophorectomy are performed using traditional (snares, biopsy forceps, endo-loops) and nontraditional (endoscopic suturing devices) endoscopic equipment. Upon withdrawal of the endoscope back into the lumen, the wall defect is closed using clips or sutures. Although most work has been limited to animal experiments (most commonly pigs), Drs Reddy and Rao, from the Asian Institute of Gastroenterology in Hyderabad, India, have performed a limited number of transgastric appendectomies in humans (personal communication). The main potential advantages of NOTES are related to the lack of transabdominal incisions. This could possibly reduce anesthetic requirements and postoperative pain, leading to faster recovery. The lack of restricted inspiration secondary to abdominal wall pain could potentially lead to a lower rate of postoperative atelectasis and pneumonia. In addition, patients who traditionally have poorer outcomes with open surgery (those with chronic obstructive pulmonary disease, the morbidly obese, corticosteroid users) may be particularly suited to NOTES, with its potential for easier access to the peritoneum and decreased postoperative recovery. The cosmetic advantage of NOTES, or ‘scarless surgery’, is obvious. However, the importance of this is still debated (2) and the significance that patients would place on this remains to be determined.

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