Abstract
Background
Natural orifice translumenal endoscopic surgery (NOTES), with its focus on eliminating incision-related complications, promises to revolutionize the way surgery is performed. This study aimed to summarize the clinical applications of NOTES for humans, outline the techniques used, and discuss the complications and limitations of current techniques.
Methods
A literature search was performed using PubMed and Medline search tools to review the extent and outcomes of human procedures undertaken using the NOTES technique in its pure form or as a hybrid procedure reported until July 2008. The end points were the types of operation performed, the approach and technique used for each operation, and the procedure-related complications and technical limitations.
Results
This review considered 16 publications reporting on 49 human subjects. All the studies except three used hybrid NOTES procedures, with varying amounts of transabdominal assistance. Three transvaginal cholecystectomies, one transvaginal appendectomy, and eight transgastric appendectomies have been performed using a pure NOTES technique. To date, 15 NOTES transvaginal cholecystectomies and 10 NOTES appendectomies (8 transgastric and 2 transvaginal) are reported. Other procedures including peritoneoscopy and sigmoid colectomy are described. Three cases of minor morbidity are reported and no mortality.
Conclusions
Although initial human results seem encouraging, it is important that this research be conducted in a way that minimizes bad publicity and describes both favorable and adverse outcomes. Robust trials must be conducted at established centers with appropriate experience and institutional board ethical review to allow safe introduction of this novel technique, with adequate and expedient reporting of serious adverse events. The limitations of the current tools and methods are discussed, and suggestions are made for further improvements in the technology to facilitate NOTES operations.
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References
Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier H (1985) Endoscopic surgery in the rectum. Endoscopy 17:31–35
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 21:1870–1874
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 60:114–117
Hawes RH (2008) Transition from laboratory to clinical practice in NOTES: role of NOSCAR. Gastrointest Endosc Clin North Am 18:333–341
Isariyawongse JP, McGee MF, Rosen MJ, Cherullo EE, Ponsky LE (2008) Pure natural orifice transluminal endoscopic surgery (NOTES): nephrectomy using standard laparoscopic instruments in the porcine model. J Endourol 22(5):1087–1091
Ryou M, Fong DG, Pai RD, Tavakkolizadeh A, Rattner DW, Thompson CC (2007) Dual-port distal pancreatectomy using a prototype endoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery (NOTES) survival study in a porcine model. Endoscopy 39:881–887
Scott DJ, Tang SJ, Fernandez R, Bergs R, Goova MT, Zeltser I, Kehdy FJ, Cadeddu JA (2007) Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments. Surg Endosc 21:2308–2316
Flora ED, Wilson TG, Martin IJ, O’Rourke NA, Maddern GJ (2008) A review of natural orifice translumenal endoscopic surgery (NOTES) for intraabdominal surgery: experimental models, techniques, and applicability to the clinical setting. Ann Surg 247:583–602
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 66:1243–1245
Branco Filho AJ, Noda RW, Kondo W, Kawahara N, Rangel M, Branco AW (2007) Initial experience with hybrid transvaginal cholecystectomy. Gastrointest Endosc 66:1245–1248
Hazey JW, Narula VK, Renton DB, Reavis KM, Paul CM, Hinshaw KE, Muscarella P, Ellison EC, Melvin WS (2008) Natural orifice transgastric endoscopic peritoneoscopy in humans: initial clinical trial. Surg Endosc 22:16–20
Gettman MT, Blute ML (2007) Transvesical peritoneoscopy: initial clinical evaluation of the bladder as a portal for natural orifice translumenal endoscopic surgery. Mayo Clin Proc 82:843–845
Marks JM, Ponsky JL, Pearl JP, McGee MF (2007) PEG “Rescue”: a practical NOTES technique. Surg Endosc 21:816–819
Bernhardt J, Gerber B, Schober HC, Kähler G, Ludwig K (2008) NOTES: case report of a unidirectional flexible appendectomy. Int J Colorectal Dis 23:547–550
Forgione A, Maggioni D, Sansonna F, Ferrari C, Di Lernia S, Citterio D, Magistro C, Frigerio L, Pugliese R (2008) Transvaginal endoscopic cholecystectomy in human beings: preliminary results. J Laparoendosc Adv Surg Tech A 18:345–351
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 142:823–826
Pearl JP, Onders RP, Marks JM et al (2007) Transgastric endoscopic peritoneoscopy in humans under laparoscopic visualization: a bridge to NOTES. Gastrointest Endosc 65:AB292
Rao GV, Reddy DN, Banerjee R (2008) NOTES: human experience. Gastrointest Endosc Clin North Am 18:361–370
Steele K, Schweitzer MA, Lyn-Sue J, Kantsevoy SV (2008) Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos). Gastrointest Endosc 68:61–66
Decarli L, Zorron R, Branco A, Lima FC, Tang M, Pioneer SR, Zanin I Jr, Schulte AA, Bigolin AV, Gagner M (2008) Natural orifice translumenal endoscopic surgery (NOTES): transvaginal cholecystectomy in a morbidly obese patient. Obes Surg 18(7):886–889
Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22:1717–1723
Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES-world’s first report. Surg Endosc 22:1343–1347
Dolz C, Noguera JF, Martín A, Vilella A, Cuadrado A (2007) Transvaginal cholecystectomy (NOTES) combined with minilaparoscopy (in Spanish). Rev Esp Enferm Dig 99:698–702
Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M (2008) NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc 22:542–547
Zornig C, Mofid H, Emmermann A, Alm M, von Waldenfels HA, Felixmüller C (2008) Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients. Surg Endosc 22:1427–1429
Tsin DA, Colombero LT, Lambeck J, Manolas P (2007) Minilaparoscopy-assisted natural orifice surgery. JSLS 11:24–29
Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Praveenraj P (2008) Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique. Endoscopy 40:428–431
Ponsky JL, Rosen MJ, Poulose BK (2008) NOTES: of caution. Surg Endosc 22:1561–1562
Simopoulos C, Kouklakis G, Zezos P, Ypsilantis P, Botaitis S, Tsalikidis C, Pitiakoudis M (2008) Peroral transgastric endoscopic procedures in pigs: feasibility, survival, questionings, and pitfalls. Surg Endosc [Epub ahead of print]
Canes D, Desai MM, Aron M, Haber GP, Goel RK, Stein RJ, Kaouk JH, Gill IS (2008) Transumbilical single-port surgery: evolution and current status. Eur Urol 54(5):1020–1029
Zacharakis E, Purkayastha S, Teare J, Yang GZ, Darzi A (2008) Natural orifices translumenal endoscopic surgery (NOTES): who should perform it? Surgery 144:1–2
von Delius S, Gillen S, Doundoulakis E, Schneider A, Wilhelm D, Fiolka A, Wagenpfeil S, Schmid RM, Feussner H, Meining A (2008) Comparison of transgastric access techniques for natural orifice transluminal endoscopic surgery. Gastrointest Endosc 68(5):940–947
Ryou M, Fong DG, Pai RD, Rattner DW, Thompson CC (2008) Transluminal closure for NOTES: an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities. Endoscopy 40:432–436
Magno P, Giday SA, Dray X, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Kalloo AN, Pasricha PJ, White JJ, Assumpcao L, Marohn MR, Gabrielson KL, Kantsevoy SV (2007) A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial. Endoscopy 39:876–880
McGee MF, Marks JM, Jin J, Williams C, Chak A, Schomisch SJ, Andrews J, Okada S, Ponsky JL (2008) Complete endoscopic closure of gastric defects using a full-thickness tissue plicating device. J Gastrointest Surg 12:38–45
von Delius S, Huber W, Feussner H, Wilhelm D, Karagianni A, Henke J, Preissel A, Schneider A, Schmid RM, Meining A (2007) Effect of pneumoperitoneum on hemodynamics and inspiratory pressures during natural orifice transluminal endoscopic surgery (NOTES): an experimental, controlled study in an acute porcine model. Endoscopy 39:854–861
Jha A (2007) £2 m to develop i-Snake robot for keyhole surgery. The guardian on-line. Retrieved December 29, 2007 at http://www.guardian.co.uk/science/2007/dec/29/medicalresearch
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Sodergren, M.H., Clark, J., Athanasiou, T. et al. Natural orifice translumenal endoscopic surgery: critical appraisal of applications in clinical practice. Surg Endosc 23, 680–687 (2009). https://doi.org/10.1007/s00464-008-0278-1
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DOI: https://doi.org/10.1007/s00464-008-0278-1