Journal of Gastrointestinal Surgery

, Volume 13, Issue 8, pp 1401–1410

Surgeon Perceptions of Natural Orifice Translumenal Endoscopic Surgery (NOTES)


    • Department of SurgeryNorthwestern University Feinberg School of Medicine
  • Eric S. Hungness
    • Department of SurgeryNorthwestern University Feinberg School of Medicine
  • Nathaniel J. Soper
    • Department of SurgeryNorthwestern University Feinberg School of Medicine
  • Lee L. Swanstrom
    • Department of SurgeryLegacy Health System and Oregon Health Sciences University
SSAT Poster Presentation

DOI: 10.1007/s11605-009-0921-8

Cite this article as:
Volckmann, E.T., Hungness, E.S., Soper, N.J. et al. J Gastrointest Surg (2009) 13: 1401. doi:10.1007/s11605-009-0921-8



If proven feasible and safe, Natural Orifice Translumenal Endoscopic Surgery (NOTES) would still need acceptance by surgeons if it were to become a mainstream approach.


Three hundred fifty-seven surgeons responded to a preliminary survey describing NOTES and were asked to rate the importance of various surgical considerations and (assuming availability and safety) if they would choose to undergo and/or perform cholecystectomies by NOTES or laparoscopy and why.


The risk of having a complication was considered most important. NOTES was theorized to be riskier and to require greater skill than laparoscopy but to potentially cause less pain and convalescence. Nearly three-fourths (72%) of surgeons expressed interest in NOTES training which correlated with younger age, SAGES membership, minimally invasive surgery specialization, and flexible endoscopic volume. Forty-four percent would like to introduce NOTES cholecystectomy into their practices. Among those not preferring NOTES, 88% would adopt NOTES if data showed improved outcomes over laparoscopy. Finally, only 24% would choose to undergo cholecystectomy themselves by NOTES, believing it to be too new and riskier than laparoscopy.


The risk of having a complication is the greatest concern among surgeons, and safety will affect NOTES acceptance.


The results of this survey seem to justify more focused future investigations.


NOTESFlexible endoscopyNew technologySurgeryAttitude of health personnel


Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a surgical approach that combines elements of flexible endoscopy and laparoscopic surgery. It is currently being studied in research labs and in limited clinical studies. Since the first report of NOTES procedures in experimental animals in 2004,1 NOTES has generated excitement among surgeons and gastroenterologists. The ability to offer even less invasive surgical techniques than conventional laparoscopy has inherent merit. NOTES procedures could theoretically be accompanied by less pain, shorter recovery time, and absent or reduced abdominal wall incisions when compared to laparoscopic operations. These considerations have resulted in a new direction of research and led to the creation of the Natural Orifice Surgery Consortium for Assessment and Research. This consortium, comprised of leaders of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Society for Gastrointestinal Endoscopy, has identified key elements to limit patient harms as well as potential barriers to NOTES requiring further investigation, and has allocated industry-sponsored grant money to researchers studying these areas of interest.2

To date, the majority of research pertaining to NOTES has been confined to studies in large animal or human cadaver models. This research has consisted of studies of various NOTES procedures, alternative translumenal access sites (gastric, colonic, urethral, and vaginal), investigations of the physiology of NOTES, and the application and testing of new technologies including those for the closure of access sites. Most of this research has been clustered at a relatively small number of academic medical centers and performed by limited numbers of skilled researchers and physicians. However, the number of researchers investigating NOTES is growing, and NOTES and NOTES-assisted minimally invasive operations have been reported in a small number of patients under experimental, IRB-approved protocols.37

For NOTES to advance beyond animal studies and anecdotal human case reports and become a mainstream surgical procedure, it will need to be accepted and embraced by both patients and physicians. The combined perceptions of these groups will affect the demand for NOTES as an alternative to current minimally invasive surgical techniques. The understanding of patient and physician perceptions of NOTES is, thus, important to help guide the trajectory of physician training, research efforts, and the allocation of research and development funding.

Recently we found that if given the choice in a hypothetical scenario, a majority of patients would prefer to have cholecystectomy via NOTES rather than by laparoscopy.8 Patients indicated that when making a decision to undergo surgery, their most important consideration was the risk of suffering a complication, followed in decreasing importance by time to full recovery, amount of postoperative recovery time, and length of hospital stay (LOS). As the hypothetical surgeon’s experience decreased and the risk of complications increased, there was a corresponding diminution in patient preference for NOTES. Furthermore, most patients preferring the NOTES approach to cholecystectomy would still choose this technique if it had a slightly greater risk of complications (2% vs. 1%) but not if associated with a markedly higher risk of complications (10% vs. 1%). In order to better understand surgeons’ perceptions of NOTES, we conducted an opinion survey of surgeons from three major surgical societies.

Material and Methods

A 75-item survey was offered electronically to members of the Society for Surgery of the Alimentary Tract (SSAT), SAGES, and the American College of Surgeons (ACS) after obtaining permission from each organization, as well as institutional review board approval from Northwestern University and Legacy Health System. Survey subjects were solicited via direct email messaging (SSAT) and email newsletters (SAGES Mini-Scope, ACS NewsScope) which briefly described the study and provided an internet hyperlink to a secure online survey ( In this manner, the study hyperlink was distributed to approximately 45,000 physicians. Eighty-five percent of these emails were sent via the ACS NewsScope, 11% were sent through the SAGES Mini-Scope, and 4% were distributed via direct email to SSAT members. Whereas the hyperlink to the survey could only be included within the electronic newsletters of the ACS and SAGES, the email sent by the SSAT was a focused, direct request for participation in the study.

The posted survey included a brief introduction describing the basic concepts of NOTES and (assuming safety and availability) how NOTES might be applied to cholecystectomy in the setting of symptomatic cholelithiasis (Appendix 1). Demographic information was then collected, and surgeons were asked to rate the importance of procedure-specific considerations including cost, complication risk, length of hospitalization, anesthesia type (general anesthesia vs. conscious sedation), cosmesis, and postoperative pain and recovery time. Surgeon perceptions of NOTES, laparoscopy, and traditional open procedures were subsequently measured with respect to these surgical considerations on an analog scale of 0–5. Questions aimed at assessing surgeons’ interest in NOTES, or lack thereof, and the reasons for these sentiments were also posed (Appendix 2).

Data were collected anonymously and coded numerically. Responses were downloaded in Microsoft Excel before analysis for significance using SPSS 14.0 (SPSS, Chicago, IL, USA). Only responses from completed surveys were recorded. Significance was determined using chi-square and Wilcoxon signed ranks tests as well as forward stepwise logistic regressions.


Three hundred fifty-seven surgeons completed the questionnaire. Overlap was present among society memberships with 85.4% of respondents belonging to the ACS, 66.4% to the SSAT, and 56.9% to SAGES (39.5% were members of all 3 societies, Table 1). The overall response rate from the study was less than 1% (0.79%). Among the 1,977 email messages sent via the SSAT, 181 members (9.2%) followed the link to the survey. It cannot be determined how many of these SSAT members completed the survey or what proportion of the total 237 respondents from the SSAT were directly attributable to this email message.
Table 1

Surgeon Demographics

Surgeons surveyed


Age (mean)


Age < 60 years old


Society membership
















Minimally invasive




General surgery




Surgical oncology






Heard of NOTES


Perform flexible endoscopy in <10% cases


The median surgeon age was 46 years, 66.1% reported using flexible endoscopy in less than 10% of their cases, and 65.2% listed their specialty as either gastrointestinal (21.8%), minimally invasive surgery (MIS; 22.7%), or general surgery (20.7%, Table 1). In deciding upon a surgical approach, the risk of a complication was the most important consideration to surgeons and complication risk, recovery time, amount of postoperative pain, and length of stay were each felt to be to be more important than cosmesis, cost, or anesthesia type (p < 0.005; Fig. 1). When NOTES was compared independently to laparoscopy and laparotomy, it was felt to require significantly greater technical skill and be associated with less pain and shorter recovery, while having higher costs and increased risk of complications than the other approaches (p < 0.05; Fig. 2).
Figure 1

Surgeon considerations 1 unimportant, 2 somewhat unimportant, 3 neither important nor unimportant, 4 somewhat important, 5 important. Complication risk, time to full recovery, postoperative pain, and LOS were each significantly more important than anesthesia type, procedure cost, or cosmesis (Wilcoxon Signed Ranks p < 0.005).
Figure 2

Procedure perceptions 0 none, 1 very low, 2 low, 3 moderate, 4 high, 5 highest. NOTES was perceived to be associated with less pain and shorter recovery, while requiring greater skill and having increased costs and risk of complications when compared independently to open and laparoscopic surgery (Wilcoxon Signed Ranks p < 0.001).

Seventy-two percent of these surgeons expressed an interest in becoming trained in NOTES, and 47% of subjects felt that it would eventually become a mainstream surgical approach. When interest in becoming trained in NOTES was analyzed by society, 81.3% (p < 0.001) of SAGES members indicated that they were interested. Although a majority of SSAT members (70.5%) and ACS members (71.5%) were interested in NOTES training, this was not statistically significant. In addition, 71.9% of SSAT and 69.3% of ACS members responding this way were also members of SAGES (Table 2). Data analysis using a forward stepwise logistic regression of physician characteristics that were found to be significant during chi-square analysis was performed to avoid confounding errors due to overlapping characteristics. This showed that age less than 60, minimally invasive surgery (MIS) specialization and SAGES membership correlated significantly with increased interest in NOTES training while the performance of flexible endoscopy in less than 10% of their practices was predictive of decreased interest (Table 3).
Table 2

Interest in Becoming Trained in NOTES by Society Membership and MIS Specialization

Society/MIS specialty

% NOTES interest

% SAGES members (among those with NOTES interest)

% MIS specialization (among those with NOTES interest)


81.3% (p < 0.001) (N = 165)

100% (N = 165)

35.3% (N = 65)


70.5% (N = 167)

71.9% (N = 120)

28.7% (N = 48)


71.5% (N = 218)

69.3% (N = 151)

28.9% (N = 63)

MIS specialization

90.1% (p < 0.001; N = 73)

89.0% (N = 65)

100% (N = 73)

Table 3

Surgeon Characteristics Correlating with Interest in Becoming Trained in NOTES


Odds ratio

P valuea

95% C.I.



Age < 60





MIS specialty





SAGES membership





Less than 10% endoscopy





aAnalysis using forward stepwise logistic regression demonstrated significantly increased interest in NOTES with age less than 60 and MIS specialization and decreased NOTES interest with low endoscopy practice volume

In addition, when surgeons were asked the question: “Assuming NOTES was feasible, available in your hospital, and that you were trained to operate in this fashion, would you choose to perform NOTES rather than laparoscopy as the preferred surgical approach for cholecystectomy?,” 44% of those surveyed answered affirmatively. If the complication rate for NOTES was slightly higher (2% vs. 1%) compared to laparoscopy, 61% of these surgeons would still prefer NOTES while only 3% would still prefer NOTES if the complication rate was significantly higher (10% vs. 1%). Surgeons choosing NOTES over laparoscopic cholecystectomy would also be less likely to do so if they had to travel farther to perform the procedure, with 76% willing to travel to another hospital in the same city to perform the procedure and only 41% and 13% willing to still perform the procedure if they had to travel 25 and 100 miles, respectively. Among the 56% of surgeons who would not prefer to perform cholecystectomy by NOTES, 88% indicated that they would change to a NOTES approach if data demonstrated improved outcomes vs. laparoscopy (Table 4). However, when surgeons were asked whether they would choose to personally undergo NOTES cholecystectomy if it were currently available, only 26% of surgeons opted for NOTES over laparoscopy, with most of these individuals citing that it was too new and more risky (Fig. 3, Table 5).
Figure 3

Percentage of surgeons who would choose to personally undergo NOTES cholecystectomy.

Table 4

Surgeon Interest in NOTES

Interested in becoming trained in NOTES


Believe NOTES will eventually become a mainstream procedure


Would prefer to perform cholecystectomy by NOTES if it was feasible and safe


Among surgeons not preferring to perform NOTES cholecystectomy, would change to NOTES if data showed improved outcomes


Table 5

Reasons Given by Surgeons for Choosing Not to Personally Undergo NOTES Cholecystectomy

NOTES more risky


NOTES too new


See no advantage to NOTES



18.3% (Enterotomy risk, 66%)

Do not like concept of NOTES



This is the first study examining the perceptions of surgeons at large regarding Natural Orifice Translumenal Endoscopic Surgery, providing valuable insight into surgeon interest in NOTES and allowing identification of potential barriers to its adoption. When the data collected in this study are compared to some of the findings from our earlier survey of patient opinions, a number of similarities and differences are apparent. Most notably, the considerations of greatest importance to surgeons when considering a surgical approach are the same as those for patients when deciding which surgical procedure to undergo. Both groups felt that the risk of suffering a complication due to surgery was the most important consideration, followed by time to full recovery, postoperative pain, and LOS, in that order. In addition, these four considerations were each judged to be significantly more important than procedure cost, anesthesia type, or cosmesis. As was found for patients, cosmesis was the least important concern for surgeons.

Surgeon perceptions were also similar to our earlier findings for patients in that they believed NOTES would be associated with less pain and shorter recovery time, but would require greater skill than either laparoscopy or open surgical procedures. In contrast to patients, who equate a NOTES approach with less risk and cost, surgeons believe NOTES carries greater risks and costs than laparoscopic or open procedures. This may explain why only 26% of surgeons would be willing to personally undergo NOTES vs. laparoscopic cholecystectomy and may be further supported by the fact that among surgeons opting not to undergo NOTES 79% felt it was too risky and another 70% felt it was too new. This finding is similar to findings by Windsor et al. that the “absence of long-term results” and potential complications were major factors in the slow introduction and adoption of laparoscopic inguinal hernia.9 A frequently voiced concern among surgeons completing the survey was the risk of leakage from the enterotomy necessary for access to the abdominal cavity. Given how important the risk of a surgical complication is to both surgeons and patients, it is likely that the differences in the perceived risk of NOTES accounts for some of the difference between patient and surgeon preference to personally undergo a NOTES procedure.

While the majority of surgeons would not elect to personally undergo a NOTES cholecystectomy, it is interesting that 72% of those surgeons surveyed would be interested in becoming trained in NOTES, and roughly half of the surgeons surveyed believed that NOTES will eventually become a mainstream surgical procedure. Not surprisingly, younger surgeons, minimally invasive surgeons, and SAGES members displayed greater interest in NOTES. Interestingly, Escarce et al. likewise demonstrated that surgeons 30–40 years of age adopted laparoscopic cholecystectomy earlier than older surgeons.10 It is possible that surgeons, particularly those with a vested interest in minimally invasive surgery and endoscopy, would want to become trained in NOTES in the event that it becomes a commonly accepted minimally invasive surgical approach with better outcomes than laparoscopy. This is echoed by the fact that although only 44% of surgeons would chose to perform a NOTES cholecystectomy even if it was judged to be feasible and safe, 88% of these surgeons would switch to the NOTES approach if it demonstrated improved outcomes versus laparoscopy. A study examining adoption of laparoscopic cholecystectomy likewise showed “[m]ore than three fourths of adopters identified the desire to keep up with the state-of-the-art and improved patient outcomes as very or extremely important reasons for adoption”.11 Furthermore, informal discussions suggest that some surgeons feel they did not adopt laparoscopy early enough in its development and so not want to “miss the boat” if NOTES becomes mainstream.

There are several limitations and potential biases with our study that need to be discussed. The low response rate of the survey is readily apparent. Using direct email rather than utilizing electronic newsletters may have improved the response rate from SAGES and ACS members, as 9.1% of SSAT members who were directly emailed followed the link to the survey. Only completed surveys were included in the study and the length of this broad, opinion survey may have further contributed to the low response rate. Our surgeon demographic may also not have been representative of the entire general surgery cohort, with a selection bias toward academic surgeons and/or those interested in minimally invasive surgery. This is represented in the fact that 57% and 66% of surgeons were members of SAGES and SSAT, respectively. Furthermore, over 60% of the SSAT and ACS members who responded to the study were also members of SAGES. Sampling the entire cohort of surgeons may or may not demonstrate greater skepticism toward NOTES. Interestingly, although one would expect academic surgeons to be early adopters of new surgical technology, Escarce et al. showed that surgeons with a full-time faculty appointment were slower to adopt laparoscopic cholecystectomy than private practice surgeons.10

The language used in the survey may also bias the results of our study. The survey posited that “appropriate instrumentation” for NOTES is available and that “you or another physician…is fully trained and credentialed to perform a NOTES cholecystectomy”. Such instrumentation, training, and credentialing issues have not been thoroughly addressed thus far in the early stages of NOTES, so our results may not apply to the present status of the practice. At the very least, our results give us a glimpse into the decision making process of surgeons on the adoption of new surgical technologies.


Although only one fourth of surgeons would currently choose to undergo a NOTES cholecystectomy themselves and 53% thought it would not become a mainstream approach, a large majority would be interested in becoming trained in NOTES if it were clinically available and easily accessible. Interest in NOTES is affected by a surgeon’s age, SAGES membership, and specialization in minimally invasive surgery, as well as flexible endoscopic volume, with younger age, and increased volume of minimally invasive and flexible endoscopic procedures being predictive of increased interest. The results of this study also demonstrate that the risk of a procedure-related complication is the most important concern for surgeons contemplating NOTES. This sentiment echoes our earlier patient survey which suggested that the majority of patients would prefer to undergo NOTES cholecystectomy as long as their surgeon was well trained, and the risks of the procedure were not significantly greater than for laparoscopic cholecystectomy. These findings suggest that the acceptance by surgeons of NOTES will be contingent upon evidence of its safety and the findings of this preliminary study may serve as a framework for more focused studies in the future.


The authors would like to thank Joseph Feinglass, PhD, Research Associate Professor, Division of General Internal Medicine, Northwestern University Medical School for his assistance with the statistical analysis of the data collected in this study.

Copyright information

© The Society for Surgery of the Alimentary Tract 2009