Exit Strategies

Abstract

Natural orifice translumenal endoscopic surgery (NOTES) offers the potential advantages of reduced pain and improved recovery time when compared to standard open or laparoscopic interventions. Laparoscopic surgical approaches set a high standard with a low rate of anastomotic breakdown and a low procedure-related morbidity. The generalized application of NOTES is limited by the lack of a reproducible, durable transvisceral closure. Many challenges are faced in designing this closure mechanism, including full-thickness tissue incorporation, visualization postprocedure until the luminal defect is closed, and avoidance of inadvertent injury to surrounding structures. Closure devices described in the literature include endoscopic suturing, stapling, clip, and t-tag closure devices, each having advantages and disadvantages. The evaluation of these closure devices has not been standardized, and the best platform on which to base anastomotic integrity remains to be determined. Techniques reviewed here include pressure testing, fluid- and air-leak models, and endoscopic monitoring. Despite many attempts, no transvisceral closure device has shown clear superiority. The challenge of providing a low-morbidity, durable closure is a hurdle that must be overcome before novel technique of NOTES can be instituted in widespread human use.