European Surgery

, Volume 40, Issue 3, pp 103–110 | Cite as

NOTES Techniques: present and future

  • B. W. MiedemaEmail author
  • J. A. Astudillo
  • E. Sporn
  • K. Thaler
Main Topic


BACKGROUND: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a promising approach to decrease surgical morbidity. However, the techniques and instrumentation are still primitive, requiring major modifications for use in NOTES procedures. METHODS: Review of the literature, personal communications and experiences. RESULTS: The operating room environment need to change with a larger sterile field and long sterile tables to accommodate long flexible instruments. Operating systems need to be improved to allow surgeons to have free ergonomic-friendly movements with long instruments. Modified endoscopes or flexible overtubes are required to provide a stable site of dissection at the end of a long flexible tube. Graspers need to be developed that are accurate and robust at a long distance from the operator. Tissue dissection through a flexible channel (ideally ultrasonic) will allow more complex NOTES procedures. Techniques of tissue closure and anastomosis are primitive and need to reach the standard seen with laparoscopic surgery. CONCLUSIONS: It is our judgment that NOTES will play a pivotal role in GI surgery. A general, coordinated effort will probably make NOTES a widespread reality.


NOTES Transluminal Minimally invasive surgery Endoscopy Innovation 

NOTES-Technologien – derzeitiger Stand und Blick in die Zukunft


GRUNDLAGEN: Technische Vorraussetzungen und Instrumentarium für NOTES (Natural Orifice Transluminal Endoscopic Surgery) stecken noch immer in ihren Kinderschuhen. METHODIK: Literaturübersicht, persönliche Erfahrungen und Expertenmeinungen. ERGEBNISSE: Sterilität von Endoskopen und der dazugehörigen Instrumente machen Adaptationen im Operationssaal erforderlich. Die Modifikation von herkömmlichen Endoskopen, die Entwicklung von flexiblen Overtubes, ergonomischen Arbeitsplattformen und von endoskopische Instrumenten, die gut steuerbar und trotzdem stabil sind, ist die Grundvoraussetzung zur sicheren Etablierung von NOTES. Endoskopische Verschluss- und Anastomosentechniken müssen weiterentwickelt werden, um den Standards der laparoskopischen Chirurgie gerecht zu werden. SCHLUSSFOLGERUNGEN: Wir glauben, dass NOTES eine bedeutende Rolle in der Chirurgie des Gastrointestinaltraktes spielen wird. Ein koordiniertes, kontrollierte Vorgehen ist nötig, um NOTES zur Realität werden zu lassen.


NOTES Transluminal Minimal-invasive Chirurgie Endoskopie Innovation 


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  1. Hochberger J, Lamade W. Transgastric surgery in the abdomen: the dawn of a new era? Gastrointest Endosc 2005;62:293–6PubMedCrossRefGoogle Scholar
  2. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004;60:114–7PubMedCrossRefGoogle Scholar
  3. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005. Gastrointest Endosc 2006;63:199–203Google Scholar
  4. Ellsmere J, Jones D, Pleskow D, Chuttani R. Endoluminal instrumentation is changing gastrointestinal surgery. Surg Innov 2006;13:145–51PubMedCrossRefGoogle Scholar
  5. McGee MF, Rosen MJ, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J. A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Innov 2006;13:86–93PubMedCrossRefGoogle Scholar
  6. Swanstrom LL, Whiteford M, Khajanchee Y. Developing essential tools to enable transgastric surgery. Surg Endosc 2008;22:600–4PubMedCrossRefGoogle Scholar
  7. Christian J, Barrier BF, Miedema BW, Thaler K. Culdoscopy: a foundation for natural orifice surgery – past, present and future. J Am Coll Surg 2008; (in press)Google Scholar
  8. Astudillo JA, Sporn E, Miedema BW, Thaler K. Transgastric cholecystectomy using a prototype endoscope with two deflecting working channels. Gastrointest Endosc 2008; (in press)Google Scholar
  9. Bachman SL, Sporn E, Furrer JA, Mytyk CR, Thaler K, Miedema BW. Colonic sterilization for NOTES procedures – acomparison of two decontamination protocols. SAGES (abstract); 2008Google Scholar
  10. Kochman ML, Swain CP. Deconstruction of the endoscope. Gastrointest Endosc 2007;65:677–8PubMedCrossRefGoogle Scholar
  11. Thompson CC, Ryou M, Rothstein RI, Fong DG, Pai RD, Smith P, Weitzner BD. Stomach – direct drive endoscopic system for endoluminal and NOTES applications. The DAVE Project, 2008Google Scholar
  12. Swanstrom LL, Smith P, Weitzner BD, Rothstein RI, Soper ND, Thompson CC, Hungness E. Engineering and evaluating an ergonomic endoscopic operating platform with triangulation. SAGES (abstract); 2008Google Scholar
  13. Lehman AC, Dumpert J, Wood BS, Visty AQ, Reden L, Farritor SM, Varnell BD, Oleynikov D. Natural orifice cholecystectomy using a miniature robot. Surg Endosc 2008;22:S157Google Scholar
  14. Scott DJ, Tang SJ, Fernandez R, Bergs R, Goova MT, Zeltser I, Kehdy FJ, Cadeddu JA. Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments. Surg Endosc 2007;21:2308–16PubMedCrossRefGoogle Scholar
  15. Ikeda K, Fritscher-Ravens A, Mosse CA, Mills T, Tajiri H, Swain CP. Endoscopic full-thickness resection with sutured closure in a porcine model. Gastrointest Endosc 2005;62:122–9PubMedCrossRefGoogle Scholar
  16. Swanstrom LL, Kozarek R, Pasricha PJ, Gross S, Birkett D, Park PO, Saadat V, Ewers R, Swain P. Development of a new access device for transgastric surgery. J Gastrointest Surg 2005;9:1129–36; discussion 1136–27PubMedCrossRefGoogle Scholar
  17. Sclabas GM, Swain P, Swanstrom LL Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES). Surg Innov 2006;13:23–30PubMedCrossRefGoogle Scholar
  18. Hu B, Chung SC, Sun LC, Kawashima K, Yamamoto T, Cotton PB, Gostout CJ, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ. Eagle Claw II: a novel endosuture device that uses a curved needle for major arterial bleeding: a bench study. Gastrointest Endosc 2005;62:266–70PubMedCrossRefGoogle Scholar
  19. Sporn E, Miedema BW, Bachman SL, Astudillo JA, Loy TS, Calaluce RD, Thaler K. Endoscopic colotomy closure after full thickness excision – Comparison of T-fastener versus multi-clip applier. Endoscopy 2008; (in press)Google Scholar
  20. Fujii T, Ono A, Fu KI. A novel endoscopic suturing technique using a specially designed so-called "8-ring" in combination with resolution clips (with videos). Gastrointest Endosc 2007;66:1215–20PubMedCrossRefGoogle Scholar
  21. Tsereteli Z, Sporn E, Geiger T, Miedema BW, Rangnekar N, Thaler K. Placement of a temporary covered stent supports healing of a colorectal anastomosis: observations in a large animal model. EAES (abstract); 2007Google Scholar
  22. Aggarwal R, Darzi A. Compression anastomoses revisited. J Am Coll Surg 2005;201:965–71PubMedCrossRefGoogle Scholar
  23. Nudelman IL, Fuko VV, Morgenstern S, Giler S, Lelcuk S. Gastrointestinal anastomosis with the nickel-titanium double ring. World J Surg 2000;24:874–7PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • B. W. Miedema
    • 1
    Email author
  • J. A. Astudillo
    • 1
  • E. Sporn
    • 1
  • K. Thaler
    • 1
  1. 1.Department of SurgeryUniversity of MissouriColumbiaUSA

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