Natural orifice translumenal endoscopic surgery (NOTES) challenges and drawbacks

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Editor-In-Chief: Mohammed A. Sbeih, M.D. [mailto:msbeih@perfuse.org] Phone:617-849-2629

Synonyms and keywords: Natural orifice translumenal endoscopic surgery, Single incision laparoscopic surgery, Minimally invasive surgery, Transanal endoscopic microsurgery, Natural orifice surgery consortium for assessment and research, Society of american gastrointestinal and endoscopic surgeons.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) Challenges and Drawbacks

 * Puncturing one of the viscera to perform the surgical procedure. This needs to be assessed thoroughly regarding the presence of long term complications, higher infection rates, and the reliability of puncture closure. Methods of reliable full thickness, watertight closure for the puncture sites in different organs should be developed. There are three closure methods:
 * Endoscopic Clips can be used to close the wound (from the periphery to the center). It is considered tight and safe but more clinical studies should be conducted to confirm the safety of this closure technique.
 * Laparoscopic closure using the single-hand fashion by inserting a needle-holder and the scope through tiny trocars.
 * New technological closure devices are underway to be used.


 * Instrumentation is still inadequate to perform all NOTES procedures. Innovative instruments are needed to perform various NOTES procedures more easily.


 * The use of flexible endoscopes may result in loss of spatial orientation and depth perception. Loss of triangulation of optics and instrumentation may limit the range of motion for performing the procedure and may obscure part of the operation field. The current version of NOTES instruments and endoscopes may preclude such triangulation in NOTES procedures . This is a potential barrier especially for surgeons who are trained to rigid laparoscopes. It may be very challenging for the surgeon to maintain spatial orientation during the NOTES procedure, and the procedure performance can be limited to certain points of natural entry. To provide a straight access to the operating field; lower abdominal and pelvic NOTES procedures usually performed via a transgastric approach. Upper abdominal procedures and cholecystectomy usually performed via transvaginal or transanal approach. Many investigators have encountered these constraints along with some ethical challenges.


 * A high quality of training should be provided for those who are going to perform NOTES procedures (surgeons or gastroenterologists). They should know abdominal anatomy and surgical principles, and be able to use flexible endoscopes professionally. They also should masterfully exhibit the ability to manage complications. Costly and time consuming NOTES training sessions should be provided for surgeons and gastroenterologists before they could be able to apply NOTES clinically.


 * An argument can be made that single-incision laparoscopic surgery (SILS) can be more convenient than NOTES for some procedures, especially with the presence of advanced surgical technologies that could be applied in laparoscopic surgery.


 * Surveys showed that most women may not favor transvaginal NOTES procedures over laparoscopic approach, especially young nulliparous women who are concerned about the sexual function . However, another study showed that there is considerable public interest in NOTES and women would be receptive to this new surgical technique because of decreased risk of hernia and operative pain . Cultural and geographical variations may also play a roll in the decision to accept a transvaginal surgery or not.


 * It is more difficult to handle complications in NOTES compared with other approaches because of the limited space available for the NOTES instruments. This may require conversion of the procedure to be open or laparoscopic sometimes. Recent studies demonstrated that 5 to 10 percent of NOTES procedures could be complicated, most of the complications occur in the transgastric approach . Beside the complications of any surgical operation (laceration, perforation and bleeding, etc.), NOTES complications may also include:
 * Injury to abdominal organs
 * Bowel perforation or injury
 * Biliary fistulae and leaks
 * Urinary incontinence
 * Fecal incontinence
 * Peritonitis


 * In NOTES procedures, There is higher risk of over insufflation of the peritoneal cavity by using a ﬂexible endoscope. This may decrease the venous return to the heart and lead to undesired systemic effects, such as hemodynamic instability and respiratory compromise . This could be prevented in laparoscopic surgery by using pressure sensors. There should be continuous monitoring of intra-abdominal pressures during NOTES procedures; this has been applied in animal studies . Using a standard autoregulated insufﬂators, which is used in laparoscopic surgery, and feedback pressure valves in ﬂexible endoscopes can also be a solution for this problem.


 * Financial resources are required for the technological developments and NOTES implementation.


 * In general, operative time may be longer in some NOTES procedures than the standard laparoscopic approach. Adequate instrumentation and training might shorten the time required for NOTES in the future.