Natural orifice transluminal endoscopic surgery

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique whereby "scarless" abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, urethra, anus, etc.) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.

State of Research
This technique has been used for diagnostic and therapeutic procedures in animal models, including transgastric (through the stomach) organ removal. Most recently, the transvesical and the transcolonic approaches have been advocated by some researchers as being more suited to access upper abdominal structures that are often more difficult to work with using a transgastric approach. In this sequence, a group from Portugal used transgastric and transvesical combined approach to increase the feasibility of moderately complex procedures such as cholecystectomy. NOTES was originally described in animals by researchers at Johns Hopkins University (Dr. Anthony Kalloo et al.), and was recently used for transgastric appendicectomy in humans in India (by Drs. G.V. Rao and N. Reddy). On June 25 2007 Swanstrom and colleagues reported the first human transgastric cholecystectomy.

The transvaginal access to NOTES seems to be the most safe and feasible for clinical application. In early March 2007, the NOTES Research Group in Rio de Janeiro, Brazil, lead by Dr. Ricardo Zorron, performed the first series of transvaginal NOTES cholecystectomy in four patients, based in previous experimental studies. Later on the same month, Dr. Marc Bessler was successful in performing a hybrid transvaginal cholecystectomy with 3 abdominal ports New York City. Dr. Marescaux, from EITS-IRCAD Strassbourg, France, has performed (arguably) the first pure NOTES cholecystectomy in a patient in early April 2007 using only a Veress needle as the only abdominal port. With fewer potential complications, the procedure has a disadvantage of being possible only in women.

Proponents and researchers in this field recognize the potential of this technique to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions. NOTES could be the next major paradigm shift in surgery, just as laparoscopy was the major paradigm shift during the 1980s and 1990s. Potential advantages include lower anesthesia requirements; faster recovery and shorter hospital stays; avoidance of the potential complications of transabdominal wound infections (e.g. hernias); less immunosuppresion; better postoperative pulmonary and diaphragmantic function; and the potential for "scarless" abdominal surgery. Critics challenge the safety and advantages of this technique in the face of effective minimally invasive surgical options such as laparoscopic surgery.

NOSCAR
Senior leadership from the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal Endoscopic Suregons (SAGES) organized a working group of surgeons and gastroenterologists in 2006 to develop standards for the practice of this emerging technique. This group is known as the Natural Orifice Surgery Consortion for Assessment and Research (NOSCAR). A White Paper on NOTES was released by NOSCAR simultaneously in two medical journals in May 2006. This paper identified the major areas of research needed to be addressed before NOTES can become a viable clinical application for human patient. These areas included development of a reliable closure technique for the internal incision, prevention of infection, and creation of advanced endoscopic surgical tools.

NESA / NOS
Parallel to the NOTES (Natural Orifice Transluminal Endoscopic Surgery) working group which looks beyond existing horizons and concentrates on the transgastric peritoneal access, the New European Surgical Academy (NESA) founded the NOS (Natural Orifice Surgery) working group which is exploring another surgical route, the Transdouglas one.

The term difference is not accidental. T in NOTES stands for transluminal. NOS includes NOTES because it refers to all surgical procedures performed through natural openings like mouth, nose, urethra and vagina.

The NESA designed a new surgical device, the Transdouglas Endoscopic Device (TED) adapted to female pelvic anatomy. The TED is a wide multi-channel flexible instrument enabling surgical procedures in the upper abdomen (cholecystectomy, liver biopsy, splenectomy etc.) as well as in the pelvis (hysterectomy, cystectomy, etc.) by using a single entry. See Pouch of Douglas.

The members of the European NOS working group are internationally renowned scientists, physiologists, pharmacologists and surgeons from various disciplines. The first meeting was on June 23, 2006 in Berlin. The planned procedures have already been simulated and preclinical studies will start soon. The NESA strongly believes that in the future, this new approach using the body natural openings and "traditional" endoscopic operations will complement one