Natural orifice translumenal endoscopic surgery
Encyclopedia
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.
s, 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 appendectomy 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. Totally transvaginal cholecystectomy has been described in experimental model without using laparoscopic assistance. In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. The surgery was called transvaginal donor kidney extraction.
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, led by Dr. Ricardo Zorron, performed the first series of transvaginal NOTES cholecystectomy in four patients, based in previous experimental studies. 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 immunosuppression; 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
.
Unlike laparoscopy, which was treated with much disdain as a passing fad by most nationally recognized academic institutions, NOTES is being embraced by several universities nationally. The general impression is that NOTES, or a derivative of its technology will be accepted as the newest frontier in minimally invasive surgery. As of today non-bariatric minimally invasive surgery fellowships offer the best opportunity to train in this new approach. However, a systematized training model,in order to translate these procedures to the clinical practice in a safe way, is needed.
(ASGE) and the Society of American Gastrointestinal and Endoscopic Surgeons
(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 Consortium 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.
NOTES as defined by the NOSCAR group stands for "Natural Orifice Translumenal Endoscopic Surgery". This describes going beyond the margins of a lumen (=hollow organ). There is a controversy about the correct spelling of "translumenal" in NOTES whether with a terminal "e" or an "i". Even if both forms (lumenal/luminal) are used, the "i" is probably more correct. Analogies are found with nomen, foramen or abdomen which build the corresponding adjective form with an "i" (nominal, foraminal, abdominal).
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 each other.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
technique whereby "scarless" abdominal
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
operations can be performed with an endoscope passed through a natural orifice (mouth
Mouth
The mouth is the first portion of the alimentary canal that receives food andsaliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth....
, urethra
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
, anus
Anus
The anus is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, unwanted semi-solid matter produced during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest,...
, etc.) then through an internal incision in the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
, vagina
Vagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
, bladder
Urinary bladder
The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
or colon
Colon (anatomy)
The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a...
, thus avoiding any external incisions or scars.
State of Research
This technique has been used for diagnostic and therapeutic procedures in animal modelAnimal model
An animal model is a living, non-human animal used during the research and investigation of human disease, for the purpose of better understanding the disease without the added risk of causing harm to an actual human being during the process...
s, 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
Portugal
Portugal , officially the Portuguese Republic is a country situated in southwestern Europe on the Iberian Peninsula. Portugal is the westernmost country of Europe, and is bordered by the Atlantic Ocean to the West and South and by Spain to the North and East. The Atlantic archipelagos of the...
used transgastric and transvesical combined approach to increase the feasibility of moderately complex procedures such as cholecystectomy
Cholecystectomy
Cholecystectomy is the surgical removal of the gallbladder. It is the most common method for treating symptomatic gallstones. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.-Open surgery:A...
. NOTES was originally described in animals by researchers at Johns Hopkins University
Johns Hopkins University
The Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...
(Dr. Anthony Kalloo et al.), and was recently used for transgastric appendectomy in humans in India
India
India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world...
(by Drs. G.V. Rao and N. Reddy). On June 25, 2007 Swanstrom and colleagues reported the first human transgastric cholecystectomy. Totally transvaginal cholecystectomy has been described in experimental model without using laparoscopic assistance. In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. The surgery was called transvaginal donor kidney extraction.
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, led by Dr. Ricardo Zorron, performed the first series of transvaginal NOTES cholecystectomy in four patients, based in previous experimental studies. 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
Paradigm shift
A Paradigm shift is, according to Thomas Kuhn in his influential book The Structure of Scientific Revolutions , a change in the basic assumptions, or paradigms, within the ruling theory of science...
in surgery, just as laparoscopy
Laparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
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 immunosuppression; 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
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...
.
Unlike laparoscopy, which was treated with much disdain as a passing fad by most nationally recognized academic institutions, NOTES is being embraced by several universities nationally. The general impression is that NOTES, or a derivative of its technology will be accepted as the newest frontier in minimally invasive surgery. As of today non-bariatric minimally invasive surgery fellowships offer the best opportunity to train in this new approach. However, a systematized training model,in order to translate these procedures to the clinical practice in a safe way, is needed.
NOSCAR
Senior leadership from the American Society for Gastrointestinal EndoscopyAmerican Society for Gastrointestinal Endoscopy
The American Society for Gastrointestinal Endoscopy, or ASGE, is a professional organization of physicians dedicated to improving endoscopy. The ASGE is made up largely of gastroenterologists from the United States. Included in its membership are endoscopists from other medical specialties as well...
(ASGE) and the Society of American Gastrointestinal and Endoscopic Surgeons
Society of American Gastrointestinal and Endoscopic Surgeons
The Society of American Gastrointestinal and Endoscopic Surgeons is a non-profit organization of surgeons. It describes itself thus: SAGES represents a worldwide community of surgeons that can bring minimal access surgery, endoscopy and emerging techniques to patients in every country...
(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 Consortium for Assessment and Research (NOSCAR). A White Paper
White paper
A white paper is an authoritative report or guide that helps solve a problem. White papers are used to educate readers and help people make decisions, and are often requested and used in politics, policy, business, and technical fields. In commercial use, the term has also come to refer to...
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.
NOTES as defined by the NOSCAR group stands for "Natural Orifice Translumenal Endoscopic Surgery". This describes going beyond the margins of a lumen (=hollow organ). There is a controversy about the correct spelling of "translumenal" in NOTES whether with a terminal "e" or an "i". Even if both forms (lumenal/luminal) are used, the "i" is probably more correct. Analogies are found with nomen, foramen or abdomen which build the corresponding adjective form with an "i" (nominal, foraminal, abdominal).
NESA / NOS
Parallel to the NOTES (Natural Orifice Translumenal 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
Liver biopsy
Liver biopsy is the biopsy from the liver. It is a medical test that is done to aid diagnosis of liver disease, to assess the severity of known liver disease, and to monitor the progress of treatment.-History:...
, splenectomy etc.) as well as in the pelvis (hysterectomy, cystectomy, etc.) by using a single entry. See Pouch of Douglas
Pouch of Douglas
The rectouterine pouch is the extension of the peritoneal cavity between the rectum and back wall of the uterus in the female human body....
.
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
Berlin
Berlin is the capital city of Germany and is one of the 16 states of Germany. With a population of 3.45 million people, Berlin is Germany's largest city. It is the second most populous city proper and the seventh most populous urban area in the European Union...
. 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 each other.