Meadows and Chamberlain
Published human NOTES cholecystectomy trials: summary
The results of all published human NOTES cholecystec- tomies are summarized in Table 5. Small sample size in most reports limits fruitful analysis of one technique versus another and limits comparison to traditional laparoscopic approaches. One hundred and seventy-four of 186 procedures were done transvaginally (93.5%) and 12 were performed transgastrically (6.45%). The average operating time for all human transvaginal NOTES procedures was 144.25 minutes (range 51–210) versus 144 minutes (range 138–150) for the 12 transgastric NOTES cholecystectomies. There were no significant complications in any of the transgastric cases reported. Among the 174 cases of transvaginal NOTES cholecystectomies, 4 procedures (2.29%) were converted to traditional laparoscopy. Of note, the national average for conversion from laparoscopic to open cholecystectomy is 5%–10%.64 Whether this low conversion rate for NOTES remains static as the criteria for patient selection expands and more patients undergo NOTES for cholecystectomy is unclear, but seems unlikely.
Laparoscopy and minimally invasive surgery has flourished for two decades. The notion that “big surgeons make big scars” is now soundly rejected. Incisionless surgery, which once seemed fanciful, is now a reality limited only by techni- cal advances and ethical dilemmas. Natural orifice translu- minal endoscopic surgery or NOTES will ultimately be the next giant step in minimally invasive surgery. The idea of eliminating all skin incisions and operating transgastrically, transvaginally, or transcolonically has revolutionized the industrial side of minimally invasive surgery and is highly anticipated by surgeons. Perhaps most limiting to NOTES development at present is the simultaneous emergence of SILS approaches. SILS, like “hybrid” NOTES, offers improved cosmesis while using current instrumentation which is familiar to the practicing surgeon. It seems quite likely that until most, if not all, technological limitations of NOTES are overcome, and educations platforms are devel- oped to allow surgeons to develop comfort and proficiency with current flexible endoscopic instruments, the adoption of NOTES in mainstream surgical practice is not imminent.
We remain convinced that the maturation of NOTES is an engineering issue that human thought and creativity will overcome. Until this happens, NOTES will (and should) be performed by only a select group of surgical innovators who possess the scientific curiosity, and the necessary endoscopic,
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laparoscopic and open surgical skills to help mature NOTES and protect patients. Whether NOTES represents a “leap” or a “step” forward is yet to be determined, and whether “hybrid” or “pure” forms ultimately emerge is unclear. “Hybrid” NOTES while sounding more attractive, may simply be SILS in a prettier box. Appropriate patient selection for NOTES remains critical to patient safety, and in the end NOTES will likely not be broadly applicable to all patients.
No conflicts of interest were declared in relation to this paper.
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