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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.


  • 1.

    Bittner R. The standard of laparoscopic cholecystecomy. Langenbecks Arch Surg. 2004;389:157–163.

  • 2.

    Auyang ED, Hungness ES, Vaziri K, Martin JA. Natural orifice trans- luminal endoscopic surgery (NOTES): dissection for the critical view of safety during transcolonic cholecystectomy. Surg Endosc. 2009; 23:1117–1118.

  • 3.

    Pham BV, Morgan K, Romagnuolo J, et al. Pilot comparison of adhesion formation following colonic perforation and repair in a pig model using a transgastric, laparoscopic, or open surgical technique. Endoscopy. 2008; 40(8):664–669.

  • 4.

    Lau WY, Leow CK, Li AK. History of endoscopic and laparoscopic surgery. orld J Surg. 1997;21:444–453.

  • 5.

    Mühe E. Die erst: cholecystecktomie durch das laparoskop (The first lap- aroscopic cholecystectomy). Langenbecks Arch Surg. 1986;369:804.

  • 6.

    KaiserAM, Corman ML. History of laparoscopy. Surg Onco Clin NAm. 2001;10:483–492.

  • 7.

    Chamberlain RS, Sakpal SV.A comprehensive review of single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy. J Gastrointest Surg. 2009;13:1733–1740.

  • 8.

    Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric perito- neoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endos. 2004;60:114–117.

  • 9.

    Reddy N, Rao P. Per oral transgastric endoscopic appendectomy in human. Abstract presented at 45th Annual Conference of the Society of Gastrointestinal Endoscopy of India; 2004 Feb 28–29; Jaipur, India.

  • 10.

    Marescaux J, Dallemagne B, Perretta S,WattiezA, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg. 2007;142(9):823–827.

  • 11.

    Rattner D, Kalloo A. ASGE/SAGES working group on natural orifice transluminal endoscopic surgery. Oct 2005. Surg Endosc. 2006; 20:329–333.

  • 12.

    Lomanto D, Chua HC, Myat MM, So J, Shabbir A, Ho L. Microbio- logical contamination during transgastric and transvaginal endoscopic techniques. J Laparoendo Adv Surg echn. 2009;19(4):465–469.

  • 13.

    Cahill RA. Natural orifice transluminal endoscopic surgery- here and now. The Surgeon. 2010;8:44–50.

  • 14.

    Ramammoorthy SL, Fischer LJ, Jacobsen G, et al. Transrectal endo- scopic retrorectal access: a novel NOTES approach to the peritoneal cavity. J Lapendo Adv Surg ech. 2009;19(5):603–606.

  • 15.

    Ryou M, Thompson CC. Transmural gastric closure and NOTES – How far have we come? Endoscopy. 2009;41:558–559.

  • 16.

    Voermans RP, Worm AM, van Berge Henegouwen MI, et al. In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES). Endoscopy. 2008; 40:595–601.

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