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Meadows and Chamberlain


Today, minimally invasive surgery stands on the verge of another giant advancement with the advent of natural ori- fice transluminal surgery (NOTES). Theoretically, NOTES combines minimally invasive surgical principles with flex- ible endoscopy and may ultimately permit some surgical procedures to be performed without skin incisions. NOTES aims to utilize the natural orifices of the body such as the mouth, anus, or vagina as the portal for entry into the perito- neal cavity. It is believed that the absence of abdominal wall incisions may allow NOTES approaches to further reduce abdominal pain, rates of infection, adhesion formation,2 and hernia formation among other benefits.3

Laparoscopy began in 1901 when German physician Georg Kelling first inserted a cystoscope into the peritoneal cavity of a dog and insufflated air to augment the view.4 In 1882, Carl Lagenbuch performed the first successful cholecystectomy on a 43-year-old man with symptomatic cholelithiasis.1 It took more than a century for these two sentinel surgical accomplishments to intersect, when in 1985 Eric Mühe performed the first laparoscopic cholecystecomy using a modified laparoscope called the galloscope.5 In 1987, with the dawn of computer chip television cameras, Phillipe Mouret performed the first video-assisted laparoscopic cholecystectomy,6 and within five years, laparoscopic cholecystectomy became the gold standard for gallbladder removal and remains the most commonly performed laparoscopic procedure worldwide (see Table 1).7

a totally transgastric appendectomy in 2004.9 The first transvaginal approach was performed by Marescaux et al in 2007, when they performed a transvaginal cholecystectomy on a 30-year-old woman with symptomatic cholelithiasis.10

In July 2005, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society for Gastrointestinal Endoscopy (ASGE) issued a joint paper designed to layout the technical challenges surrounding NOTES and to compile a set of guidelines aimed at the respon- sible development of NOTES platforms and technology. The group defined the technical challenges as (1) access to the peritoneal cavity, (2) safe gastric closure, (3) prevention of infection, (4) development of suturing devices, (5) develop- ment of anastomotic (nonsuturing) devices, (6) maintenance of spatial orientation, (7) development of a multitasking plat- form to accomplish procedures, (8) control of intraperitoneal hemorrhage, (9) management of iatrogenic intraperitoneal complications, (10) prevention of physiologic untoward events, (11) avoidance of compression syndromes, and (12) development of training platforms.11 The committee further recommended that all initial NOTES procedures be tested in animal models prior to human experimentation, stressed that appropriate IRB approval was a necessity and requested that all outcomes be recorded in a global registry and reported.

Obstacles and challenges to the NOTES development

In 2004, Kalloo et al published an innovative paper in which a transgastric peroral approach for entry into the peri- toneal cavity was described.8 He performed this procedure on 17 porcine models, whereby a needle-knife puncture was made through the gastric wall and further widened by dilatation. A biopsy of the liver was performed followed by closure of the gastrotomy with clips. Since this initial report on the feasibility of NOTES in an animal model, there has been an increasing interest in the potential role of NOTES in humans.

Reddy and Rao were the first to successfully complete a NOTES procedure in a human subject when they performed

As noted in the prior section, SAGES and theASGE, as well as other organizations, have detailed the challenges involved with developing a broadly applicable NOTES platform.As a whole these obstacles can be grouped into three broad categories, which include patient access and closure, technological limita- tions, and ethical and training limitations.

Patient access and closure

NOTES is currently being investigated through three pri- mary peritoneal access points: the vagina, stomach, and rectum.12 Safe access requires the ability to maintain a seal





Carl Lagenbuch Georg Kelling erich Mühe Phillipe Mouret Kalloo et al Reddy et al Marescaux et al Gumbs et al

Germany Germany Germany France india india France USA

1882 1901 1985 1987 2004 2004 2007 2009

First open cholecystectomy First laparoscopic view of the peritoneal cavity with insufflation in a dog First laparoscopic cholecystectomy First video-assisted laparoscopic cholecystectomy First published description of NOTeS First human NOTeS procedure (appendectomy) First “hybrid” transvaginal human NOTeS cholecystectomy First transvaginal “pure” NOTeS cholecystectomy

Table 1 Surgical milestones in the transition from the first open cholecystectomy to the first NOTES cholecystectomy

Open Access Surgery 2010:3


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