Natural orifice translumenal endoscopic surgery (NOTES)

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Editor-In-Chief: Mohammed A. Sbeih, M.D. [1]

Related Key Words and Synonyms: Natural orifice translumenal endoscopic surgery, single incision laparoscopic surgery, minimally invasive surgery, transanal endoscopic microsurgery, Natural orifice surgery consortium for assessment and research.

Overview

Natural orifice translumenal endoscopic surgery (NOTES) is an experimental surgical technique whereby "scarless" abdominal operations can be performed. The surgeon accesses the peritoneal cavity or the thoracic cavity via a hollow viscus and performs diagnostic or therapeutic procedures. NOTES involves passing surgical instruments and a tiny camera through a natural orifice (mouth, urethra, anus, etc.), then the procedure can be performed through an internal incision in the stomach, vagina, bladder or colon, thus avoiding scars and external incisions through the skin, muscles, and nerves. The patients recover more quickly and experience less pain with better cosmetic results. The postoperative complications such as wound infections and hernias are significantly reduced.

Animal models and cadavers have been used to demonstrate the possible applications of NOTES, including abdominal cavity screening, abdominal organs biopsy, appendectomy, cholecystectomy, tubal ligation, gastrojejunostomy, partial hysterectomy, oophorectomy, colorectal resection and trans-esophageal myotomy.

NOTES describes going beyond the margins of a lumen (hollow organ). The word translumenal could be spelled as "transluminal". Analogies are found with nomen, foramen or abdomen which build the corresponding adjective form with an "i" (nominal, foraminal, abdominal) instead of "e".

Historical Perspective

  • In 1901, Dimitri Ott from Russia performed transvaginal inspection of the peritoneal cavity. In the same year, the first experimental laparoscopy reported by Georg Kelling (a German Surgeon), he initially used a cystoscope to insufflate and explore the abdominal cavity of a dog [1].
  • In 1940s, the first natural orifice procedure has been mentioned. Culdoscopies were performed using an endoscope passed through the recto-uterine pouch to view pelvic organs [2].
  • Laparoscopic surgery innovation was introduced in the late 1980s, and the minimally invasive surgery started spreading worldwide in 1987, when the first laparoscopic cholecystectomy reported by Dr. Philippe Mouret Spaner (a French gynecologist) [3][4].
  • In 1990, a multicenter team of investigators (the Apollo Group) used the term flexible transluminal endoscopy before the NOTES concept was coined [5].
  • In 2002, Gettman et al published a transvaginal nephrectomy in a porcine model [6].
  • The first reported human transgastric endoscopic appendectomy was in India in 2003 by Dr. G.V. Rao and Dr. N. Reddy [7].
  • NOTES was originally described in animals by researchers at Johns Hopkins University. Dr. Anthony Kalloo published the first report of a true transluminal procedure in 2004 , which was a transgastric peritoneoscopy in a porcine model [8][9].
  • The first international conference on NOTES was held in Scottsdale, Arizona March 9-11, 2006. One hundred forty physicians from 11 countries met to develop a detailed roadmap for overcoming the technical barriers of NOTES that had been identified in the original White Paper of NOSCAR.
  • EURO-NOTES Foundation, established in 2006 in cooperation between European Asociation for Endoscopic Surgery (EAES) and the European Society of Gastrointestinal Endoscopy (ESGE) to focus on all activities regarding Natural Orifice Transluminal Endoscopic Surgery (NOTES). The first meeting was in June 23, 2006 in Berlin/Germany.
  • Japan launched the JWNOTES (Japan Working group for NOTES) in 2007.
  • Radical sigmoidectomy using a pure NOTES transanal approach was first described in 3 human cadavers in 2007 by Whiteford et al who used TEM as an endoscopic platform without the need for any abdominal incisions [12].
  • In 2007, the first transvaginal laparoscopically assisted cholecystectomy in the United States was formally operated by Marc Bessler (US team)[13], and the first transgastric cholecystectomy in the United States was performed by Lee Swanstrom (US team) [14], and J. Marescaux (French team) [15].
  • The first published human NOTES procedure was by Marks et al[16] who performed a transgastric rescue of a prematurely dislodge gastrostomy tube in 2007.
  • 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. The first human transvaginal endoscopic cholecystectomy case was reported in 2007 [17][18].
  • In late March, 2008, Dr. Santiago Horgan became the first US surgeon to perform transgastric appendectomy and remove a patient's appendix through the mouth. He also applied the EndoSurgical Operating System (EOS) on pigs to perform the entire operation through the stomach without laparoscopic assistance or any abdominal incision [19].
  • 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 [20].
  • The first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance was performed at the Hospital Clinic in Barcelona by a team of surgeons from the Hospital Clinic in Barcelona and Massachusetts General Hospital in Boston in November 2009 (Dr. Antonio Lacy and Dr. Patricia Sylla) [21].

Advantages Over Current Surgical Techniques

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 of NOTES include [22]:

  • Faster recovery and shorter hospital stay. NOTES may cause less physiologic insult than laparoscopy or laparotomy, and there are some underway laboratory studies which try to reveal and compare the cytokine levels with NOTES in comparison to laparoscopy or laparotomy procedures. One study on animals reported that the circulating levels of cytokines (IL1, IL6, and TNF-alpha) are similar in NOTES and other approaches immediately after the surgery, but. However, in the later postoperative period, the levels of the cytokines was lower in NOTES procedures compared with the open or laparoscopic approach [23].
  • Avoidance of the potential complications of abdominal wound infections. Wound infection is a common surgical complication, with a reprted incidence varies between 2% to 25%, depending on the type of surgery [24][25]. Eliminating all skin incisions would eliminate the adverse impact of wound infection on the health care costs and patient recovery [26].
  • Decrease the incidence of incisional hernias and postoperative adhesions. The rates of small intestinal obstruction are lower after laparoscopic surgery compared with open surgery and will perhaps be further decreased with NOTES [27].
  • Moving the equipment to the patient (portable NOTES instruments) may avoid transporting a patient to the operating room, and thus making some NOTES procedures suited for an intensive care unit.
  • Requirements for anesthesia are relatively less than other types of surgeries. Some NOTES procedures could be performed under conscious sedation.
  • Less immunosuppression.
  • Better postoperative pulmonary and diaphragmatic function.
  • Better cosmetic results with the potential for "scarless" abdominal surgery even when peritoneal intervention is required [28].
  • Advantages in specific subpopulations. NOTES can be performed in morbidly obese patients, in whom traditional access to the peritoneal cavity can be difficult because of abdominal wall thickness, NOTES may provide an easy alternative in these patients.
  • Theoretical, patients may prefer NOTES procedure over laparoscopic procedure based upon the assumption that it is scarless and less painful. Studies and surveys demonstrated that patients prefer NOTES if it is safe and effective [29].

Experimental Evolution

The fields of gastrointestinal surgery and interventional endoscopy are converging to each other since the advent of interventional endoscopic therapy field. Gastroenterologists and therapeutic endoscopists perform more invasive interventions than before and have started to manage cases that was managed only surgically. In the other hand, surgical interventions in the abdominal, peritoneal, and thoracic cavities have become less invasive and a new minimally invasive surgical methods have been invented to minimize trauma. The evolving concept of natural orifice translumenal endoscopic surgery (NOTES) combines the techniques of minimally invasive surgery with flexible endoscopy.

In the late 1990s, a multicenter team of investigators (the Apollo Group) developed the concept of flexible transluminal endoscopy (a term used before NOTES) [5]. The first published report of a true transluminal procedure in 2004 by Kalloo et al. [9] showed the possibilities of penetrating the gastric wall and operating in animal model using a perorally introduced flexible endoscope [30]. The NOTES procedures moved quickly from a concept to human clinical trials based on many preclinical studies, these studies demonstrate that several types of NOTES operations can be performed in survival animal models and human cadavers [31][32][33][34][35]. Puncturing one of the viscera to perform NOTES procedures leads to many questions regarding the infectious complications and the reliable puncture closure. Many clinical trials tried to answer these questions before proceeding to clinical (NOTES) [36].

NOTES surgical procedures have been expanded in the last few years to cover a wide range of complex surgical operations, using the right translumenal route, endoscopic platform and the suitable instrumentation. Endoscopic access to the abdominal cavity using transoral (transgastric) route was intensely investigated initially to perform various abdominal procedures over the last few years, these procedures include cholecystectomy [37], appendectomy, splenectomy [38], ligation of fallopian tubes [39], gastrojejunostomy [40], peritoneal exploration and organ resection [41], lymphadenectomy [42], partial hysterectomy [43], oophorectomy [44], interventions on pelvic organs and other abdominal procedures. Recently, alternate access routes for NOTES procedures have been investigated such as transvaginal, transesophageal, transcolonic (transanal) and transvesical/transurethral access. The most rapidly evolved experimental studies were transvaginal NOTES procedures, including cholecystectomy [45][46], nephrectomy and appendectomy [47], and the first human case was described in 2007 [17][18]. Cholecystectomy, which is a high volume and relatively simple end organ operation, has been the focus of most early NOTES research studies. Recently, NOTES approach has been extended from the peritoneum to other body compartments, such as transesophageal approaches to the thoracic cavity (mediastinum, heart and lung) [48][49]. Also some recent animal studies have been focused on transgastric intrauterine procedures.

NOTES has also inspired the development of new and novel instrumentation and innovative surgical techniques for minimally invasive and endoscopic procedures. Gergard Buess (from Germany) introduced in the 1980s the Transanal Endoscopic Microsurgery (TEM), a natural orifice procedure used for full-thickness resection of rectal tumours followed by closure of the resultant defect by a suture [50]. TEM fulfils most requirements for the ideal NOTES operating platform based on what was published in NOSCAR white paper. TEM provides stable base, suction, irrigation, multiple working ports, pneumoperitoneum maintainance, and the capacity to close the viscotomy [51][52].

Recently, Robotic surgery has been investigated to be applied in NOTES procedures, a miniature in vivo robot has been developed for NOTES. The robot can be advanced through the esophagus and into the peritoneal cavity. The robot may provide a stable platform for visualization and manipulation. The NOTES robot has been tested in a porcine model as well.

Investigators are trying to eliminate the laparoscopic component of NOTES and performing most of the NOTES procedures through the "natural orifices" only without any laparoscopic assistance or guidance.

What has been achieved so far?

  • Laboratory Reports
  • Human Cases

Current Challenges and Drawbacks to Clinical Application of NOTES

  • Puncturing one of the viscera to perform the surgical procedures. This needs to be assessed thoroughly regarding the presence of long term complications, higher infection rates, and the reliability of puncture closure. Methods of reliable full thickness, watertight closure for the puncture sites in different organs should be developed.
  • Instrumentation is still inadequate to perform all types of NOTES procedures. Innovative instruments are needed for the surgeons to perform various NOTES procedures more easily.
  • Loss of triangulation of optics and instrumentation may limit the range of motion of instruments and may obscure part of the operator field. The current version of NOTES instruments and endoscopes may precludes such triangulation in NOTES procedures [53].
  • NOTES surgeons should be highly trained to perform NOTES procedures and to be able to use flexible endoscopes professionally. They should know abdominal anatomy and surgical principles and should masterfully exhibit the ability to manage complications. Only a small fraction of gastroenterologists and surgeons will become NOTES surgeons.
  • There are some technical difficulties for implementation of NOTES in humans. Many investigators have encountered these difficulties along with some ethical challenges [54].
  • An argument can be made that single-incision laparoscopic surgery (SILS) can be more convenient than NOTES for some procedures, especially with the presence of advanced surgical technologies that could be applied in laparoscopic surgery [55][56].
  • Surveys showed that most women may not favor transvaginal NOTES procedures over laparoscopic approach, especially younger nulliparous women who are concerned about the sexual function [57]. However, another study showed that there is considerable public interest in NOTES surgery and women would be receptive to this new surgical technique because of decreased risk of hernia and decreased operative pain [58]. Cultural and geographical variations may also play a roll in the decision to accept a transvaginal surgery or not.
  • There are some technical constraints and challenges which limit the surgeon ability to perform certain procedures. For example, it may be very challenging for the surgeon to maintain spatial orientation during the NOTES procedure, and the procedure performance can be limited to a certain points of natural entry. To provide a straight access to the operating field, lower abdominal and pelvic NOTES procedures usually performed via a transgastric approach, but upper abdominal procedures and cholecystectomy usually performed via transvaginal or transcolonic approach.
  • It is more difficult to handle complications easily with a NOTES approach because of the limited space available for the NOTES instruments. This may require conversion of the procedure to other approach (open or laparoscopic). Beside the complications of any surgical operation such as laceration, perforation and bleeding, these complications may also include injury to abdominal organs, bowel perforation or injury, biliary fistulae, biliary leaks, urinary incontinence, fecal incontinence and peritonitis. Recent studies reported that 5 to 10 percent of NOTES procedures could have complications, most of them occur in the transgastric approach [54].
  • There is a higher risk for over insufflation of the peritoneal cavity by using the flexible endoscope in NOTES procedures which may decrease the venous return to the heart and lead to undesired systemic effects such as hemodynamic instability and respiratory compromise [59]. This could be prevented in laparoscopic surgery by using pressure sensors. There should be successful monitoring of intra-abdominal pressures during NOTES; and this has been applied in animal studies [54][59]. Useing a standard autoregulated insufflators (used in laparoscopic surgery) and feedback pressure valves on flexible endoscopes can resolve this problem [60][61][62].
  • Financial resources are required for the technological developments and NOTES implementation.

Human Experience

There are hundreds of human cases have been reported since the first human NOTES reported case in India in 2003 [63]. More than 500 cases have been reported in Germany and more than 300 cases have been reported in Brazil [64][54]. Many human cases have been reported in the United States and in other countries. Most of the reported cases are not purely NOTES but with laparoscopic assistance. A few number of the reported cases are pure NOTES procedures.

Potential Applications

NOTES procedures have been performed through different natural orifices. So far, transvaginal approach is the most common and has the highest success rate for certain procedures.

Transvaginal NOTES

This is the most common apprach to be used in NOTES procedures. This approach has been used for cholecystectomy, appendectomy, colon resections, abdominal wall hernia repair, and sleeve gastrectomy [54]. Transvaginal cholecystectomy and transvaginal appendectomy have been performed in humans. Around 85% of the Notes procedures that have been reported in Germany is transvaginal cholecystectomy (the most common) [64]. There are many advantages for this approach which include:

  • The organ (Gallbladder, appendix or others) can be extracted easily outside the body through the flexible walls of the vagina even the large organs.
  • It is relatively easier and safer to perform the procedure through this approach. Vaginal wall closure is less complex than gastric wall closure and has less complications rate.

The drawback of this approach is that it can be used only in females. Also, the NOTES surgeon should have the basics of gynecological surgery before perform a transvaginal procedure. Women may present with dyspareunia and infertility after the procedure, also there is a potential risk for urinary tract infection after cannulation of the urinary bladder (required in transvaginal NOTES procedures).

Transanal/Transrectal NOTES

Transanal rectosegmoid resection using transanal endoscopic microsurgery (TEM) and laparoscopic assistance has been demonstrated to be feasible and safe in a swine survival model and in human cadavers [65]. Currently, there are clinical trials that aim to assess the oncological safety of this approach in treating benign and malignant colorectal tumors.

Transanal colorectal resection procedures requires a stable platform for endolumenal and direct translumenal access to the peritoneal cavity. The first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance has been performed successfully by a team of surgeons from Barcelona and Boston in 2009 [21]. The progression and substantial improvement in NOTES instrumentation may optimize this approach to be widespread applied in humans, and may ultimately permit completely NOTES transanal colorectal resection instead of abdominoperineal resection (APR), low anterior resection (LAR) and laparoscopic colorectal resection procedures.

Transgastric NOTES

This NOTES approach is more sophisticated than the transvaginal one, especially in terms of gastric wall closure after extracting the organ (requires laparoscopic assistance [66]. Also, the complications rate is higher in this rout compared with transvaginal route. Trials in the field (on animal and cadaver models) are trying to create a new devices and techniques to simplify the stomach incision closure.

Appendectomy, cholecystectomy and cancer staging have been performed via this approach [67]. Retrieval of dislodged endoscopic gastrostomy tube via this approach has been reported as well [68]. however, all cases require Some degree of hybridization is required for all transgastric NOTES procedures. This approach can be used in all patients (males and females) but the extracted specimen (through the oral cavity) needs to be relatively smaller than those extracted by other routs.

Transesophageal NOTES

This approach can be used for the management of achalasia (failure of relaxation of the lower esophageal sphincter that cause dysphagia). Many cases of per oral endoscopic myotomy (POEM) have been performed successfully to treat achalasia [69].

Transurethral/Transcystic NOTES

Future Directions

Operating on intensive care unit patients may be the future progression in NOTES procedures which may offer many benefits. Transgastric placement of diaphragm pacing for weaning the ICU patients from the ventilator may lead to several potential benefits over other methods of pacing [70], this procedure could be performed at the bedside.

More studies should be conducted to find a clear clarifications for the following issues [71]:

  • The best way to traverse the wall of the lumen in order to get access to the organ (the safest way).
  • Controlling the complications of every single NOTES procedure.
  • Improving spatial orientation to perform the procedure.
  • The best closure for the translumenal access site after the procedure.
  • Specific ways for organ extraction from the body through the natural orifices.
  • Methods for NOTES procedures infection prevention.
  • Anesthesia level requirement for every NOTES procedure.
  • Optimal instrumentation and devices for every NOTES procedure.

Current Technological Developments

The development of NOTES instruments is emerging to make these procedures feasible and to move the field forward, these instruments include platforms and many other tools [72]. The preferred way to gain access to the peritoneal cavity via a a hollow viscus (lumen) is a very small incision (minimal) followed by a balloon expansion and dilatation, a tiny incision can be made using a sphincterotome or a needle knife. Overtube is usually used to permit multiple entries to the operating field and to perform complex maneuvers, but a direct insertion of the endoscope and the NOTES instruments is possible.

Natural Orifice Surgery Consortium for Assessment and Research (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 who met in New York City on July 22 and 23, 2005 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 [73]. 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 [74].

NOSCAR tasks include the following:

  • Produce White Papers which focus on the challenges that need thought and research.
  • Track the groups of similar research projects that address the previous challenges.
  • Organize the research projects, enhance collaboration and attract funding to key areas of study.
  • To build a robust outcomes database by collecting submission of data.
  • Foster collaborative clinical trials.

The White Paper on NOTES and the guidlines for participation in NOSCAR can be found in the external links below [75].

Conclusions

Natural orifice transluminal surgery (NOTES) is a rapidly evolving field which may shift the minimally invasive surgery world from laparoscopic and video assisted thoracic surgery to procedures that can be done via the natural body orifices without any abdominal or thoracic incisions. This may provide many advantages and lessen many surgical complications. New NOTES procedures should be experimental at the beginning, these procedures should be performed only in research labs in advanced institutions before reaching the goal of applying NOTES clinically.

We are on the way for routine clinical applications of NOTES by the steady progression of the field. Patient safety and the research trials that ensure this safety is paramount. Innovative instruments are needed for the surgeons and gastroenterologists to perform safe NOTES.

The development of such therapeutic techniques and advanced endoscopic devices will allow the endoscopists to perform various procedures more easily such as large and deep mucosal lesions resection, and taking full thickness biopsies [76].

Published Trials

  • Dr. G.V. Rao and Dr. N. Reddy performed a human transgastric endoscopic appendectomy in India in 2003 [77].
  • A novel endoscopic peroral transgastric approach to the peritoneal cavity was tested in a porcine model in acute and long-term survival experiments at Johns Hopkins Hospital in 2004 by Kalloo et al. [9]. He demonstrated the feasibility and safety of this approach to be an alternative to laparoscopy and laparotomy. The peritoneal cavity was examined, and a liver biopsy specimen was obtained. The gastric wall incision was closed with clips [9].
  • A transgastric lymphadenectomy has been performed on survival porcine model by Fritscher-Ravens et al. and reported in 2004 [78]. This study showed that EUS (Endoscopic Ultrasonography) guided transgastric approach for lymph node selection and lymphadenectomy is feasible.
  • A transgastric Fallopian tube ligation has been reported in a porcine survival model in 2005 by Jagannath et al. [79].
  • A transgastric partial hysterectomy and oophorectomy on a porcine survival model has been reported in 2005 by Wagh et al [80].
  • A transgastric cholecystectomy and cholecystogastric anastomosis in a nonsurvival model has been reported in 2005 by Park et al [81].
  • A transgastric gastrojejunostomy procedure in a porcine survival model has been reported in 2005 by Kantsevoy et al [82].
  • A survival and nonsurvival transvesical liver biopsy has been performed on pigs and reported by Lima et al in 2006. This study provides encouragement for additional preclinical studies of transvesical surgery with or without combinations with other natural orifices approaches to design new intra-abdominal scarless procedures in what seems to be third generation surgery [83].
  • A transgastric splenectomy has been performed on a nonsurvival porcine model and reported by Kantsevoy et al in 2006 [33].
  • A survival and nonsurvival transgastric gastrocholecystic anastomosis has been performed on pigs by Bergstrom et al and reported in 2006 [84]. This procedure has been performed by using a new double-channel endoscopic method.
  • A new transgastric closure method for stomach incision has been compared to other closure methods by Ryou et al in 2007. The study showed by using ex vivo porcine stomach model that prototype gastrotomy device yielded the highest median air leak pressure (most leak-resistant gastrotomy closure) compared to the QuickClip closure method and the hand-sewn closure. It also dramatically diminishing time for incision and gastrotomy closure to approximately 5 min [85].
  • A transcolonic abdominal exploration on a swine survival model has been performed by Fong et al and reported in 2007 [86]. In contrast to the transgastric method, a transcolonic approach provides more consistent identification of structures in the upper abdomen and provides better en face orientation and scope stability.
  • A transgastric diaphragmatic pacing and peritoneal exploration procedure on a nonsurvival porcine model has been performed by Onders et al and reported in 2007 [70]. This study demonstrated the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation.
  • A nonsurvival transgastric intraperitoneal pressure measurement procedure has been performed and reported by Meirless et al in 2007 [87]. This study demonstrated that the use of an on-demand unregulated endoscopic insufflator for translumenal surgery can cause large variation in intraperitoneal pressures, leading to the risk of hemodynamic compromise. Well-controlled intraabdominal pressures achieved with a standard autoregulated laparoscopic insufflator maybe much safer.
  • Radical sigmoidectomy using a pure NOTES transanal approach was first described in 3 human cadavers in 2007 by Whiteford et al who used TEM as an endoscopic platform to perform the procedure without the need for any abdominal incisions [12]. This showed that NOTES sigmoid colon resection with en bloc lymphadenectomy and primary anastomosis can be performed successfully, and it is possible to complete the critical steps of a NOTES sigmoid resection, en bloc lymphadenectomy, primary anastomosis, and retrieval of an intact specimen without any incisions using transanal endoscopic microsurgery instrumentation.
  • Completely NOTES transvaginal cholecystectomy has been reported by a team of surgeons in Philadelphia (USA). The patient was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up. Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans [45].
  • The first series of transvaginal NOTES cholecystectomy has been performed by the NOTES Research Group in Rio de Janeiro (Brazil) in 2007, based in previous experimental studies. The first human transvaginal endoscopic cholecystectomy case was reported in 2007 [17].
  • A transvaginal laparoscopically assisted endoscopic cholecystectomy has been reported by Marc Bessler (Columbia University College of Physicians & Surgeons, New York, USA) [18].
  • Transgastric appendectomy has been performed by Dr. Santiago Horgan (University of California San Diego) in 2008 [88]. The patient's appendix was removed through the mouth. He also applied the EndoSurgical Operating System (EOS) on pigs to perform the entire operation through the stomach without laparoscopic assistance or any abdominal incision.
  • 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 first case of robotic-assisted laparoscopic live-donor transvaginal nephrectomy with the uterus in place has been performed by a multidisciplinary team of surgeons at University of Pavia (Italy) in 2010. The initial experience with the combination of robotic surgery and transvaginal extraction of the donated organ opened a new opportunity to minimize the trauma in transplant surgery [89].
  • A NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance was performed on a 76-year-old woman at the Hospital Clinic in Barcelona by a team of surgeons from the Hospital Clinic in Barcelona and Massachusetts General Hospital/Boston in November 2009 [21].
  • Transvaginal purely endoscopic appendectomies were reported in 2008 by investigators from Germany and another group of investigators from India [90][91].

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References

  1. ↑ Litynski GS (1999) Endoscopic surgery: the history, the pioneers. World J Surg 23: 745-753
  2. ↑ Halim I, Tavakkolizadeh A. NOTES: The next surgical revolution? Int J Surg 2008; 6: 273-276
  3. ↑ Mouret P (1991) From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery: the future perspectives. Dig Surg 8: 1124-1125
  4. ↑ SJ, Warnock GL. A brief history of endoscopy, laparoscopy, and laparoscopic surgery. J Laparoendosc Adv Surg Tech A 1997; 7: 369-373
  5. ↑ 5.0 5.1 Pasricha PJ (2007). "NOTES: a gastroenterologist's perspective". Gastrointest. Endosc. Clin. N. Am. 17 (3): 611–6, viii–ix. doi:10.1016/j.giec.2007.05.002. PMID 17640587. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)
  6. ↑ Gettman MT, Lotan Y, Napper CA, Cadeddu JA. Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model. Urology 2002; 59: 446-450
  7. ↑ Rao GV, Reddy DN. Transgastric appendectomy in humans. Montreal: World Congress of Gastroenterology, 2006
  8. ↑ Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004; 60: 114-117
  9. ↑ 9.0 9.1 9.2 9.3 Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004). "Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity". Gastrointest. Endosc. 60 (1): 114–7. PMID 15229442. Retrieved 2012-02-16. Unknown parameter |month= ignored (help)
  10. ↑ Rattner D, Kalloo A (2006). "ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005". Surg Endosc. 20 (2): 329–33. doi:10.1007/s00464-005-3006-0. PMID 16402290. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  11. ↑ Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)
  12. ↑ 12.0 12.1 Whiteford MH, Denk PM, Swanström LL (2007). "Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery". Surg Endosc. 21 (10): 1870–4. doi:10.1007/s00464-007-9552-x. PMID 17705068. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  13. ↑ Bessler M, Stevens PD, Milone L, Parikh M, Fowler D. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 2007; 66: 1243-1245
  14. ↑ USGImedical. (2007, Jun). USGI announces first NOTES transgastric cholecystectomy procedures [Online]. Available: http://www.usgimedical.com/pr_transgastric_cholecystectomy.html
  15. ↑ Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 2007; 142: 823-826; discussion 823-826
  16. ↑ Marks JM, Ponsky JL, Pearl JP, McGee MF. PEG "Rescue": a practical NOTES technique. Surg Endosc 2007; 21: 816-819
  17. ↑ 17.0 17.1 17.2 Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007). "Surgery without scars: report of transluminal cholecystectomy in a human being". Arch Surg. 142 (9): 823–6, discussion 826–7. doi:10.1001/archsurg.142.9.823. PMID 17875836. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  18. ↑ 18.0 18.1 18.2 Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007). "Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery". Gastrointest. Endosc. 66 (6): 1243–5. doi:10.1016/j.gie.2007.08.017. PMID 17892873. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  19. ↑ Surg Endosc. 2009 July; 23(7): 1512–1518.Published online 2009 April 3. PubMed Central. doi: 10.1007/s00464-009-0428-0
  20. ↑ "Surgeons Remove Healthy Kidney Through Vagina". InfoNIAC.com. Retrieved 2009-02-03.
  21. ↑ 21.0 21.1 21.2 Sylla P, Rattner DW, Delgado S, Lacy AM (2010). "NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance". Surg Endosc. 24 (5): 1205–10. doi:10.1007/s00464-010-0965-6. PMID 20186432. Retrieved 2012-02-15. Unknown parameter |month= ignored (help)
  22. ↑ Swain P (2007). "A justification for NOTES--natural orifice translumenal endosurgery". Gastrointest. Endosc. 65 (3): 514–6. doi:10.1016/j.gie.2006.11.034. PMID 17321258. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  23. ↑ McGee MF, Schomisch SJ, Marks JM, Delaney CP, Jin J, Williams C, Chak A, Matteson DT, Andrews J, Ponsky JL (2008). "Late phase TNF-alpha depression in natural orifice translumenal endoscopic surgery (NOTES) peritoneoscopy". Surgery. 143 (3): 318–28. doi:10.1016/j.surg.2007.09.032. PMID 18291252. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  24. ↑ Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004 Jun 15;38(12):1706–15
  25. ↑ DiPiro JT, Martindale RG, Bakst A, Vacani PF, Watson P, Miller MT. Infection in surgical patients: effects on mortality, hospitalization, and postdischarge care. Am J Health Syst Pharm 1998 Apr 15;55(8):777–81
  26. ↑ Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999 Nov;20(11):725–30
  27. ↑ Duepree HJ, Senagore AJ, Delaney CP, Fazio VW. Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy. J Am Coll Surg 2003 Aug;197(2):177–81
  28. ↑ Invisible mending. The Economist. June 8, 2006:14
  29. ↑ Varadarajulu S, Tamhane A, Drelichman ER (2008). "Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy". Gastrointest. Endosc. 67 (6): 854–60. doi:10.1016/j.gie.2007.09.053. PMID 18355816. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  30. ↑ Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004; 60: 114-117
  31. ↑ Merrifield BF, Wagh MS, Thompson CC (2006). "Peroral transgastric organ resection: a feasibility study in pigs". Gastrointest. Endosc. 63 (4): 693–7. doi:10.1016/j.gie.2005.11.043. PMID 16564875. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  32. ↑ Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Deters JL, Knipschield MA, Hawes RH, Kalloo AN, Pasricha PJ, Chung S, Kantsevoy SV, Cotton PB (2006). "Pilot study of the porcine uterine horn as an in vivo appendicitis model for development of endoscopic transgastric appendectomy". Gastrointest. Endosc. 64 (5): 808–12. doi:10.1016/j.gie.2006.04.038. PMID 17055881. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  33. ↑ 33.0 33.1 Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN (2006). "Transgastric endoscopic splenectomy: is it possible?". Surg Endosc. 20 (3): 522–5. doi:10.1007/s00464-005-0263-x. PMID 16432652. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  34. ↑ Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006). "Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video)". Gastrointest. Endosc. 64 (3): 428–34. doi:10.1016/j.gie.2006.06.079. PMID 16923495. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  35. ↑ Wagh MS, Merrifield BF, Thompson CC (2006). "Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model". Gastrointest. Endosc. 63 (3): 473–8. doi:10.1016/j.gie.2005.06.045. PMID 16500399. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  36. ↑ McGee MF, Rosen MJ, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J (2006). "A primer on natural orifice transluminal endoscopic surgery: building a new paradigm". Surg Innov. 13 (2): 86–93. doi:10.1177/1553350606290529. PMID 17012148. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  37. ↑ P. O. Park, M. Bergstrom, K. Ikeda, et al., “Experimental studies of transgastric gallbladder surgery: Cholecystectomy and cholecystogastric anastomosis [with video],” Gastrointest Endosc, vol. 61, pp. 601-606, 2005
  38. ↑ S. V. Kantsevoy, B. Hu, S. B. Jagannath, et al., “Transgstric endoscopic splenectomy: Is it possible?” Surg Endosc, vol. 20, pp. 522-525, 2006.
  39. ↑ S. B. Jagannath, S. V. Kantsevoy, C. A. Vaughn, et al., “Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model,” Gastrointest Endosc, vol. 61, pp. 449-453, 2005
  40. ↑ M. Bergstrom, K. Ikeda, P. Swain, and P. O. Park, “Transgastric anastomosis by using flexible endoscopy in a porcine model [with video],” Gastrointest Endosc, vol. 63, pp. 307-312, 2006
  41. ↑ M. S. Wagh, B. F. Merrifield, and C. C. Thompson, “Endoscopic transgastric abdominal exploration and organ resection: intial experience in a porcine model,” Clin Gastroenterol Hepatol, vol. 3, pp. 892-896, 2005
  42. ↑ A. Fritscher-Ravens, C. A. Mosse, K. Ikeda, and P. Swain, ”Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance,” Gastrointest Endosc, vol. 63, pp. 302-306, 2006
  43. ↑ B. F. Merrifield, M. S. Wagh, C. and C. C. Thompson, “Peroral transgastric organ resection: A feasibility study in pigs,” Gastrointest Endosc, vol. 63, pp. 693-697, 2006
  44. ↑ ] M. S. Wagh, B. F. Merrifield and C. C. Thompson, “Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model,” Gastrointest Endosc, vol. 63, pp. 473-478, 2006
  45. ↑ 45.0 45.1 Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M (2009). "Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique". Ann. Surg. 249 (6): 908–12. doi:10.1097/SLA.0b013e3181a802e2. PMID 19474690. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  46. ↑ Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M (2008). "NOTES transvaginal cholecystectomy: preliminary clinical application". Surg Endosc. 22 (2): 542–7. doi:10.1007/s00464-007-9646-5. PMID 18027043. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  47. ↑ Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2009) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES: world’s first report. Surg Endosc 23(3):668
  48. ↑ Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Chung S, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ (2008). "Pilot study of transesophageal endoscopic epicardial coagulation by submucosal endoscopy with the mucosal flap safety valve technique (with videos)". Gastrointest. Endosc. 67 (3): 497–501. doi:10.1016/j.gie.2007.08.040. PMID 18294512. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  49. ↑ Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P (2007). "Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures". Endoscopy. 39 (10): 870–5. doi:10.1055/s-2007-966907. PMID 17968802. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  50. ↑ Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier H (1985). "Endoscopic surgery in the rectum". Endoscopy. 17 (1): 31–5. doi:10.1055/s-2007-1018451. PMID 3971938. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  51. ↑ Denk PM, Swanström LL, Whiteford MH (2008). "Transanal endoscopic microsurgical platform for natural orifice surgery". Gastrointest. Endosc. 68 (5): 954–9. doi:10.1016/j.gie.2008.03.1115. PMID 18984102. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  52. ↑ Gavagan JA, Whiteford MH, Swanstrom LL (2004). "Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications". Am. J. Surg. 187 (5): 630–4. doi:10.1016/j.amjsurg.2004.01.004. PMID 15135680. Retrieved 2012-02-21. Unknown parameter |month= ignored (help)
  53. ↑ Pasricha PJ (2004). "The future of therapeutic endoscopy". Clin. Gastroenterol. Hepatol. 2 (4): 286–9. PMID 15067621. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  54. ↑ 54.0 54.1 54.2 54.3 54.4 Chukwumah C, Zorron R, Marks JM, Ponsky JL (2010). "Current status of natural orifice translumenal endoscopic surgery (NOTES)". Curr Probl Surg. 47 (8): 630–68. doi:10.1067/j.cpsurg.2010.04.002. PMID 20620259. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  55. ↑ Curcillo PG, Wu AS, Podolsky ER, Graybeal C, Katkhouda N, Saenz A, Dunham R, Fendley S, Neff M, Copper C, Bessler M, Gumbs AA, Norton M, Iannelli A, Mason R, Moazzez A, Cohen L, Mouhlas A, Poor A (2010). "Single-port-access (SPA) cholecystectomy: a multi-institutional report of the first 297 cases". Surg Endosc. 24 (8): 1854–60. doi:10.1007/s00464-009-0856-x. PMID 20135180. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  56. ↑ Ahmed, K, Wang, TT, Patel, VM, et, al. The role of single-incision laparaoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc 2010; Jul 10:Epub ahead of print.
  57. ↑ Strickland AD, Norwood MG, Behnia-Willison F, Olakkengil SA, Hewett PJ (2010). "Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique". Surg Endosc. 24 (10): 2424–31. doi:10.1007/s00464-010-0968-3. PMID 20224999. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  58. ↑ Peterson CY, Ramamoorthy S, Andrews B, Horgan S, Talamini M, Chock A (2009). "Women's positive perception of transvaginal NOTES surgery". Surg Endosc. 23 (8): 1770–4. doi:10.1007/s00464-008-0206-4. PMID 19057953. Retrieved 2012-02-28. Unknown parameter |month= ignored (help)
  59. ↑ 59.0 59.1 McGee MF, Rosen MJ, Marks J, Chak A, Onders R, Faulx A, Ignagni A, Schomisch S, Ponsky J (2007). "A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery". Surg Endosc. 21 (4): 672–6. doi:10.1007/s00464-006-9124-5. PMID 17285385. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  60. ↑ Meireles O, Kantsevoy SV, Kalloo AN, et al. Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery. Surg Endosc 2007;21:998-1001
  61. ↑ McGee MF, Rosen MJ, Marks J, et al. A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery. Surg Endosc 2007;21:672-6
  62. ↑ Bergstrom M, Swain P, Park PO. Measurements of intraperitoneal pressure and development of a feedback control valve for regulating pressure during flexible transgastric surgery (NOTES). Gastrointest Endosc 2007;66:174-8
  63. ↑ Rao GV, Reddy DN. Transgastric appendectomy in humans. Montreal: World Congress of Gastroenterology, 2006
  64. ↑ 64.0 64.1 Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ (2010). "The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients". Ann. Surg. 252 (2): 263–70. doi:10.1097/SLA.0b013e3181e6240f. PMID 20585238. Retrieved 2012-02-27. Unknown parameter |month= ignored (help)
  65. ↑ Sylla P, Sohn DK, Cizginer S, Konuk Y, Turner BG, Gee DW, Willingham FF, Hsu M, Mino-Kenudson M, Brugge WR, Rattner DW (2010). "Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model". Surg Endosc. 24 (8): 2022–30. doi:10.1007/s00464-010-0898-0. PMID 20174948. Retrieved 2012-02-28. Unknown parameter |month= ignored (help)
  66. ↑ Nikfarjam M, McGee MF, Trunzo JA, Onders RP, Pearl JP, Poulose BK, Chak A, Ponsky JL, Marks JM (2010). "Transgastric natural-orifice transluminal endoscopic surgery peritoneoscopy in humans: a pilot study in efficacy and gastrotomy site selection by using a hybrid technique". Gastrointest. Endosc. 72 (2): 279–83. doi:10.1016/j.gie.2010.03.1070. PMID 20541750. Retrieved 2012-02-27. Unknown parameter |month= ignored (help)
  67. ↑ Zorrón R, Soldan M, Filgueiras M, Maggioni LC, Pombo L, Oliveira AL (2008). "NOTES: transvaginal for cancer diagnostic staging: preliminary clinical application". Surg Innov. 15 (3): 161–5. doi:10.1177/1553350608320553. PMID 18614547. Retrieved 2012-02-27. Unknown parameter |month= ignored (help)
  68. ↑ Marks JM, Ponsky JL, Pearl JP, McGee MF (2007). "PEG "Rescue": a practical NOTES technique". Surg Endosc. 21 (5): 816–9. doi:10.1007/s00464-007-9361-2. PMID 17404790. Retrieved 2012-02-27. Unknown parameter |month= ignored (help)
  69. ↑ Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ (2007). "Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia". Endoscopy. 39 (9): 761–4. doi:10.1055/s-2007-966764. PMID 17703382. Retrieved 2012-02-27. Unknown parameter |month= ignored (help)
  70. ↑ 70.0 70.1 Onders R, McGee MF, Marks J, Chak A, Schilz R, Rosen MJ, Ignagni A, Faulx A, Elmo MJ, Schomisch S, Ponsky J (2007). "Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients". Surg Endosc. 21 (3): 475–9. doi:10.1007/s00464-006-9125-4. PMID 17177078. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  71. ↑ Flora ED, Wilson TG, Martin IJ, O'Rourke NA, Maddern GJ (2008). "A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting". Ann. Surg. 247 (4): 583–602. doi:10.1097/SLA.0b013e3181656ce9. PMID 18362621. Retrieved 2012-02-29. Unknown parameter |month= ignored (help)
  72. ↑ Mummadi RR, Pasricha PJ (2008). "The eagle or the snake: platforms for NOTES and radical endoscopic therapy". Gastrointest. Endosc. Clin. N. Am. 18 (2): 279–89, viii. doi:10.1016/j.giec.2008.01.005. PMID 18381169. Retrieved 2012-02-23. Unknown parameter |month= ignored (help)
  73. ↑ "ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005". Gastrointest. Endosc. 63 (2): 199–203. 2006. doi:10.1016/j.gie.2005.12.007. PMID 16427920. Retrieved 2012-02-22. Unknown parameter |month= ignored (help)
  74. ↑ Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)
  75. ↑ D. Rattner, A. Kalloo, and the SAGES/ASGE Working Group on Natural Orifice Translumenal Endoscopic Surgery
  76. ↑ Jay Pasricha P, Krummel TM (2009). "NOTES and other emerging trends in gastrointestinal endoscopy and surgery: the change that we need and the change that is real". Am. J. Gastroenterol. 104 (10): 2384–6. doi:10.1038/ajg.2009.150. PMID 19806084. Retrieved 2012-02-27. Unknown parameter |month= ignored (help)
  77. ↑ Rao GV, Reddy DN. Transgastric appendectomy in humans. Montreal: World Congress of Gastroenterology, 2006
  78. ↑ Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P (2006). "Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance". Gastrointest. Endosc. 63 (2): 302–6. doi:10.1016/j.gie.2005.10.026. PMID 16427939. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  79. ↑ Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN (2005). "Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model". Gastrointest. Endosc. 61 (3): 449–53. PMID 15758923. Retrieved 2012-02-29. Unknown parameter |month= ignored (help)
  80. ↑ Wagh MS, Merrifield BF, Thompson CC (2005). "Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model". Clin. Gastroenterol. Hepatol. 3 (9): 892–6. PMID 16234027. Retrieved 2012-02-29. Unknown parameter |month= ignored (help)
  81. ↑ Park PO, Bergström M, Ikeda K, Fritscher-Ravens A, Swain P (2005). "Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos)". Gastrointest. Endosc. 61 (4): 601–6. PMID 15812420. Retrieved 2012-02-29. Unknown parameter |month= ignored (help)
  82. ↑ Kantsevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN (2005). "Endoscopic gastrojejunostomy with survival in a porcine model". Gastrointest. Endosc. 62 (2): 287–92. PMID 16046997. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  83. ↑ Lima E, Rolanda C, Pêgo JM, Henriques-Coelho T, Silva D, Carvalho JL, Correia-Pinto J (2006). "Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery". J. Urol. 176 (2): 802–5. doi:10.1016/j.juro.2006.03.075. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  84. ↑ Bergström M, Ikeda K, Swain P, Park PO (2006). "Transgastric anastomosis by using flexible endoscopy in a porcine model (with video)". Gastrointest. Endosc. 63 (2): 307–12. doi:10.1016/j.gie.2005.09.035. PMID 16427940. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  85. ↑ Ryou M, Pai RD, Pai R, Sauer JS, Sauer J, Rattner DW, Rattner D, Thompson CC, Thompson C (2007). "Evaluating an optimal gastric closure method for transgastric surgery". Surg Endosc. 21 (4): 677–80. doi:10.1007/s00464-006-9075-x. PMID 17160493. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  86. ↑ Fong DG, Pai RD, Thompson CC (2007). "Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model". Gastrointest. Endosc. 65 (2): 312–8. doi:10.1016/j.gie.2006.08.005. PMID 17173916. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  87. ↑ Meireles O, Kantsevoy SV, Kalloo AN, Jagannath SB, Giday SA, Magno P, Shih SP, Hanly EJ, Ko CW, Beitler DM, Marohn MR (2007). "Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery". Surg Endosc. 21 (6): 998–1001. doi:10.1007/s00464-006-9167-7. PMID 17404796. Retrieved 2012-03-01. Unknown parameter |month= ignored (help)
  88. ↑ Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009). "Natural orifice surgery: initial clinical experience". Surg Endosc. 23 (7): 1512–8. doi:10.1007/s00464-009-0428-0. PMC 2695868. PMID 19343435. Retrieved 2012-02-28. Unknown parameter |month= ignored (help)
  89. ↑ Pietrabissa A, Abelli M, Spinillo A, Alessiani M, Zonta S, Ticozzelli E, Peri A, Dal Canton A, Dionigi P (2010). "Robotic-assisted laparoscopic donor nephrectomy with transvaginal extraction of the kidney". Am. J. Transplant. 10 (12): 2708–11. doi:10.1111/j.1600-6143.2010.03305.x. PMID 21114647. Retrieved 2012-02-28. Unknown parameter |month= ignored (help)
  90. ↑ Bernhardt J, Gerber B, Schober HC, Kähler G, Ludwig K (2008). "NOTES--case report of a unidirectional flexible appendectomy". Int J Colorectal Dis. 23 (5): 547–50. doi:10.1007/s00384-007-0427-3. PMID 18256848. Retrieved 2012-02-29. Unknown parameter |month= ignored (help)
  91. ↑ Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2008). "Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES--world's first report". Surg Endosc. 22 (5): 1343–7. doi:10.1007/s00464-008-9811-5. PMID 18347865. Retrieved 2012-02-29. Unknown parameter |month= ignored (help)

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