Natural orifice translumenal endoscopic surgery (NOTES) experimental evolution

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Editor-In-Chief: Mohammed A. Sbeih, M.D. [1]Phone: 617-849-2629; Assistant Editor-In-Chief: Kristin Feeney, B.S. [2]

Synonyms and keywords: Natural orifice translumenal endoscopic surgery, Single incision laparoscopic surgery, Minimally invasive surgery, Transanal endoscopic microsurgery, Natural orifice surgery consortium for assessment and research, Society of american gastrointestinal and endoscopic surgeons.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) Experimental Evolution

The advent of the interventional endoscopic therapy field has increased the convergence of gastrointestinal surgery and interventional endoscopy. Gastroenterologists and therapeutic endoscopists have started performing more invasive interventions than before. Recently, these clinicians have even started to manage cases that were previously only managed surgically.

On the other hand, surgical interventions in the abdominal, peritoneal, and thoracic cavities have become less invasive than before 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. This permits performing certain procedures endoscopically by passing the endoscope and the surgical instruments through a natural orifice, then transluminally into areas that would not otherwise be accessible endoscopically. A successful transgastric gastrojejunostomy procedure in a porcine survival model (a long-term survival) was an important step in proving that NOTES maybe feasible; it demonstrated that basic techniques in surgery such as organ removal and anastomoses could be performed via natural orifices [1].

In the late 1990s, the Apollo Group developed the concept of flexible transluminal endoscopy; a term which precedes the conception of NOTES [2]. The first published report of a true transluminal procedure in 2004 by Kalloo et al [3] has demonstrated the possibilities of penetrating the gastric wall and operating in animal model using a perorally introduced flexible endoscope [4]. NOTES procedures moved quickly from a concept to clinical trials on humans based on many preclinical studies. These studies have demonstrated that several types of NOTES operations can be performed in animal survival models and human cadavers [5][6][7][8][9]. Puncturing one of the viscera to perform NOTES procedures leaded to many questions regarding the infectious complications and the reliable incisional closure. Many clinical trials have been tried to answer these questions before proceeding to clinical NOTES [10].

NOTES procedures have been expanded in the last few years to cover a wide range of complex surgical operations by using the right translumenal route, endoscopic platform and the suitable instrumentation. Initially and over the last few years, endoscopic access to the peritoneal cavity using transoral (transgastric) route has been intensely investigated to perform various abdominal procedures, these procedures include cholecystectomy [11], appendectomy, splenectomy [12], ligation of fallopian tubes [13], gastrojejunostomy [14], peritoneal exploration and organ resection [15], lymphadenectomy [16], partial hysterectomy [17], oophorectomy [18], 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 routs. The most rapidly evolved experimental studies were transvaginal NOTES procedures, including cholecystectomy [19][20], nephrectomy and appendectomy [21], and the first human case was described in 2007 [22][23]. 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 the thoracic cavity (mediastinum, heart and lung) through a transesophageal approach [24][25]. Other 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 suture closure of the resultant defect [26]. 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 [27][28].

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 into the peritoneal cavity. The robot may provide a stable platform for visualization and manipulation. This has been tested in a porcine model as well.

Investigators are trying to eliminate the laparoscopic component of NOTES procedures in order to perform them through the natural orifices only without any laparoscopic assistance or guidance.

References

  1. ↑ 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)
  2. ↑ 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 2012-02-22. Unknown parameter |month= ignored (help)
  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)
  4. ↑ 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
  5. ↑ 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)
  6. ↑ 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)
  7. ↑ 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)
  8. ↑ 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)
  9. ↑ 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)
  10. ↑ 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)
  11. ↑ 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
  12. ↑ S. V. Kantsevoy, B. Hu, S. B. Jagannath, et al., “Transgstric endoscopic splenectomy: Is it possible?” Surg Endosc, vol. 20, pp. 522-525, 2006.
  13. ↑ 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
  14. ↑ 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
  15. ↑ 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
  16. ↑ 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
  17. ↑ 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
  18. ↑ ] 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
  19. ↑ 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)
  20. ↑ 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)
  21. ↑ 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
  22. ↑ 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 2012-02-21. Unknown parameter |month= ignored (help)
  23. ↑ 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 2012-02-21. Unknown parameter |month= ignored (help)
  24. ↑ 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)
  25. ↑ 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)
  26. ↑ 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)
  27. ↑ 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)
  28. ↑ 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)

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