Natural orifice translumenal endoscopic surgery (NOTES) potential applications

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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.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) Potential Applications

NOTES procedures have been performed through different natural orifices. So far, transvaginal approach is the most commonly used 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 [1]. Transvaginal fertility procedures and oocytes procurement transvaginally has been performed for years [2]. 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) [3]. 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 [4]. A single stitch can be easily used to close the incision.
  • In general, transvaginal NOTES has lower complications rates than other approaches.
  • Transvaginal rout is considered the best rout for performing minor uterine procedures for benign uterine diseases [5].
  • Sexual function is not affected by transvaginal extraction of the uterus or other organs [6].

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). There is a risk for injury to nearby organs, the rectum and the sigmoid colon are at higher risk than other structures, that is why visualizing the pelvis directly by a laparoscope (through the trocar site) may be a safe method to ensure there are no injuries for pelvic organs. Transvaginal approach may have higher incidence rates for certain complications (bladder injury and vaginal hematoma) than other surgical approaches [7]. The long-term effects of transvaginal procedures have not been investigated.

Transvaginal cholecystectomy are usually performed with a single 5mm umbilical port. An additional 3mm transabdominal port can be used as a safety precaution in few cases [4]. The average operating time to perform the procedure is 2 hours. Blood loss is less than 50 ml in most cases [4]. Using the laparoscopic hook which is inserted via the umbilical port to dissect the gallbladder from the liver is considered easier, quicker and safer than the dissection by using the smaller size endoscopic hook [4]. Currently, laparoscopic clipping of the cystic duct is the safest and most secured method for securing the duct [4]. More occlusive endoscopic clips and instrumentation should be developed.

In transvaginal NOTES (and most NOTES procedures), insufflation through a laparoscopic port (which can be used also for single laparoscopic instrument insertion) is better controlled than endoscopic insufflation [8].

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 [9]. 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. 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 [10]. 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 [11][12]. This is considered a less invasive option to perform colorectal procedures such as resection of colonic ulcers, adenomas, and early colorectal cancers [13].

In transrectal approach, spatial orientation permits visualizing abdominal organs easily with the endoscopes (no need for retroflextion). Another advantages over other approaches is the ease of closure of the colotomy after the procedure [14][15]. Studies demonstrated that there is no higher risk of infection or peritonitis by entering into the peritoneal cavity via a transcolonic/transanal puncture in the presence of adequate colotomy closure [12].

Transrectal surgery is considered a unique NOTES approach to perform transrectal rectosegmoid resection due to two facts:

  • The punctured organ in this approach is the diseased organ itself, which should be excised, rather than puncturing an organ to operate in another organ as in other NOTES approaches [16].
  • Closure of the puncture is achieved via colorectal anastomosis which is required in all cases regardless the surgical method for performing the procedure [17].

A pilot study at Harvard Medical School and Massachusetts General Hospital has demonstrated that although it is more time consuming, a longer segment of the sigmoid colon can be resected and extracted transanally by combining transgastric and transanal dissection rather than transanal dissection alone.

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 [18]. 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

Initially, there were difficulties in achieving orientation and navigation based on retroflection of the endoscopes to visualize the upper abdomen and perform upper abdominal procedures. Better results had been achieved for lower abdominal surgeries, such as pelvic surgery, tubal ligation, and appendectomy.

This NOTES approach is more sophisticated than the transvaginal one, especially in terms of gastric wall closure after extracting the organ (requires laparoscopic assistance [19]. 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 [20]. Retrieval of dislodged endoscopic gastrostomy tube via this approach has been reported as well [21]. 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.

In general, the following steps should be considered for most NOTES transgastric procedures:

  • The patient should be in an overnight fasting state. General anesthesia is inducted and single dose intravenous antibiotics are administered (amoxicillin and metronidazole). The position of the patient is usually Lloyd-Davies position.
  • Gastric lavage should be done before the procedure using chlorhexidine solution.
  • The puncture site is chosen for adequate visibility to perform the procedure. The best areas of entry are the proximal body and the distal antrum (both are relatively avascular) [22].
  • A flexible endoscope is inserted via the oral cavity to the stomach, the puncture is made by a needle knife. The puncture site is dilated by an endoscopic balloon and and the scope is inserted into the peritoneal cavity.
  • Intraperitoneal pressure is controlled using laparoscopic carbon dioxide insufflator and the procedure is performed. Usually 2 to 3mm trocars are used in the procedure.
  • The puncture site is closed by a suturing device after extracting the specimen or the organ via the oral cavity.

Peritonitis and esophageal rupture may occur after transgastric procedures. In general, complications are more common in transgastric procedures than in transvaginal procedures.

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 [23]. Esophageal injuries could be prevented during performing the procedure by using gastroesophageal overtubes. The instruments and ports for transesophageal NOTES have more restrictions in their size and shape compared with other approaches. Large organ (specimen) extraction is not suitable for this approach (a maximal diameter of 2 cm) according to the relatively smaller size of esophageal lumen compared with other hollow organs.

Transurethral/Transcystic NOTES

References

  1. ↑ 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 2012-02-27. Unknown parameter |month= ignored (help)
  2. ↑ Schulman JD, Dorfmann AD, Jones SL, Pitt CC, Joyce B, Patton LA (1987). "Outpatient in vitro fertilization using transvaginal ultrasound-guided oocyte retrieval". Obstet Gynecol. 69 (4): 665–8. PMID 3103035. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  3. ↑ 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)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 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 2012-03-05. Unknown parameter |month= ignored (help)
  5. ↑ McCracken G, Lefebvre GG (2007). "Vaginal hysterectomy: dispelling the myths". J Obstet Gynaecol Can. 29 (5): 424–8. PMID 17493374. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  6. ↑ Roussis NP, Waltrous L, Kerr A, Robertazzi R, Cabbad MF (2004). "Sexual response in the patient after hysterectomy: total abdominal versus supracervical versus vaginal procedure". Am. J. Obstet. Gynecol. 190 (5): 1427–8. doi:10.1016/j.ajog.2004.01.074. PMID 15167858. Retrieved 2012-03-06. Unknown parameter |month= ignored (help)
  7. ↑ Milad MP, Morrison K, Sokol A, Miller D, Kirkpatrick L (2001). "A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy". Surg Endosc. 15 (3): 286–8. doi:10.1007/s004640000328. PMID 11344430. Retrieved 2012-03-06. Unknown parameter |month= ignored (help)
  8. ↑ 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 2012-03-05. Unknown parameter |month= ignored (help)
  9. ↑ 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)
  10. ↑ 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)
  11. ↑ 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)
  12. ↑ 12.0 12.1 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)
  13. ↑ Cataldo PA (2006). "Transanal endoscopic microsurgery". Surg. Clin. North Am. 86 (4): 915–25. doi:10.1016/j.suc.2006.06.004. PMID 16905416. Retrieved 2012-03-07. Unknown parameter |month= ignored (help)
  14. ↑ Fong DG, Ryou M, Pai RD, Tavakkolizadeh A, Rattner DW, Thompson CC (2007). "Transcolonic ventral wall hernia mesh fixation in a porcine model". Endoscopy. 39 (10): 865–9. doi:10.1055/s-2007-966916. PMID 17968801. Retrieved 2012-03-07. Unknown parameter |month= ignored (help)
  15. ↑ Ryou M, Fong DG, Pai RD, Tavakkolizadeh A, Rattner DW, Thompson CC (2007). "Dual-port distal pancreatectomy using a prototype endoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery (NOTES) survival study in a porcine model". Endoscopy. 39 (10): 881–7. doi:10.1055/s-2007-966908. PMID 17968804. Retrieved 2012-03-07. Unknown parameter |month= ignored (help)
  16. ↑ World J Gastrointest Surg. 2010 June 27; 2(6): 193-198. Published online 2010 June 27. doi: 10.4240/wjgs.v2.i6.193
  17. ↑ World J Gastrointest Surg. 2010 June 27; 2(6): 193-198. Published online 2010 June 27. doi: 10.4240/wjgs.v2.i6.193
  18. ↑ 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 2012-02-28. Unknown parameter |month= ignored (help)
  19. ↑ 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)
  20. ↑ 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)
  21. ↑ 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)
  22. ↑ Rao GV, Reddy DN, Banerjee R (2008). "NOTES: human experience". Gastrointest. Endosc. Clin. N. Am. 18 (2): 361–70, x. doi:10.1016/j.giec.2008.01.007. PMID 18381176. Retrieved 2012-03-05. Unknown parameter |month= ignored (help)
  23. ↑ 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)

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