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Natural Orifice Translumenal Endoscopic Surgery (NOTES) Towards Brighter Future
REVIEW ARTICLE
Natural Orifice Translumenal Endoscopic

Surgery (NOTES) Towards Brighter Future

S Abbas, R Rizvi

Consultant, Minimal Access Surgery, Rizvi Clinic and Research Center, Aligarh, Uttar Pradesh, India

Abstract
In natural orifice translumenal endoscopic surgery (NOTES) intentional puncture of one of the viscera (e.g., stomach, rectum, vagina,
and urinary bladder) is made and an endoscope is used to access the abdominal cavity and perform an intra-abdominal operation. Early
studies focused on feasibility, including such accomplishments as pure transgastric splenectomy and gastrojejunostomy. Contemporary
studies are investigating the infectious and immunologic implications of NOTES and honing the tools and techniques required for
complex abdominal operations.
Today NOTES has entered the clinical arena in quite a few cases: The first clinical series of transgastric peritoneoscopy has recently
been published; many groups are accumulating patients in studies of NOTES cholecystectomy, either via the transgastric or transvaginal
route; and a series of transgastric appendectomies has been well publicized, yet they remains unpublished. Although clinically NOTES
is gaining momentum, the field should remain in check while rigorous studies are performed and clinical trials are undertaken. The zeal
for NOTES should not take precedence over the welfare of the patient.
Keywords: Endoscopic surgery, translumenal, peritoneoscopy.

Kalloo’s publication of transgastric peritoneoscopy in 2004 1 needleknife, a wire is passed through the site into the
has led to evolution of field of natural orifice translumenal abdominal cavity, and then the tract is enlarged with an
endoscopic surgery (NOTES). In a short time period, endoscopic dilating balloon to accommodate the endoscope.
NOTES has been shown to be feasible in numerous Transvesical and transcolonic operations use similar
laboratory animal studies and NOTES-specific instrumen- methods for entering the peritoneal cavity. Once the
tation have already reached the research and development endoscope is inside the abdominal cavity, a pneumo-
stages. Furthermore, the infectious and immunologic impact peritoneum is generated using endoscopic insufflation and
of NOTES has, in many cases, shown the equivalence of then scope is maneuvered to view the organ of interest.
NOTES to laparoscopy and conventional abdominal surgery. Endoscopic instruments, such as biopsy forceps and
As of now careful clinical trials of NOTES peritoneoscopy polypectomy snares can then be passed through the working
and cholecystectomy are being conducted, and as the data channels and used for tissue manipulation. Once the
accumulate and instrumentation improves, NOTES will play operation is completed, the endoscope is returned to the
lumen of the viscus and the viscerotomy is closed.
a major role in the future of abdominal surgery.
SHORT COMINGS OF
BASICS
CONTEMPORARY TECHNIQUES
Fundamentally NOTES consist of passage of a flexible As we can see from the description above, many limitations
endoscope through one of the body’s natural orifices, of current NOTES techniques are evident. Foremost is the
perforation of a viscous, and performance of abdominal fact that a hole is intentionally made in one of the viscera,
surgery using endoscopic visualization. The endoscope may which ridicules the decades of surgical dogma.
be inserted through the mouth, anus, urethra, or vagina The flexibility of the endoscope causes difficulty in
with puncture of the stomach (the esophagus for mediastinal achieving a stable operating field. A deep loop into the pelvis
exploration), rectum, urinary bladder, or vagina, respectively. is required to view the right upper quadrant in transgastric
Although details of NOTES procedures vary between approach, and the endoscope might resist this positioning.
centers, most groups usually adhere to the same general Because of retroflexion, the endoscopic image might be
principles. For transgastric surgery, a standard gastroscope reversed or inverted, further complicating the operation.
is passed through the mouth into the stomach, small anterior The current shortcomings of adequate instrumentation
gastrotomy is made, typically with an endoscopic restricts the ability to perform meticulous dissection in
World Journal of Laparoscopic Surgery, January-April 2010;3(1):19-25 19