Page 20 - World Journal of Laparoscopic Surgery

S Abbas, R Rizvi

NOTES. In-line endoscopic tools are also a shortcoming as Finally, last but not the least the esthetic benefits of
they have a restricted range of motion and limited degrees NOTES the concept of “no-scar” abdominal operations.
of freedom thus hindering the diamond baseball concept of This has captivated the public at large and is feasible with
the visual field and instruments, a concept found to be critical pure NOTES cases, although esthetics should not be the
in laparoscopy. only driving force behind NOTES.
As a purposeful viscerotomy is made in NOTES, its
secure closure is a must to ensure the safety of the operation. NOSCAR (NATURAL ORIFICE SURGERY
Initial research work managed the viscerotomy without CONSORTIUM FOR ASSESSMENT AND
closure or by occlusion using a percutaneous endoscopic RESEARCH)
2
gastrostomy (PEG-type gastrostomy tube). Both methods In a collaborative effort, members of the American Society
were not successful with high rates of intra-abdominal for Gastrointestinal Endoscopy and the Society of American
contamination in the porcine model. Thus, more reliable Gastrointestinal Endoscopic Surgeons joined to form
methods that achieve full-thickness closure of the NOSCAR. The purpose of this organization is to regulate
viscerotomy are currently being evaluated. the progress of NOTES and ensure the safety of clinical
applications.
ADVANTAGES OF NOTES
A NOSCAR publication which delineates the guidelines
Some critics are apprehensive with NOTES, because of its
for laboratory and clinical natural orifice surgery has been
differences with conventional surgical teaching. As of now, 4
deemed the “White Paper”. In the White Paper, the authors
advances are being made in limiting some of the current
outlined the current shortcomings of NOTES techniques
shortcomings of NOTES. However, there may be some
and some of the potential solutions. A call for rigorous
benefits of natural orifice surgery that make its pursuit
scientific research was made before clinical employment
rewarding.
of NOTES. Cooperation between the fields of gastro-
The immunologic impacts of NOTES are favorable for
enterology and surgery was mandated, ensuring the
the patient. A recent study from Case Western Reserve
communication of research findings and the multidisciplinary
University showed lower levels of tumor necrosis factor-α
make-up of NOTES teams.
(TNF-α) after NOTES peritoneoscopy compared to Recently, NOSCAR has launched a comprehensive
laparotomy and laparoscopic abdominal exploration. 3
NOTES database. All patients throughout the world who
NOTES may lead to a lesser degree of impairment of
are enrolled in NOTES trials will be entered into the database.
the peritoneal immune system and possibly even improved
oncologic and infectious outcomes. ACHIEVEMENTS TO DATE
Natural orifice surgery may decrease postoperative
The publication by Kalloo led to the organization of the Apollo
abdominal adhesion formation, like laparoscopy, the minimal
group. Shortly after the publication of transgastric perito-
access nature of NOTES might decrease the stimuli for
neoscopy, the Apollo group published reports on transgastric
adhesions formation and, subsequently, reduce the incidence 5 6 7
of postoperative adhesive bowel obstruction. tubal ligation, gastrojejunostomy, and splenectomy in a
NOTES can be performed without the need for general porcine model.
anesthesia under conscious sedation as no skin incision is Recently, members of the Apollo group collaborated in
made, therefore NOTES could be performed in the intensive the performance of per oral transgastric ventral hernia repairs
care unit or endoscopy suite, rather than an operating room. in a porcine model. These publications were significant as
The NOTES team and its equipment are more portable it proved that complex operations were feasible using
as single endoscopy tower houses all of the necessary NOTES techniques and the animals survived without undue
equipment. complications.
Furthermore, in NOTES, procedures are performed Many studies followed and performed animal feasibility
without sterile instruments, only with scopes subjected to studies. Transgastric appendectomy, 8 cholecystectomy, 9
high-level disinfection. This makes NOTES more applicable and oopherectomy 10 were performed. The transcolonic 9
to compromised environments, such as battlefields and approach was used to perform cholecystectomy, and the
especially in developing countries, where sterilization transvaginal approach has been used in laboratory animals
equipment is not readily available. to perform nephrectomy. 11 Combined transrectal and

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