Page 23 - World Journal of Laparoscopic Surgery

Natural Orifice Translumenal Endoscopic Surgery (NOTES) Towards Brighter Future

After all, abdominal operations are typically under the hemi diaphragms and externalization of the wires. The same
purview of the general surgeon, but gastroenterologists are procedure of insertion could be performed through a
usually expert in flexible endoscopy. In all likelihood, minimal gastrotomy using NOTES which might obviate the need to
access surgeons and a small subset of advanced
transport a critically ill patient to the operating room.
gastrointestinal endoscopists will be the NOTES surgeons
Another scenario applicable to NOTES is the question
of the future.
The NOTES surgeon should be expert in flexible of necrotic small bowel in cases of potential mesenteric
39
endoscopy, abdominal anatomy, and surgical techniques. ischemia in ICU patients. These types of patients are usually
He or she should be capable of managing the pre- and critically ill and cannot taken to the computed tomography
postoperative care of the patients and, in particular, should (CT) scanner without risks. The presence of ischemic small
be capable of handling complications from the procedure bowel might be confirmed with transgastric peritoneoscopy
itself. It is also practical and of paramount importance that and should a short segment of ischemic small bowel be
NOTES surgeons should be able to perform an operation visualized, the patient could be wheeled to the operating
laparoscopically and conventionally, as conversion to one room. Extensive small bowel necrosis not compatible with
of these modalities is a possibility in any NOTES procedure. life might not be suitable for an operation, and the costs
These qualifications cross the boundaries of most associated with a nontherapeutic laparotomy would be
gastrointestinal endoscopy teaching programs; hence, a new spared.
training model should be adopted. A gastrointestinal surgeon The minimal requirements of instruments and only the
wishing to practice NOTES should pursue fellowship need for disinfection, rather than sterilization, make NOTES
training in advanced endoscopy while gastroenterologist appropriate for developing regions of the world. NOTES
should complete a year of advanced interventional could be performed without the infrastructure requirements
endoscopy and possibly an additional year dedicated to of an operating theater and sterilization unit. The light source,
Surgery. Trainees from both the fields of surgery and video processor, and monitor could be easily transported
gastroenterology should dedicate a substantial amount of from one place to another to best serve populations in need.
time to laboratory endeavors, as this is where skills can be NOTES might be the means to bring surgical care to
safely polished before clinical application. Training for a underserved people even in the remotest of places.
future in NOTES surgery will be different for surgeons and The transportable nature of NOTES might make it
gastroenterologists. A gastrointestinal surgeon will likely amenable for battlefield abdominal exploration. A frontline
focus on the technical aspects of flexible endoscopy, and a facility could be arranged to explore the abdomen after
gastroenterologist might need familiarization with gross serious abdominal trauma, If required hemostasis might be
abdominal anatomy and laparoscopy. Neither surgeons nor achieved with topical hemostatics or endoscopically placed
gastroenterologists should consider NOTES an infringement packing. Once stabilized, the patient could then be transported
on their territory or the demise of traditional surgery or to a higher center for definitive management.
endoscopy. Another possible derivative of NOTES is single port
laparoscopy. For example a cholecystectomy might be
A BRIGHT FUTURE performed through a single 10 mm umbilical port. A flexible
laparoscope could be maneuvered into position and locked
Although today we are not far from but still we are not on
into place and special triangulating instruments with multiple
the brink of widespread pure clinical NOTES. There are
degrees of freedom could then be used for the dissection.
many potential applications of NOTES that will likely
Specimen removal would then occur through the single
manifest in the near future. Given the portability of NOTES
umbilical port.
equipment and the requirement for only conscious sedation,
NOTES is ideally suited for the intensive care units. There
CRITIQUES
are two potential scenarios that have been described are
applicable to ICU NOTES: diaphragm pacing and It is more than tempting to be swept up in the euphoria for
peritoneoscopic examination for ischemic bowel. NOTES, but hard data supporting the clinical applications
Diaphragm pacing has been shown to be effective of NOTES need to be accumulated before widespread use.
modality in promoting ventilator weaning in ICU patients. 38 NOSCAR put forward the questions regarding the safety
The procedure is commonly performed laparoscopically in and utility of NOTES in the White Paper, and some of the
the operating room with insertion of pacing wires into both answers are manifesting.

World Journal of Laparoscopic Surgery, January-April 2010;3(1):19-25 23