Dr. Sallama Hamid Abbas
Specialist in Obstetrics & Gynecology
CABOG, FICOG, DOG Head of CME unit
Alkarkh Birth Hospital
Baghdad, Iraq

Abstract:

Introduction: Natural-orifice transluminal endoscopic surgery (NOTES) is regarded by many surgeon and gynecologist as safer and less invasive than conventional laparoscopic surgery. However, there has been no documentation of the opinions of surgically active, experienced gynecologists about the indications, contraindications, risks, and complications of NOTES. Objective: to review previous articles & found out the role of NOTES in Gynecology. Method: As many articles had studied NOTES in different surgical procedures as gall bladder stones ,gastrointestinal diseases & colorectal operations, very little or no much studies has been done to evaluate its role in gynecological operations specifically, although vagina is a good access for these operations. A systematic review using available databases evaluation of all these studies to investigate for our aim of the study. Results:Transvaginal applications have been the first to be adopted clinically for NOTES, with the proposed benefits of reduced surgical trauma and improved cosmesis compared with other natural orifices. Operations done transvaginally involve the following procedures transvaginal cholecystectomy peritoneoscopy, appendicectomy, sleeve gastrectomy, sigmoidectomy, nephrectomy, splenectomy & transvaginal liver biopsy or resection & the most commonly performed application is transvaginal cholecystectomy with acceptable reported outcomes and complications.

Although the traditional vaginal hysterectomy is the earliest surgical operation done through natural orifice that’s the vagina ,no much application for NOTES has been reported in gynecological operations except few cases of tubal ligation & salingoopherectomy done on animals bases for research purposes hysterectomy is difficult to be done by NOTES except few cases of partial hysterectomy. Discussion: transvaginal NOTES is argued to be a promising access for scarless surgery.

The real question is not who is going to be performing NOTES, gastroenterologists or surgeons? The real question is how do practicing health care professionals learn new techniques and technology and introduce them safely into their practice to optimize patient care?No difference in the incidence of complications was observed with the newer techniques. Future studies will be needed to elucidate the learning curve for this new technique and the contraindications in its use.

Conclusions: NOTES is good for cholecystectomy and other bowel surgeries. NOTES is not easily applicable for gynecological operation. SILS is more preferable than NOTES in gynecology. Transvaginal approach is good one for different surgical procedures other than gynecological. SILS has more surgical domain than NOTES. Further studies are recommended on gynecological procedures performed by NOTES to evaluate its indications, applicability & complications.

Introduction:

Natural orifice transluminal endoscopic surgery (NOTES) refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic visualization (“scarless surgery”), these operations with faster recovery times, improved cosmetic results, and reduced postoperative pain. Since its introduction in 2004, numerous reports have been published describing different surgical interventions. Recently, a group of expert laparoscopic surgeons and endoscopists outlined the limitations of this approach and issued recommendations for progress toward human trials. Herein we review the published data and propose, a series of questions to be considered for future value of NOTES in laparoscopic surgery & its role in gynecology (1). The first report of natural orifice transluminal endoscopic surgery (NOTES) was published in 2004 by Kalloo et al (2). The use of the vaginal route for endoscopic procedures is not new. In 1901, Dr. Ott described ventroscopy(3), some years later, Klaften presented colpolaparoscopy (4) and Decker and Cherry reported culdoscopy (4,5). Culdoscopy was the preferred endoscopic method used by gynecologists for many years. Although abandoned in favor of laparoscopy, in recent years we have witnessed a resurgence of vaginal endoscopic techniques.

In 1998, we introduced culdolaparoscopy, which entails the use of mini laparoscopy to assist natural orifice surgery (6,7), with this technique, the posterior vaginal fornix is used for the insertion of the larger, 10-mm or 12-mm port, which serves visual function similar to culdoscopy and is used for introduction of operative instruments and extraction of specimens. Culdolaparoscopy is a feasible, simple, safe technique that avoids additional and larger abdominal ports, potentially decreasing the morbidity associated with conventional operative laparoscopy while overcoming the limitations of mini laparoscopy. This approach enabled us to perform gynecological and non gynecological procedures utilizing abdominal ports no larger than 3 mm or 5 mm (8). Human beings, don’t like to undergo surgical procedures, not only for the fear and effect of the disease, but also for the expected postoperative pain, the risks and side effects of anesthesia, the recovery time needed after an operation and the permanent visible scars that will forever leave an unpleasant reminder of the experience (9).

Natural orifices could be mouth, nose, vagina, rectum without an external incision; an internal incision of the peritoneum and possibly an incision of the diseased organ (e.g. stomach, bladder, colon) is necessary (10). NOTES approach is also stimulating the appreciation of complementary advanced technologies and new surgical concepts, that will allow us not only to perform the procedures via a minimal access, but also to minimize the extent or even the need for a surgical resection (11) (12). Other names for this surgical procedures is incisionless laparoscopic surgery.

Preoperative management includes mechanical and pharmacological (antibiotic) preparation of the proper section of the gastrointestinal tract, such as the esophagus, stomach, colon, or vagina. Most researchers agree that the risk of peritoneal infection in NOTES is small and similar to the risk of infection associated with classic procedures of gastrointestinal tract. Another promising type of laparoscopic surgery which comparable to Notes is SILS which is single incision laparoscopic surgery, it has been used to perform oophorectomy, salpingectomy, bilateral tubal ligation, ovarian cystectomy, surgical treatment of ectopic pregnancy, and both total and partial hysterectomy (13,14).

As the standard approach to laparoscopic hysterectomy consists of four incisions where four separated ports are placed, one for the laparoscope and three for surgical instruments, a new approach is by trans umbilical single-port access laparoscopic approach for total (TLH), subtotal (SLH), and vaginal (LAVH) hysterectomy (15).

METHODS:

A systematic review using available database of Medline, scholar google, pupmed, WLH, SAGES, US national library of medicine, european association of endoscopic surgery EAES, medscape, ANZJOG (The Australian and Newziland Journal of Obstetrics & Gynecology), EMBASE, CINAL current cont-cochrane Library and reviewing of about more than 50 articles & evaluation of all these studies to see if NOTES has important role in gynecology and if it has a promising future in laparoscopic surgery for surgeons and gynecologists, also we will talk about surgical domain of both NOTES & SILS.

RESULTS:

Most of the studies about NOTES focus on technical and training issues, with little attention to date paid to the opinions of women and perceptions of female health care workers towards trans vaginal NOTES. NOTES is regarded as safer and less invasive than laparoscopic surgery. However, there has been no documentation of the opinions of surgically active, experienced gynecologists about the indications, contraindications, risks and complications of trans vaginal access (16). NOTES is experimental and its many potential uses are being investigated in animal models (10).

Table 1: Procedures done by NOTES within the abdomen and pelvis (trans gastric pig model) (17) (18).

NOTES entails the intentional creation of perforations, a concept that has hitherto been considered taboo and associated with poor outcome. Theoretical advantages of NOTES over the laparoscopic approach include less invasiveness, elimination of any abdominal incision, and a reduction in postoperative abdominal wall pain, wound infection, hernia formation and adhesions. In the USA and indeed, most of the world. NOTES has been confined to the experimental operation theateroratory. Only a single group has used NOTES in humans; the first clinical procedure was carried out by Rao and Reddy in India (N. Reddy,personal communication), in a patient whose severe burn injuries of the abdominal wall prohibited safe entry into the peritoneal cavity for conventional surgery (19). NOTES will probably be complementary to laparoscopic surgery; it may become the preferred approach in selected patients, such as the morbidly obese and those with severe intra-abdominal adhesions. The widespread adoption of NOTES will require many scientific and non scientific issues to be addressed, and new endoscopes and endoscopic tools to be developed. At the very least, however, this technology will have applications within current endoscopic procedures. The reliable closure of a luminal perforation will allow the non surgical treatment of this condition and will also permit a more aggressive resection of gastrointestinal lesions, especially those involving the deep layers of the bowel wall (20).

Regarding SILS at least two recent studies have concluded that SILS is an acceptable way to treat many benign and malignant gynecologic conditions that are currently treated using multi port laparoscopy (21,22). One hundred thirty-five papers including 4703 patients (714 NOTES, 3989 SIS) were selected for analysis. Overall complication rate was 4.2% in the NOTES group versus 4.3% in the SIS group, with a distinct complication profile. No mortality was reported in either group. NOTES procedures had a longer mean operative time than SIS techniques (107 versus 79 minutes). The conversion rate between NOTES and SILS was similar (3.4% versus 3.3%), respectively (23).

American Society for Gastrointestinal Endoscopy (ASGE) and the Society of Gastrointestinal Surgeons (SAGES), have convened in an attempt to advance NOTES through cooperation and complementary approaches. In general, gastroenterologists have much greater experience of transluminal endoscopy than surgeons, but they have limited understanding of abdominopelvic anatomy and are ill equipped to handle major intra procedural complications.

Discussion:

One study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified. Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficiency. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents (24).

While transvaginal NOTES is argued to be a promising access for scarless surgery, gynecologists mention postoperative infection, visceral lesions, infertility and adhesions as conceivable complications. Since long-term experience has not yet been achieved, potential problems such as dyspareunia, infertility, and the spread of preexisting endometriosis remain definitely conceivable complication (16). However other authors mentioned that in gynecology there is extensive experience with the transvaginal approach to the abdominal cavity & it is easy to perform, closure is safe and there is little risk of infection. Hence, this is the approach most suitable for NOTES. By means of rigid laparoscopic instruments cholecystectomy can be routinely performed transvaginal access for NOTES (22). Traditional flexible endoscopy has been limited to the confines of the gastrointestinal lumen; however, recent developments involving transluminal access to intra-abdominal structures hold the potential to revolutionize flexible endoscopy. Over the past few years various studies have detailed techniques that intentionally breach the lumen and provide endoscopic access to the peritoneal cavity for diagnostic and therapeutic procedures (25). The real question is not who is going to be performing NOTES – gastroenterologists or surgeons? The real question is how do practicing health care professionals learn new techniques and technology and introduce them safely into their practice to optimize patient care?

NOTES is an example of the ever quickening pace of change in medical technology putting unprecedented pressure on health care providers to stay current. The advent of an international network of educational institutes coupled with the development of validated metrics of procedural competence will help procedurally based physicians adopt new techniques safely with maximum patient benefit. In this way surgery continues to move away from an apprentice model of skills acquisition to a criterion-based one. Such a move is required to address the fast pace of change in health care (26). This mean that NOTES is not surgically dominant in reverse to SILS and other laparoscopic technique, this is one of the drawbacks of NOTES as a new approach still under research. Future studies will be needed to elucidate the learning curve for this new technique and the contraindications in its use (26). No difference in the incidence of complications was observed with the newer techniques. Adequately powered randomized control trials are needed to clarify whether SILS/NOTES cholecystectomy has a similar length of hospital stay to traditional laparoscopic cholecystectomy. The increased occurrence of specific types of complications and their use in acute pathology needs further investigation to warrant further use in routine surgical practice (23).

Conclusions:

• NOTES is good for cholecystectomy and other bowel surgeries.
• NOTES is not easily applicable for gynecological operation.
• SILS is more preferable than NOTES in gynecology.
• Transvaginal approach is good one for different surgical procedures other than gynecological.
• SILS has more surgical domain than NOTES.
• Further studies are recommended on gynecological procedures performed by NOTES to evaluate its indications, applicability & complications.

Acknowledgements:

For our great teacher Prof. R K Mishra for his big support & directions.

For Dr. J. S. Chowhan for explanations & continuous assistance.

For all the staff of the World Laparoscopy Hospital.

For my family, Dear sister, Brothers & their families for being beside me in all situations.

For my lovely little child Abdullah.

And at the last but not the least for the spirits of my dear father, mother & husband.

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