Has a new dimension been added to minimally invasive surgery that eliminates complications associated with traditional surgery such as postoperative abdominal wall pain, wound infections, hernias, adhesions, and impaired immune function? Are second generation devices currently being evaluated and have any of the prototypes been proven to be more feasible for clinical application?
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Review > Surgery Insight: natural orifice transluminal endoscopic surgery—an analysis of work to date
Mihir S Wagh and
Christopher C Thompson, Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
Minimally invasive surgical techniques have been evolving for more than 100 years, with the first experimental laparoscopy reported in 1901 by the German surgeon Georg Kelling. He initially used a cystoscope to insufflate the abdominal cavity of a dog with air and explore its abdomen. He later used filtered atmospheric air to create a pneumoperitoneum in patients with the aim of stopping intra-abdominal bleeding. These studies, however, did not garner the support of the medical community of the time. By the 1930s technical advances in laparoscopes, lenses and insufflation techniques led to widespread acceptance of the technique for diagnostic purposes and a few basic gynecologic therapeutic applications…
In 1985, Erich Muhe reported the first laparoscopic cholecystectomy—the procedure was summarily rejected by the German Surgical Society. Two years later, the French gynecologist Mouret was able to perform laparoscopic cholecystectomy with only four trocars, and interest in the technique rapidly developed.4 Laparoscopic cholecystectomy was subsequently performed with great success and became the trendsetter for minimally invasive surgery, leading to revolutionary changes in all fields of surgery. This advance has resulted in a significant expansion of minimally invasive surgical techniques in the past few decades. Hybrid procedures combining flexible endoscopy and laparoscopy are also being performed in increasing numbers. Examples include intraoperative enteroscopy and laparoscopic-assisted endoscopic retrograde cholangiopancreatography (ERCP).
A new dimension has now been added to minimally invasive surgery, with the advent of natural orifice transluminal endoscopic surgery (NOTES). The transluminal endoscopic route for surgery has the potential to eliminate complications associated with traditional surgery (e.g. postoperative abdominal wall pain, wound infections, hernias, adhesions, and possibly impaired immune function) and offer ’scarless’ surgery. The transluminal approach could be particularly important for morbidly obese patients and others at high risk for standard surgery…
Rao and Reddy have performed transgastric appendectomy in humans in Hyderabad, India; however, this is the only report of NOTES being performed in humans and the full manuscript of this study has not yet been published.
The initial reports of transgastric endoscopic procedures, as noted above, have led to bolder transluminal ventures. For example, preliminary results of the first transcolonic procedures were presented at the First International Conference on NOTES in March 2006, in Scottsdale, Arizona, and were later published…
A second, therapeutic double-channel gastroscope is then advanced through the overtube to limit contamination of the endoscope with oral microbial flora. Various techniques for gastrotomy have been reported, with the most common location for the incision being the anterior gastric wall. A needle-knife incision can be made to puncture the wall and the gastrotomy extended by various instruments, including the needle-knife, insulation-tipped (IT) knife, pull-type sphincterotome, or controlled radial expansion (CRE) balloon. Our group initially used endoscopic ultrasound (EUS) to mark the gastrotomy location, but this technique was abandoned after initial experiments found it to not be particularly useful. A percutaneous endoscopic gastrostomy (PEG) technique has also been described to help prevent damage to adjacent structures.
The therapeutic gastroscope is then advanced into the peritoneal cavity and various surgical procedures can be performed with standard endoscopic accessories (e.g. biopsy and grasping forceps, snares, endoloops, endoclips). Once the surgical procedure is complete, the therapeutic endoscope is withdrawn and the gastric incision is closed with endoclips or with specialized, prototype suturing devices placed endoscopically into the stomach. Several promising prototypes have been studied; however, at this point no technique has been proven to be superior…
The future of notes
The enthusiasm for NOTES seems to be outpacing scientific evaluation of this new technique. It is too early to determine which conditions will be best treated by NOTES. The ideal application for NOTES will probably need to show that NOTES provides a significant incremental benefit over existing procedures that leads to its broad adoption, and this application must inspire further innovation that makes other NOTES procedures reasonable options. The NOSCAR group has attempted to manage the development of this new field prospectively, thereby averting the problems seen during the maturation of laparoscopic surgery. In the early days of laparoscopic surgery, rapid and premature adoption of new techniques by individuals still near the beginning of the learning curve led to complications that could have been prevented.
NOSCAR is attempting to limit the number of preventable errors that occur with NOTES, by emphasizing the need for institutional review board approved protocols, patient registries, and close collaboration across disciplines. Some specific guidelines on the safe pursuit of the field are offered in the NOTES White Paper. The NOSCAR group now exists as a joint committee of the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and more information about NOTES can be obtained on the NOSCAR website. Several academic centers now have institutional review board approved protocols for various NOTES procedures and we will probably see the resulting preliminary reports and case series in the very near future…
We are currently witnessing the advent of a brave new dimension for endoscopy. Various transluminal procedures have been successfully performed in animal models but have not yet been translated to humans, with the exception of an anecdotal report of human transgastric appendectomy. These early advances are, however, hampered by various technical and scientific hurdles. With the availability of improved endoscopic tools, NOTES could become an acceptable alternative—and the preferred approach—for the management of certain abdominopelvic conditions in select patients. The proposed benefits and safety of having scarless access to the peritoneal cavity need to be conclusively demonstrated in clinical studies before NOTES is universally accepted.
Key points
Endoscopic access to the peritoneal cavity via transgastric and transcolonic routes has been recently described in animal models and termed Natural Orifice Transluminal Endoscopic Surgery (NOTES)
This ’scarless’ surgery avoids abdominal incisions and could be advantageous in specific patient populations
With improved endoscopic tools, NOTES could become an acceptable alternative and the preferred approach for management of certain abdominopelvic conditions in select cases
The proposed benefits and safety of scarless access to the peritoneal cavity need to be conclusively demonstrated in clinical studies before universal acceptance of NOTES.
Georg Kelling, Cystoscope, Filtered atmospheric air, Pneumoperitoneum, Intra-abdominal bleeding, Erich Muhe, Trendsetter for minimally invasive surgery, Revolutionary changes in all fields of surgery, Hybrid procedures combining flexible endoscopy and laparoscopy, Intraoperative enteroscopy, Paroscopic-assisted endoscopic retrograde cholangiopancreatography ERCP, New dimension added to minimally invasive surgery, Important for morbidly obese patients, Rao and Reddy transgastric appendectomy, Hyderabad India, International Conference on NOTES, Therapeutic double-channel gastroscope, Overtube. Contamination of the endoscope, Oral microbial flora, Gastrotomy, Anterior gastric wall, Needle-knife incision, insulation-tipped (IT) knife, pull-type sphincterotome, controlled radial expansion (CRE) balloon, Endoscopic ultrasound (EUS), A percutaneous endoscopic gastrostomy (PEG) technique, Peritoneal cavity, Standard endoscopic accessories, biopsy and grasping forceps, snares, endoloops, endoclips, gastric incision. Endoclips, Prototype suturing devices, Placed endoscopically into the stomach, beginning of the learning curve, Complications that could have been prevented, Need for institutional review board approved protocols, patient registries, collaboration across disciplines, The NOSCAR group, Joint committee of the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Brave new dimension for endoscopy, Transluminal procedures, Transgastric appendectomy, Managed care and scientific hurdles, Availability of improved endoscopic tools, Acceptable alternative or preferred approach, Management of certain abdominopelvic conditions in select patients, Safety of having scarless access to the peritoneal cavity, Conclusively demonstrated in clinical studies, NOTES is universally accepted.
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