What are the benefits of performing a cholecystectomy through a 20mm umbilical port that might increase the risk of abdominal wall complications? Will it be possible to reduce the size of the instruments and scopes to make them suitable for a smaller umbilical port? What role have flexible scopes with operative channels and endoscopic instruments?
When Antony Kalloo presented his experience in transgastric surgery in 2004, he could not imagine that he and NOTES would be at the epicentre of a revolution in laparoscopic surgery.
When ASGE and SAGES created a working group to develop transluminal surgery, while some did think that NOTES would improve conventional flexible endoscopy, none of the leaders sensed that this idea would have some repercussion on laparoscopic surgery.
The initial idea behind NOTES was that of an incisionless surgery, which would de facto eliminate scars accessing the peritoneal cavity via natural orifices. This implies the use of controlled procedures that breech the lumen of a healthy hollow viscus such as the stomach, the colon, the vagina or the urinary bladder.
The first intellectual challenge begins here. How can we possibly conceive an evolution when this will be drenched with unsolved potential problems and complications?
Research has to focus on finding the best way of accessing the peritoneal cavity, on the development of leak-proof closure methods and on minimizing the potential risks related to contamination. While secure closure of gastric or colonic incisions are critical and difficult, the experience of gynecologists performing transvaginal procedures has demonstrated the safety of this route: infection rate is 0.001%, rectal injury is 0.002%, localized bleeding is 0.2%… This compares favourably with the risks related to the use of trocars in laparoscopic surgery: 0.03-0.3% of visceral and vascular injuries, 0.7-1.8% of incisional hernia…This is the reason why the first clinical application of NOTES, cholecystectomy, was performed through the transvaginal route… The idea behind this was to create a model for NOTES, avoiding the drawbacks of new entry sites, thus allowing for an objective evaluation of the potentials of this concept.
But this approach, per se, has limitations. In addition, time is needed to develop technologies that would facilitate the procedure and to study the consequences of the breach of a hollow viscus of the GI tract…Studies have shown that postoperative pain is decreased when fewer and smaller trocars are used…Laparoscopic cholecystectomy with micro-instruments confirmed these findings…Nevertheless, this technique did not become as popular and as widespread as one would have imagined. This is mainly due to the technical challenge related to the size and lack of stability of micro-instrumentation. Therefore, surgeons needed to rethink this and look for other solutions.
How can we possibly reduce the number of trocars, how can we improve the cosmesis in laparoscopic surgery? How can we perform a procedure that needs several instruments and therefore multiple ports, when aiming at reducing the number of ports?
Several options are available: decrease the number of instruments, gather ports in the same incision, use multiple instruments through the same port or use an operative scope through a single port. In the nineties, the first descriptions of cholecystectomy techniques performed through an approach that allowed to reduce the number of ports or gather them at the umbilicus… Single-port laparoscopic appendectomies were reported… These experiments were not known to all. It was brought to the general attention with the advent of NOTES.
Now the embryologists started to think. The umbilicus is a natural orifice, a well-healed natural scar that would allow access to the peritoneal cavity. Natural Orifice Endoscopic Surgery can thus be carried out through the umbilicus. This would immediately overcome the technical and intellectual challenges related to the perforation of the lumen of a hollow viscus. Nevertheless, this embryological interpretation of a natural orifice does not exactly correspond to the sheer definition of NOTES because it requires an abdominal incision to enter the peritoneal cavity.
Several definitions have subsequently been crafted: Natural Orifice Trans Umbilical Surgery (NOTUS), Trans Umbilical Endoscopic Surgery (TUES), Trans Umbilical Laparoscopic Assisted (TULA)…What will these techniques bring?
Clearly the reduction of postoperative pain is related not only to the decrease in the number of ports, but also to the size of such ports…