Saudi Journal of Gastroenterology
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Year : 2007  |  Volume : 13  |  Issue : 4  |  Page : 207-210
NOTES: Evolving trends in endoscopic surgery

Gastroenterology Division, Medical Department, King Fahad General Hospital, P.O. Box 16865, Jeddah - 21474, Saudi Arabia

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Date of Submission14-Sep-2007
Date of Acceptance19-Sep-2007


Intraluminal endoscopic surgery is a recent innovation to minimally invasive surgery. This technique provides access to the peritoneal cavity through a natural orifice. The technique holds the promise for "incisionless," less invasive procedures without the risk of postoperative sequelae as in the standard surgical approach, particularly in high risk patients. The hope of combining the skill and experience of endoscopists and surgeons into a defined specialty has attracted worldwide attention. It is anticipated that the skill sets required will be a hybrid that includes laparoscopic skills as well as endoscopic expertise. The studies in animal models of natural orifice translumenal endoscopic surgery (NOTES) have demonstrated the safety and feasibility of various types of intraabdominal surgeries, including transgastric liver biopsy, cholecystectomy, tubal ligation and peritoneoscopy amongst others. This review discusses the evolution of NOTES, the types of procedures performed and the challenges that lie ahead in the further development of this technique.

Keywords: Endolumenal, endoscopy, minimally invasive surgery, natural orifice translumenal endoscopic surgery, transcolonic, transgastric

How to cite this article:
Babatin MA. NOTES: Evolving trends in endoscopic surgery. Saudi J Gastroenterol 2007;13:207-10

How to cite this URL:
Babatin MA. NOTES: Evolving trends in endoscopic surgery. Saudi J Gastroenterol [serial online] 2007 [cited 2021 Dec 7];13:207-10. Available from:

For decades, the surgical application of endoscopy was thought to be limited to diagnostic biopsies, polypectomies and biliary endoscopy. This was followed by the somewhat more adventurous mucosal resections and endoscopic suture plications for gastroesophageal reflux disease. Over the last few years, however, a new modality of intraluminal endoscopy has evolved, in effect competing with surgery and offering a new dimension to translumenal endoscopy. Many surgical procedures performed previously have now been replaced by less invasive options that require fewer days of hospitalization, lower costs and less unwanted after effects such as prolonged time to wound healing and development of adhesions. The testament to this inference is the fact that since its introduction in the 1990s, laparoscopic cholecystectomy has become the most common surgery to be performed in present times.

The goal of therapeutic endoscopy has been to find low-risk alternatives to more invasive surgery. With recent advances in endoscopic technology, therapeutic endoscopy is rapidly expanding into newer dimensions. The endoscopic insertion of gastric feeding tubes has become a routine procedure in most endoscopy units. The previous two decades have also seen various other intra-abdominal organs being targeted, albeit on an experimental basis, through an endoscopic, transgastric approach. [1],[2] Since its initial description in the year 2000, [3] natural orifice translumenal endoscopic surgery (NOTES) has evolved into a more comprehensive endoscopic technique, thereby attracting increasing attention from gastroenterologists and surgeons alike. The procedure involves the interventional skill and expertise of an experienced endoscopist working in tandem with a surgeon with an in-depth knowledge of surgical anatomy organ resection and homeostasis. It entails access to the abdominal cavity via transoral, transcolonic, transvesical or transvaginal routes.

Since its initial description, several studies on animal models have been published on NOTES, including transgastric tubal ligation, [4] cholecystectomy, [5] liver biopsy, [6] gastrojejunostomy [7] and splenectomy. [8] Once human experiences get published, it will undoubtedly provide further momentum to clinical trials that are already in preparation at various centers across the world. This review aims to address the challenges that lie ahead in further developing this technique.

   Historical Aspect of Notes Top

Although the concept of NOTES is recent, it has been practiced since 1976 when the first reported procedure of intraluminal endoscopic intervention of colonoscopic appendectomy was described by Wirtschafter et al . [9] The next step in NOTES development came when the now routinely performed, transgastric procedure of percutaneous endoscopic gastrostomy (PEG) tube insertion was first described by Gauderer and colleagues in 1980. [10] Further progress in the evolution of this technique was ushered in by the advent of laparoscopic cholecystectomy. While this procedure was important in transporting the surgical technique to an endoscopic platform, it also revealed a desire within "interventionalists" to minimize surgical invasiveness, which is essential to the concept of NOTES.

The realm of the surgeons was further eroded with the development of the endoscopic technique for intragastric drainage of pancreatic cyst through the gastric or duodenal wall by the creation of a fistulous tract. [1] These experiences inspired the motivation of getting an access to the peritoneal cavity and enabling organ resection, particularly in high risk patients. The first report on NOTES appeared in 2000 when Kalloo et al. , performed transgastric peritoneoscopy and liver biopsy in a porcine model. [3] Then, in 2004, the same group provided the proof-of-principle by demonstrating the feasibility and safety of peroral transgastric endoscopic approach to the peritoneal cavity in a porcine model. [6] In another animal study, Park et al. , reported transgastric cholecystectomy by a technique similar to laparoscopic cholecystectomy using two intragastric endoscopes. [5] Since then this proof-of-principle has been adequately established by several other studies reporting successful transgastric resection of  Fallopian tube More Detailss, [4] spleen, [8] gastric gastrojejunostomy [7] and exploration of the peritoneal cavity in a nonsurvival model. [11]

Then, in 2004, Rao and Reddy presented during the annual meeting of the American Society of Gastrointestinal Endoscopy (ASGE), Rao and Reddy presented (unpublished) the first transgastric appendectomy in a human subject. [12] This prompted the ASGE and the Society of Gastrointestinal Endoscopic Surgeons (SAGES) to arrange for a conference in 2005 to develop a consensus among endoscopists and surgeons on the ideal way to proceed with this procedure. Finally, in 2007 Hazey et al . described the safety and feasibility of NOTES in the first human pilot trial. [13] Ten patients were recruited in the study for laparoscopic diagnosis and staging of a pancreatic mass followed by diagnostic transgastric endoscopic peritoneoscopy. In comparison between the two procedures, the average mean exploration time was longer in NOTES than traditional laparoscopy, i.e., 24.8 and 12.3 min, respectively. The visualization of right upper quadrant structures was inadequate endoscopically in four patients and endoscopic biopsies were unsuccessful in two patients due to inability to access these areas. None of the patients had complications related to the procedures.

   The 'Why' Factor Top

It is apparent that presently the science of NOTES is being eclipsed by the enthusiasm of its practitioners. Beyond being a novelty at best, NOTES has yet failed to demonstrate any real advantage to removing organs through a natural orifice. Thus far, no studies have been performed to objectively assess the advantages with this approach. The enthusiasts of NOTES are quick to compare the success story of laparoscopic surgery as analogous to the potential of natural orifice surgery. However, skeptics demand a rigorous debate to the concept, and it is crucial that before translumenal surgery can become commonplace, it must face various technical and intellectual challenges.

The rationale for "incisionless" surgery stems from the theoretical benefit of lesser complications such as reduced abdominal pain, adhesions and ileus, improved access to the peritoneal cavity in obese patients and better cosmetic outcomes in that it is scarless surgery.

The ideal application for NOTES will probably require that this type of surgery provides a significant advantage over more traditional forms of surgery. It must also be determined which procedures and conditions can be utilized as safer alternatives in this type of surgery. Towards this, techniques must be refined, the concept should be aggressively researched in the setting of controlled trials and adequate industry funding must be courted towards the development of tools and instruments essential to overcome the existing difficulties.

   Procedural Methods Top

The technical method used in published studies for endoscopic surgery begins with the standard single-channel endoscope. However, the procedure is performed under general anesthesia and the possibility of infectious complications is overcome by creating a sterile working field using prophylactic antibiotics, chemical disinfection with glutaraldehyde and gas sterilization of endoscopes with ethylene oxide. The gastric lumen is emptied of the residual gastric content by aspiration and disinfected with antibiotic lavage. Kalloo and colleagues used neomycin and polymyxin B sulfate solutions towards this end. [6] In another study, the same authors used cefazolin with a similar outcome. [14]

For transcolonic surgery, the preparation consists of cleansing with sterile water enemas, followed by aggressive stool removal endoscopically. A cefazolin suspension is instilled endoscopically and the distal colon, rectum and anal orifice are instilled with Betadine®. [14]

Subsequently, a percutaneous access wire is placed into the stomach via a 12-gauge needle under endoscopic guidance. A needle knife is then used to create a gastric wall by opening blindly and extended by different methods either by a pull-type sphincterotome, needle knife or TTS (through the scope) balloon dilator and advanced into the abdominal cavity. A dilating balloon is advanced over the access wire and used to radially dilate the linear incision to an 18-mm-diameter circular gastrotomy.

Then, in 2004, Rao and Reddy presented various studies reported different sites of gastrotomy (depending on the desired surgical procedure) although the anterior gastric wall is the commonest location. To avoid a blinded procedure and subsequent injury to adjacent intraabdominal organs, Wagh et al . in their study used EUS to localize the site of gastrostomy. [11] In another study, Kantsevoy et al . reported a PEG-like approach to the peritoneal cavity without any reported organ injury. [15] There were no complications, except for one animal that had bleeding from the gastric wall incision; this occurring when a pure cutting current was used. In addition, the authors reported that the anterior wall access limited the exposure to the intraperitoneal organs.

A second therapeutic gastroscope may be introduced where indicated, preferably through an overtube to reduce the risk of infection. [4] Park et al . used two endoscopes in his experimental study for transgastric cholecystectomy. [5] After the procedure is completed, the endoscope is withdrawn into the stomach and the gastric opening is closed by endoclips, plicator or suturing devices.

   Challenges to Notes Top

In the mould of any new technical procedure, there will be challenges that must be addressed before the widespread utilization of these techniques in humans. It must be remembered that the overwhelming majority of the studies were conducted only in animals. In March 2006, a large international NOTES conference was held in Scottsdale, Arizona, to explore the challenges that surround translumenal endoscopic surgery. These include the gastroscopic access to peritoneal cavity, infection prevention, endoscopic access closure and management of the expected complications.

Access to the peritoneum

One of the major challenges in transgastric endoscopic surgery is the accessibility to intraabdominal organs higher than the stomach. Obtaining an access to the gallbladder or biliary system is somewhat difficult due to an angle from the anterior gastrostomy opening. In a study by Park et al ., the first transgastric cholecystectomy and biliary anastomosis were performed. [5] The limitation encountered in their study was the poor visualization, difficulty in making vigorous grasping and retraction of tissues due to the flexibility of the endoscope. Other challenges include the reduced angulations of the endoscope when the accessory channel is used in a retroflexed position. A more feasible approach to the upper abdominal organs is from the lower part of the abdomen, either transcolonic (hepatic flexure for cholecystectomy), transvesical or transvaginal routes. [16],[17] However, the transgastric approach may be more viable due to a thicker gastric wall with its potential for better healing and a reduced risk of bacterial contamination. In contrast, the endoscopic visualization of pelvic organs through the transgastric approach is technically easier. [4] In a study by Sumiyama et al ., a standard two-channel gastroscope was compared with a therapeutic multibending endoscope. [18] The multibending endoscope had a better access to the gallbladder and cholecystectomy performed in all pigs compared to the standard endoscope failed to access the gallbladder in two out of four procedures.

Prevention of infection

Significant concerns remain that intraperitoneal contamination and infection may arise from the use of a translumenal approach. To date, no studies have been performed to quantify the bacteriological load that the peritoneum is exposed to during transgastric procedures. The clinical experience of bacteriological contamination of the peritoneum derived from decades of bowel surgery suggests that it is well tolerated, provided the gross spillage is avoided and patients receive prophylactic antibiotics. In the animal studies published thus far, maneuvers to sterilize the stomach prior to the procedure and the use of a sterile overtube seem to have reduced the risk of developing intraperitoneal abscesses. It is therefore feasible that infection may not pose additional difficulties in harnessing this technique further.

Closure of gastrostomy site

Reliable and complete closure of the gastrostomy point represents another challenge in the field of transgastric surgery. Despite obtaining a sterile environment by using antibiotics, gastric lavage and a sterile overtube, complete closure of the gastric incision appears to be necessary. Thus far, there is no standardized efficacious method, and most of the techniques used are limited to individual experience in animal models. Several accessories are used and these include endoscopic clippings, [6] suturing, [19] tissue fasteners [20] and NDO plicators. [21] None of these techniques are superior to the others, although endoclips are the most commonly used. The potential for complications is higher when two or more instruments are passed at different sites through the gastric wall due to the development of shearing forces. Therefore, the onus of such unconventional experimentation mandates that a 100% reliable means of gastric closure must be developed. The aforementioned ASGE/SAGES consensus document suggests the usage of nonporcine models to test the suitability of gastric closure devices prior to human use. [12]

Management of complications

Inevitably, with the performance of more complex procedures, complications such as hemorrhage, bowel perforation, splenic injury and possibly a new set of complications unique to NOTES are likely to occur. Currently available transgastric devices make the management of such complications inherently difficult. Moreover, the concerns remain over the possible injury of adjacent organs when the gastric wall is punctured. A recent study by Kantesevoy et al . in 12 porcine models using a PEG-like approach showed only one complication related to bleeding from the gastric incision but no injury to the adjacent organs. [15] Further refinement of endoscopic suturing techniques in the future may lead to the repair of injured organs, where it occurs, through the translumenal approach.

   Conclusions Top

Translumenal endoscopic surgery has potential advantages over the traditional transcutaneous approach in that it is less invasive, has a rapid recovery time, decreases postoperative sequelae such as adhesions, incisional scars and herniae and is perhaps more suitable in special categories of patients. A comprehensive application of translumenal endoscopic surgery in the future requires additional clinical studies in humans to assess its reproducibility, safety and indication.

   References Top

1.Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995;42:219-24.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Wiersema MJ, Hawes RH, Tao LC, Wiersema LM, Kopecky KK, Rex DK, et al . Endoscopic ultrasonography as an adjunct to fine needle aspiration cytology of the upper and lower gastrointestinal tract. Gastrointest Endosc 1992;38:35-9.  Back to cited text no. 2  [PUBMED]  
3.Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, et al . Flexible transgastric peritoneoscopy: A novel approach to diagnostic and therapeutic applications in the peritoneal cavity. Gastroenterology 2004;60:114-7.  Back to cited text no. 3    
4.Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SS, Cotton PB, Gostout CJ, et al . Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 2005;61:449-53.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Park PO, Bergstr φm M, Ikeda K, Fritscher-Ravens A, Swain P. Experimental studies of transgastric gallbladder surgery: Cholecystectomy and cholecystogastric anastomosis (videos). Gastrointest Endosc 2005;61:601-6.  Back to cited text no. 5    
6.Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, et al . Flexible transgastric peritoneoscopy: A novel approach to diagnostic and therapeutic interventions. Gastrointest Endosc 2004;60:114-7.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Kantsevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, et al . Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 2005;62:287-92.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, et al . Transgastric endoscopic splenectomy: Is it possible? Surg Endosc 2006;20:522-5.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Wirtschafter SK, Kaufman H. Endoscopic appendectomy. Gastrointest Endosc 1976;22:173-4.  Back to cited text no. 9  [PUBMED]  
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12.ASGE/SAGES. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005. Gastrointest Endosc 2006;63:199-203.  Back to cited text no. 12    
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16.Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC. Transcolonic endoscopic cholecystectomy: A NOTES survival study in a porcine model. Gastrointest Endosc 2006;64:428-34.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
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18.Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Chung S, et al . Transgastric cholecystectomy: Transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope. Gastrointest Endosc 2007;65:1028-34.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Hu B, Chung SC, Sun LC, Kawashima K, Yamamoto T, Cotton PB, et al . Transoral obesity surgery: Endoluminal gastroplasty with an endoscopic suture device. Endoscopy 2005;37:411-4.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Deters JL, Knipschield MA. Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors. Gastrointest Endosc 2007;65:134-9.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.McGee MF, Marks JM, Onders RP, Chak A, Jin J, Williams CP, et al . Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO plicator. Surg Endosc 2007.  Back to cited text no. 21    

Correspondence Address:
Mohamed A Babatin
Medical Department, King Fahad General Hospital, P.O. Box 16865, Jeddah - 21474
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-3767.36757

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