Natural Orifices Transluminal Endoscopic Surgery

Natural orifice transluminal endoscopic surgery (NOTES), is an experimental minimal access surgical technique whereby "scarless" abdominal operations can be performed with an flexible endoscope passed through a natural orifice like, mouth, urethra, anus or vagina then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.

In female the transvaginal access to NOTES seems to be the most safe and feasible for clinical application. In early March 2007, the NOTES Research Group in Rio de Janeiro, Brazil, led by Dr. Ricardo Zorron, performed the first series of transvaginal NOTES cholecystectomy in four female patients, based in previous experimental studies. With fewer potential complications, the procedure has a disadvantage of being possible only in women.

As NOTES is associated with equally profound changes, specific complications are likely to occur. To detect possible problems early, outcome databases have been established by individual medical societies. This generation experienced such a paradigm shift with the introduction and development of laparoscopic surgery. It is possible that we are on the verge of another paradigm shift – Natural Orifice Translumenal Endoscopic Surgery (NOTES). A Natural Orifice Transluminal Endoscopic Surgery is an experimental surgical technique in which abdominal operations "scarless" may be performed with an endoscope passes through a natural orifice (mouth, urethra, anus, etc.), then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding external incisions or scars.

This technique was used for diagnostic and therapeutic procedures in animal models, including Transgastric (through the stomach), the removal of organs. More recently, the transvesical and transcolonic approaches have been advocated by some researchers as more suitable for access to the upper abdominal structures that are often more difficult to work with using a Transgastric approach. In this sequence, a group of Portugal used Transgastric with Transvesical combined approach to increase the sustainability of relatively complex procedures such as cholecystectomy. NOTES has been described in animals by researchers from Johns Hopkins University (Dr Anthony Kalloo et al.), And has already been used for some time Transgastric appendectomy in humans in India (by Drs. Rao GV and N. Reddy). On June 25, 2007 Swanstrom and his colleagues reported the first human Transgastric cholecystectomy. Transvaginal cholecystectomy fully described in the experimental model without using laparoscopic assistance. In late 2008 surgeons at Johns Hopkins School of Medicine removed a healthy kidney from a donor woman using Notes. The surgery is called transvaginal donor kidney extraction.

Access to transvaginal NOTES seems to be the most safe and feasible for clinical application. In early March 2007 NOTES Research Group in Rio de Janeiro, Brazil, led by Dr. Ricardo Zorron, he made the first series of NOTES transvaginal cholecystectomy in four patients, on the basis of previous experimental studies. With fewer potential complications, the method has the disadvantage of being possible except in women.

Researchers in the field recognize the potential of this technology to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions. NOTES could be the next great paradigm shift in surgery such as laparoscopy was the major paradigm shift in the years 1980 and 1990. The potential advantages include the lowest anesthetic requirements; faster recovery and shorter hospital stays; avoid possible complications infections transabdominal wounds (eg hernia); less immunosuppression; improved postoperative pulmonary function and diaphragmantic function; and the potential of abdominal surgery "scarless". Critics question the safety and benefits of this technique in the face of effective, such as minimally invasive laparoscopic surgical options. However, research continues to face the challenge of critical access. Proposed solutions include the use of permanent magnets.

Unlike laparoscopy, which was treated with much contempt as a fad that passes through most renowned academic institutions nationwide, NOTES is adopted by several universities. The general impression is that the notes, or a derivative technology will be accepted as the new frontier in minimally invasive surgery. Today no minimum invasive bariatric surgery fellowships offer the best opportunity to train in this new approach. However, a systematic training model to translate these processes into clinical practice in a safe manner is needed.

The use of flexible endoscopes findings to partial loss of spatial orientation and depth feeling. This is a potential obstacle, especially for surgeons who are trained to rigid laparoscope. Therefore, research engineers focuses computer assisted image systems which provide additional information 3-D of the intervention area. Virtual view off-axis allows surgeons better visual depth perception during surgery. Other approaches to maintain a stable horizon to improve the spatial orientation during surgery. Video images can be corrected by the impact of gravity on an accelerometer with integrated 3-axes in the tip of the endoscope.


Senior management of the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal Endoscopic Surgeons and (SAGES) organized a working group of surgeons and gastroenterologists in 2006 to develop standards for the practice of this emerging technique. This group is known as Natural orifice surgery Consortium for Assessment and Research (NOSCAR). A white paper was published by NOSCAR on NOTES simultaneously in two medical journals in May 2006. This presentation identifies the main areas of research needed to be addressed before NOTES can become a viable clinical application to human. These areas include the development of a reliable technique for the closure of the internal incision, preventing infection, and creation of advanced endoscopic surgical instruments.

NOTES defined by the NOSCAR group means "Natural Orifice Translumenal Endoscopic Surgery." This describes moving beyond the margins of a Lumen (= hollow organ). There is controversy about the correct way to write "transluminal" NOTES is in a terminal "e" or "i". Although both forms (lumenal/ luminal) are used, the "i" is probably more correct. Analogies with nomen, the foramen or shape of building abdomen adjective corresponding with an "i" (nominal, foraminal, abdominal).


Same as NOTES (Natural Orifice Transluminal Endoscopic Surgery) working group that goes beyond existing horizons and focuses on Transgastric peritoneal access, the New European Surgical Academy (NESA) founded the Natural Orifice Surgery(NOS) Working Group exploring another surgical route, a transdouglas. The terms difference are not accidental. NOTES Transluminal means T. NOS includes NOTES because it refers to all surgical procedures conducted through natural orifices such as the mouth, nose, urethra and vagina.

NESA has designed a new surgical device, Transdouglas Endoscopic Device (DET) adapted to the female pelvic anatomy. TED is a great flexible multi-channel instrument for surgery in the upper abdomen (cholecystectomy, liver biopsy, etc. splenectomy) and pelvic (hysterectomy, cystectomy, etc.) with a single entry. View Douglas bag. Members of NOS in European Working Group are recognized scientists, physiologists, pharmacologists and surgeons from various disciplines at the international level. The first meeting was June 23, 2006, in Berlin. The planned procedures were simulated and preclinical studies will begin soon. NESA firmly believes that in the future, this new approach through natural body openings and endoscopic operations with "Traditional" complement each other.

NOTES Results Databases

The latest surgical innovation with such a radical change had been laparoscopic surgery, which was introduced in late 1980. Laparoscopic surgery was initially associated with higher rates of specific complications that threatened to discredit the art at that time. Consequently, extensive research on the safety measures taken in the following years. Laparoscopy is a mature technology today and is a standard procedure for many abdominal operations. As NOTES is associated with changes as profound, specific complications may occur. To detect possible problems in time, the results of databases were established by individual medical societies. These databases are the result available in November 2010:

NOTES/NOSCAR Outcomes Registry

German national NOTES register (551 patients in April 2009 and over 3000 NOTES procedures last accessed as at October 2013). EUROPEAN-NOTES Registry

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