Natural orifice translumenal endoscopic surgery
Natural orifice transluminal endoscopic surgery (NOTES) is an experimental surgical technique whereby "scarless" abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, urethra, anus, etc.) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.
State of Research
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This technique has been used for diagnostic and therapeutic procedures in animal models, including transgastric (through the stomach) organ removal. Most recently, the transvesical and the transcolonic approaches have been advocated by some researchers as being more suited to access upper abdominal structures that are often more difficult to work with using a transgastric approach. In this sequence, a group from Portugal used transgastric and transvesical combined approach to increase the feasibility of moderately complex procedures such as cholecystectomy. NOTES was originally described in animals by researchers at Johns Hopkins University (Dr. Anthony Kalloo et al.), and was once upon a time used for transgastric appendectomy in humans in India (by Drs. G.V. Rao and N. Reddy). On June 25, 2007 Swanstrom and colleagues reported the first human transgastric cholecystectomy. Totally transvaginal cholecystectomy has been described in experimental model without using laparoscopic assistance. In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. The surgery was called transvaginal donor kidney extraction.
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 patients, based in previous experimental studies. With fewer potential complications, the procedure has a disadvantage of being possible only in women.
Proponents and researchers in this field recognize the potential of this technique to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions. NOTES could be the next major paradigm shift in surgery, just as laparoscopy was the major paradigm shift during the 1980s and 1990s. Potential advantages include lower anesthesia requirements; faster recovery and shorter hospital stays; avoidance of the potential complications of transabdominal wound infections (e.g. hernias); less immunosuppression; better postoperative pulmonary and diaphragmantic function; and the potential for "scarless" abdominal surgery. Critics challenge the safety and advantages of this technique in the face of effective minimally invasive surgical options such as laparoscopic surgery. However, research continues in addressing the critical access challenge. Proposed solutions include the use of permanent magnets.
Unlike laparoscopy, which was treated with much disdain as a passing fad by most nationally recognized academic institutions, NOTES is being embraced by several universities nationally. The general impression is that NOTES, or a derivative of its technology will be accepted as the newest frontier in minimally invasive surgery. As of today non-bariatric minimally invasive surgery fellowships offer the best opportunity to train in this new approach. However, a systematized training model to translate these procedures to the clinical practice in a safe way is needed.
The use of flexible endoscopes results in a partial loss of spatial orientation and depth perception. This is a potential barrier especially for surgeons who are trained to rigid laparoscopes. So research of engineers focuses on computer assisted imaging systems that provide additional 3-D information of the intervention site. Virtual off-axis view assists surgeons with a better visual depth perception during the intervention.  Other approaches keep a stable horizon in order to enhance spatial orientation during the intervention. Video images can be rectified using the impact of gravity on a 3-axis accelerometer integrated in the tip of the endoscope. 
Senior leadership from the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal and Endoscopic Surgeons (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 the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). A White Paper on NOTES was released by NOSCAR simultaneously in two medical journals in May 2006. This paper identified the major areas of research needed to be addressed before NOTES can become a viable clinical application for human patient. These areas included development of a reliable closure technique for the internal incision, prevention of infection, and creation of advanced endoscopic surgical tools.
NOTES as defined by the NOSCAR group stands for "Natural Orifice Translumenal Endoscopic Surgery". This describes going beyond the margins of a lumen (=hollow organ). There is a controversy about the correct spelling of "translumenal" in NOTES whether with a terminal "e" or an "i". Even if both forms (lumenal/luminal) are used, the "i" is probably more correct. Analogies are found with nomen, foramen or abdomen which build the corresponding adjective form with an "i" (nominal, foraminal, abdominal).
NESA / NOS
Parallel to the NOTES (Natural Orifice Translumenal Endoscopic Surgery) working group which looks beyond existing horizons and concentrates on the transgastric peritoneal access, the New European Surgical Academy (NESA) founded the NOS (Natural Orifice Surgery) working group which is exploring another surgical route, the transdouglas one.
The term difference is not accidental. T in NOTES stands for transluminal. NOS includes NOTES because it refers to all surgical procedures performed through natural openings like mouth, nose, urethra and vagina.
The NESA designed a new surgical device, the Transdouglas Endoscopic Device (TED) adapted to female pelvic anatomy. The TED is a wide multi-channel flexible instrument enabling surgical procedures in the upper abdomen (cholecystectomy, liver biopsy, splenectomy etc.) as well as in the pelvis (hysterectomy, cystectomy, etc.) by using a single entry. See Pouch of Douglas.
The members of the European NOS working group are internationally renowned scientists, physiologists, pharmacologists and surgeons from various disciplines. The first meeting was on June 23, 2006, in Berlin. The planned procedures have already been simulated and preclinical studies will start soon. The NESA strongly believes that in the future, this new approach using the body natural openings and "traditional" endoscopic operations will complement each other.
NOTES outcome databases
The last surgical innovation with such radical changes was laparoscopic surgery which was introduced in the late 1980s. Laparoscopic surgery was initially associated with an increased rate of specific complications which threatened to discredit the technique at that time. As a result, extensive research regarding safety measures was conducted in the following years. Laparoscopy is a mature technique today and is the standard procedure for many abdominal operations.
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. These outcome databases are accessible in November 2010:
- NOTES/NOSCAR Outcomes Registry (currently under recontruction)
- German national NOTES registry
- EURO-NOTES registry
Outcome data have been published for the German NOTES registry (551 patients in April 2009). The German NOTES registry currently contains more than 3000 NOTES procedures (last accessed in October 2013).
- Halim I, Tavakkolizadeh A (August 2008). "NOTES: The next surgical revolution?". International Journal of Surgery 6 (4): 273–6. doi:10.1016/j.ijsu.2007.10.002. PMID 18614409.
- Lima E, Rolanda C, Pêgo JM, et al. (August 2006). "Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery". The Journal of Urology 176 (2): 802–5. doi:10.1016/j.juro.2006.03.075. PMID 16813951.
- Baron TH (January 2007). "Natural orifice transluminal endoscopic surgery". The British Journal of Surgery 94 (1): 1–2. doi:10.1002/bjs.5681. PMID 17205508.
- Fong DG, Pai RD, Thompson CC (February 2007). "Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model". Gastrointestinal Endoscopy 65 (2): 312–8. doi:10.1016/j.gie.2006.08.005. PMID 17173916.
- Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (September 2006). "Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video)". Gastrointestinal Endoscopy 64 (3): 428–34. doi:10.1016/j.gie.2006.06.079. PMID 16923495.
- ICVS - Development & Neoplasia Research Domain[dead link]
- Rolanda C, Lima E, Pêgo JM, et al. (January 2007). "Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video)". Gastrointestinal Endoscopy 65 (1): 111–7. doi:10.1016/j.gie.2006.07.050. PMID 17185089.
- NOTES Transgastric Cholecystectomy : USGI Medical
- Sánchez-Margallo FM, Asencio JM, Tejonero MC, et al. (2008). "Technical feasibility of totally natural orifice cholecystectomy in a swine model". Minimally Invasive Therapy & Allied Technologies 17 (6): 361–4. doi:10.1080/13645700802528199. PMID 18972251.
- "Surgeons Remove Healthy Kidney Through Vagina". InfoNIAC.com. Retrieved 2009-02-03.
- McEvoy R. P., McMenamin M., Ha G., Lang J. H., Cantillon-Murphy P. (2013). "Self-Deployed Magnetic Polygons: Design, Construction, and Application". IEEE Transactions on Magnetics 49 (1): 496–505. doi:10.1109/TMAG.2012.2205935.
- Sánchez-Margallo FM, Asencio Pascual JM, Del Carmen Tejonero Alvarez M, et al. (May 2009). "Diseño del entrenamiento y la adquisición de habilidades técnicas en la colecistectomía transvaginal (NOTES)" [Training design and improvement of technical skills in the transvaginal cholecystectomy (NOTES)]. Cirugía Española (in Spanish) 85 (5): 307–13. doi:10.1016/j.ciresp.2009.02.004. PMID 19376505.
- Hoeller, Kurt (2010). Novel Techniques for Spatial Orientation in Natural Orifice Translumenal Endoscopic Surgery (NOTES) (PDF) (Ph.D.). Central Institute of Healthcare Engineering (ZiMT) at Friedrich-Alexander-Universitaet Erlangen-Nuernberg (FAU). ISBN 978-3-8322-9766-4.
- Hoeller, Kurt; et al. (September 2009). G.-Z. Yang; et al., eds. Endoscopic Orientation Correction (PDF). 12th International Conference on Medical Image Computing and Computer-Assisted Intervention (MICCAI 2009). London, UK: Springer. pp. 459–466. doi:10.1007/978-3-642-04268-3_57. ISBN 978-3-642-04267-6.
- WO application 2010105946, Gutiérrez Boronat, Javier; Jahn, Jasper; Schneider, Armin; Hoeller, Kurt, "Endoscope and Imaging Device", published 2010-09-23, assigned to Fraunhofer-Gesellschaft zur Foerderung der angewandten Forschung e.V.
- Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)
- Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ (August 2010). "The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients.". Ann Surg 252 (2): 263–70. doi:10.1097/SLA.0b013e3181e6240f. PMID 20585238.
- NOTES - Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie e.V. (DGAV)
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cholecystectomy: report of the first case. Surg Innov. 2007 Dec;14(4):279-83. doi: 10.1177/1553350607311090. PMID 18178917
- Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M. "NOTES transvaginal
cholecystectomy: preliminary clinical application. Surg Endosc. 2008 Feb;22(2):542-7. PMID 18027043
- Zorron R, Palanivelu C, Galvão Neto MP, et al. International multicenter trial on clinical natural
orifice surgery—NOTES IMTN study: preliminary results of 362 patients. Surg Innov. 2010 Jun;17(2):142-58. doi: 10.1177/1553350610370968 PMID 20504792
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