NOTES

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NOTES

Natural orifice transluminal endoscopic surgery (NOTES) is an experimental surgical

Surgery

Surgery is a medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, to help improve bodily function or appearance, or sometimes for some other reason....
technique whereby "scarless" abdominal

Abdomen

In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity....
operations can be performed with an endoscope passed through a natural orifice (mouth

Mouth

The mouth, buccal cavity, or oral cavity is the first portion of the alimentary canal that receives food and begins digestion by mechanically breaking up the solid food particles into smaller pieces and mixing them with saliva....
, urethra

Urethra

In anatomy, the urethra is a tube which connects the urinary bladder to the outside of the body. The urethra has an excretory function in both sexes to pass urine to the outside, and also a reproductive function in the male, as a passage for semen....
, anus

Anus

The anus is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to expel feces, unwanted semi-solid matter produced during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest, such as coprolite ; food material after all the nutrients have b...
, etc.) then through an internal incision in the stomach

Stomach

In most mammals, the stomach is a hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication....
, vagina

Vagina

The vagina is a fibromuscular cylinder tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles....
, bladder

Urinary bladder

In anatomy, the urinary bladder is a solid, muscle, and distensible organ that sits on the pelvic floor in mammals. It is the organ that collects urine excreted by the kidneys prior to disposal by urination....
or colon

Colon (anatomy)

The colon is the last portion of the digestive system in most vertebrates; it extracts water and salt from feces before they are defecation from the body....
, thus avoiding any external incisions or scars.

technique has been used for diagnostic and therapeutic procedures in animal model

Animal model

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State of Research

This technique has been used for diagnostic and therapeutic procedures in animal model

Animal model

An animal model is a non-human animal that has a disease or injury that is similar to a human condition. These test conditions are often termed as animal models of disease....
s, 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

Portugal

Portugal , officially the Portuguese Republic , is a country on the Iberian Peninsula. Located in southwestern Europe, Portugal is the westernmost country of mainland Europe and is bordered by the Atlantic Ocean to the west and south and by Spain to the north and east....
used transgastric and transvesical combined approach to increase the feasibility of moderately complex procedures such as cholecystectomy

Cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, although there are other indications for the procedure, including carcinoma....
. NOTES was originally described in animals by researchers at Johns Hopkins University

Johns Hopkins University

The Johns Hopkins University, commonly referred to as Hopkins or JHU, is a private university research university located in Baltimore, Maryland, Maryland, United States....
(Dr. Anthony Kalloo et al.), and was recently used for transgastric appendectomy in humans in India

India

India, officially the Republic of India , is a country in South Asia. It is the List of countries and outlying territories by total area country by geographical area, the List of countries by population country, and the most populous liberal democracy in the world....
(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, lead 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

Paradigm shift

Paradigm shift is the term first used by Thomas Samuel Kuhn in his influential book The Structure of Scientific Revolutions to describe a change in basic assumptions within the ruling theory of science....
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 immunosuppresion; 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

Laparoscopic surgery

Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, keyhole surgery is a modern surgery technique in which operations in the abdomen are performed through small incisions as compared to larger incisions needed in traditional surgical procedures....
.

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.

NOSCAR

Senior leadership from the American Society for Gastrointestinal Endoscopy

American Society for Gastrointestinal Endoscopy

The American Society for Gastrointestinal Endoscopy, or ASGE, is a professional organization of physicians dedicated to improving endoscopy. The ASGE is made up largely of gastroenterologists from the United States....
(ASGE) and the Society of American Gastrointestinal 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 Consortion for Assessment and Research (NOSCAR). A White Paper

White paper

A white paper is an authoritative report or guide that often addresses problems and how to solve them. White papers are used to educate readers and help people make decisions....
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. Nevertheless you often find the term "Natural Orifice Transluminal Endoscopic Surgery".

NESA / NOS

Parallel to the NOTES (Natural Orifice Transluminal 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

Liver biopsy

Liver biopsy is the biopsy from the liver. It is a medical test that is done to aid medical diagnosis of liver disease, to assess the severity of known liver disease, and to monitor the progress of treatment....
, splenectomy etc.) as well as in the pelvis (hysterectomy, cystectomy, etc.) by using a single entry. See Pouch of Douglas

Pouch of Douglas

The rectouterine pouch is the extension of the Peritoneum between the rectum and back wall of the uterus in the female human body.The rectouterine pouch is used in the treatment of end-stage renal failure in patients who are treated by peritoneal dialysis....
.

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

Berlin

Berlin is the Capital of Germany city and one of sixteen States of Germany of Germany. With a population of 3.4 million within its city limits, Berlin is the country's largest city....
. 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 one

NOTES

State of Research

NOSCAR

NESA / NOS

See also

External links