Natural orifice translumenal endoscopic surgery: progress in humans since white paper

Abstract

Since the first description of the concept of natural orifice translumenal endoscopic surgery (NOTES), a substantial number of clinical NOTES reports have appeared in the literature. This editorial reviews the available human data addressing research questions originally proposed by the white paper, including determining the optimal method of access for NOTES, developing safe methods of lumenal closure, suturing and anastomotic devices, advanced multitasking platforms, addressing the risk of infection, managing complications, addressing challenges with visualization, and training for NOTES procedures. An analysis of the literature reveals that so far transvaginal access and closure appear to be the most feasible techniques for NOTES, with a limited, but growing transgastric, transrectal, and transesophageal NOTES experience in humans. The theoretically increased risk of infection as a result of NOTES procedures has not been substantiated in transvaginal and transgastric procedures so far. Development of suturing and anastomotic devices and advanced platforms for NOTES has progressed slowly, with limited clinical data on their use so far. Data on the optimal management and incidence of intraoperative complications remain sparse, although possible factors contributing to complications are discussed. Finally, this editorial discusses the likely direction of future NOTES development and its possible role in clinical practice.

Keywords: Complications; Endoscopic; Natural orifice translumenal endoscopic surgery; Outcomes; Surgery.

Figure 1

The Transanal Endoscopic Operations device from Karl-Storz allows the insertion of rigid or flexible instruments through the anus and is currently used for performing transanal endoscopic microsurgery excisions of rectal tumors. It also has the potential to serve as a stable transrectal natural orifice translumenal endoscopic surgery (NOTES^®) platform. Image used with permission (©Karl Storz).

Figure 2

The TransPort™ multi-channel access device from USGI has been used as a transgastric natural orifice translumenal endoscopic surgery platform. It has a steering mechanism similar to a flexible endoscope, along with multiple, large-diameter channels to accommodate a small-diameter flexible endoscope and other large caliber flexible endoscopic instruments (g-Prox^® tissue anchor device is shown). Image used with permission (©USGI Medical).

Figure 3

The Anubis^® platform from Karl-Storz is an advanced flexible natural orifice translumenal endoscopic surgery platform (in development), with a tip that opens to expose working instruments capable of multiple degrees of freedom controlled by the surgeon. Image used with permission (©Karl Storz).

Figure 4

EndoSamurai is a prototype, advanced platform in development by Olympus. To operate the system, a surgeon uses an intuitive, bi-manual interface to control instruments with multiple degrees of freedom (inset shows close-up of endoscope tip with working instruments). Image used with permission (©Olympus Medical Systems Corp.).

Figure 5

Direct-Drive Endoscopic System from Boston Scientific is a prototype, advanced multi-channel platform currently in development, featuring instruments with multiple degrees of freedom controlled through a bi-manual user interface. Inset figure shows close-up of device tip with a small diameter flexible endoscope in place. Image used with permission (©Boston Scientific).