Natural orifice translumenal endoscopic surgery (NOTES): emerging trends and specifications for a virtual simulator

Abstract

Introduction and study aim: A virtual translumenal endoscopic surgical trainer (VTEST) is being developed to accelerate the development of natural orifice translumenal endoscopic surgery (NOTES) procedures and devices in a safe and risk-free environment. For a rapidly developing field such as NOTES, a needs analysis must be conducted regularly to discover emerging research trends and areas of potential high impact for a virtual simulator. This paper presents a survey-based study which follows a similar study conducted by this group in 2011 (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013).

Methods: A 32-point questionnaire was distributed at the 2012 Natural Orifice Surgery Consortium for Assessment and Research annual meeting. These data were subsequently augmented by an identical online survey, targeted at the members of the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons, and analyzed.

Results: Twenty-eight NOTES experts participated in the 2012 study. Cholecystectomy (CE) procedure remained the most commonly performed NOTES technique, with 18 positive responses (64%). In contrast to 2011, the popularity of the NOTES appendectomy (AE) was significantly lower, with only 2 (7%) instances (CE vs. AE, p < 0.001), while the number of peroral endoscopic myotomy (POEM, PE) cases had increased significantly, with 11 (39%) positive responses, respectively (PE vs. AE, p = 0.013). Strong preference toward hybrid rather than pure NOTES techniques (82 vs. 11%, p < 0.001) was also expressed. Other responses were similar to those in the 2011 study, with the VTEST™ utility in developing and testing new techniques and instruments ranked particularly high.

Conclusion: Based on the results of this study, a decision was made to focus exclusively on the transvaginal hybrid NOTES cholecystectomy procedure, including both rigid and flexible scope techniques. The importance of developing a virtual NOTES simulator was reaffirmed, with POEM identified as a promising candidate for future simulator development.

Keywords: NOTES; Natural orifice surgery; POEM; Simulator; Transvaginal; Virtual reality.

Figure 1

Number of years of clinical practice of the participants

Figure 2

Number of hybrid NOTES procedures

Figure 3

Number of pure NOTES procedures

Figure 4

Cumulative NOTES experience

Figure 5

NOTES procedures performed on live human subjects

Figure 6

Preferred approach for NOTES cholecystectomy

Figure 7

Preferred environment for training in NOTES cholecystectomy

Figure 8

Comparison of the NOTES procedures performed on live human subjects

Figure 9

NOTES standard of care indicator

Figure 10

NOTES and POEM publication trends

Figure 11

Pure vs hybrid NOTES procedure preferences