Laura Newman

May 01, 2009

May 1, 2009 — Operating through the body’s natural orifices, using a technique known as natural orifice transluminal endoscopic surgery (NOTES) is one of the hottest areas in surgery development, according to new research at the Society of American Gastrointestinal and Endoscopic Surgery (SAGES) 2009 Annual Scientific Session and Postgraduate Course.

When used in combination with the smallest laparoscopic instrumentation, NOTES has the potential to minimize the likelihood of leakage into the abdominal cavity during surgery, a consequence that could be lethal.

Angel Cuadrado-Garcia, MD, PhD, from the Department of General Surgery, Hospital Son Llatzer, Palma de Mallorca, Spain, reported early results with the technique in humans using a hybrid technique that combined transvaginal NOTES with minilaparoscopy for cholecystectomy as an alternative to conventional laparoscopic cholecystectomy.

“This is really revolutionary: 20 years ago, the laparoscopy revolution began,” said Dr. Cuadrado-Garcia. “Now we are beginning a new revolution using transvaginal procedures. The vagina is easy to close and completely clean, unlike the stomach or rectum.”

What the hybrid technique allows surgeons to do is perform intraperitoneal surgical procedures with a minimum number of access points in the abdominal wall using the same instruments that general surgeons are accustomed to using for endoscopy and laparoscopy.

Effectiveness of Hybrid Technique

Dr. Cuadrado-Garcia’s study consisted of 25 consecutive female patients randomly chosen. There was no control group. All patients underwent a fusion transvaginal NOTES/minilaparascopy procedure with 2 trocars (a 5-mm umbilical trocar and a 3-mm trocar for the upper quadrant). There were no intraoperative complications. Two patients had urinary tract infections, and 1 had mild hematuria that resolved within 24 hours. Twenty of 25 patients were discharged within 24 hours of surgery; 5 were discharged less than 12 hours after the procedure. Follow-up at 140 days revealed no residual complications. Dr. Cuadrado-Garcia has also used a fused approach to perform an appendectomy and a hemicolectomy.

Advantages of the technique are improved cosmesis and no pain, according to Dr. Cuadrado-Garcia. However, one limitation is that “only 50% of the population [women] can benefit” from the fusion technique, he said. To make NOTES available to men for similar surgeries, research is actively underway exploring transgastric, transcolonic, and transurethral NOTES procedures.

Although transvaginal procedures have been a mainstay for gynecologists for decades, the vagina is “truly a novel access factor” for general surgeons, said Peter Stevens, MD, associate director of clinical medicine and director of endoscopy at Columbia University – New York Presbyterian Medical Center, said in an interview with Medscape General Surgery.

Refining Transvaginal Techniques

“What this study adds is a new series at another center performing hybrid or fusion NOTES.” Series like these play a valuable role in refining transvaginal techniques, but he questioned whether it would ever supplant laparoscopic cholecystectomy — a surgery that has a very low complication rate. “I am a little cautious about recommending it as standard operating procedure. It should be able to show that it has benefits beyond the lack of skin incisions.”

What Dr. Stevens foresees is a burst of “wow” with hybrid surgeries, followed by using them in more limited surgeries. It is most likely to play a role in “niche operations ... [making them] easier, safer, or more effective by the NOTES approach, including endoscopic jejunostostomy, bariatric procedures, diagnostic evaluation of ICU [intensive care unit] patients, insertion of diaphragmatic pacemakers, and nerve blocks for pain relief,” he said.

Another setting where it will provide added benefit is in settings where access to operating rooms and to a surgical sterile environment is limited — for example, the battlefield. “In that setting,” said Dr. Stevens, “a NOTES procedure could make the patient’s own abdomen the operating room where specially developed endoscopic tools would be used.”

Dr. Cuadrado-Garcia and Dr. Stevens have disclosed no relevant financial relationships.

Society of American Gastrointestinal and Endoscopic Surgery (SAGES) 2009 Annual Scientific Session and Postgraduate Course: Session S077. Presented April 25, 2009.

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