Natural Orifice Transluminal Laparoscopic Surgery By Dr.Hisham Hussein Mohamed Ahmed Assistant professor of General Surgery Benha University 2016

NOTES Introduction Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a surgical technique whereby a flexible endoscope passed through a natural orifice (mouth, vagina, urethra and anus) thus avoiding any external incisions or scars. 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.

Surgery through body’s natural openings like mouth, vagina,

The first NOTES transgastric appendectomy performed Introduction NOTES was originally described in animals by researchers at Johns Hopkins University (Dr. Anthony Kalloo et al.). The first NOTES transgastric appendectomy performed by Rao and Reddy in 2004. The first transvaginal appendectomy performed by Bernhardt in 2007. 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 Introduction On June 25, 2007 Swanstrom and colleagues reported the first human transgastric cholecystectomy. In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. "Surgeons Remove Healthy Kidney Through Vagina". InfoNIAC.com. Retrieved 2009-02- 03.

NOTES Introduction Hybrid NOTES Are procedures which combine a NOTES approach usually with laparoscopic instrumentation. Palanivelu C, Rajan PS, Rangarajan M, Parasarathi R, Senthilnathan P, Praveenraj P. Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique. Endoscopy.2008;40:428–32.

Tips and Justifications Peritoneal access; The principles of safe and reproducible NOTES are; Minimal tissue injury Good exposure Safety (avoiding vascular and visceral injury) Ability to maintain a seal and manipulate the instrument. Ryou M, Fong DG, Pai RD, Rattner DW, Thompson CC. Transluminal closure for NOTES: an ex vivostudy comparing leak pressures of various gastrotomy and colostomy modalities. Endoscopy. 2008;40:432–7.

Favoured routes for NOTES; Transvaginal Transgastric Transcolonic Transvesical All routes are under experimental usage. In clinical application Transvaginal access appears to be the safest, most feasible and potentially less complications but only possible in women.

transvaginal approach passing through the posterior vaginal fornix

Set up for transvaginal appendectomy using flexible endoscopic instrumentation

Transgastric cholecystectomy using flexible endoscope

Transrectal route of NOTES

Urological applications of natural orifice transluminal endoscopic surgery (NOTES)

Common procedures that can be done using “notes” Transgastric cholecystectomy Transgastric appendectomy Transvaginal cholecystectomy Transrectal colectomy

Two issues of suturing during NOTES deserve special mention Suturing and Closure Two issues of suturing during NOTES deserve special mention First “closure of the access site” must ensure no anastomotic breakdown and subsequent leak Second “the need for suturing during the procedure” to secure haemostasis or complete the operation The instrumentation currently available is not consistently capable of permitting safe suturing of tissues. Voermans RP, Worm AM, Van Berge Henegouwen MI, Breeveld P, Bemelman WA, Fockens P. In vitrocomparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES) Endoscopy. 2008;40:595–602. 

Closure of the vagina

Complications of notes Visceral injury Vascular injury Infection Delayed anastomotic or entry site leaks Adhesion formation Dyspareunia Vascular and visceral injuries can both passed unrecognized and difficult to control due to the position and orientation of the endoscope Pham BV, Morgan K, Romagnuolo J, Glenn J, Bazaz S, Lawrence C, Hawes R. Pilot study of adhesion formation following colon perforation and repair in a pig model using transgastric, laparoscopic or open surgical repair. Endoscopy. 2008;40:664–70. 

NOTES instrumentation technology The ultimate goal remains the design and production of a flexible endoscope or NOTES platform that is; Multichannelled, Can bend in more than two axes Can be stabilized once the correct operating position has been reached. Pham BV, Morgan K, Romagnuolo J, Glenn J, Bazaz S, Lawrence C, Hawes R. Pilot study of adhesion formation following colon perforation and repair in a pig model using transgastric, laparoscopic or open surgical repair. Endoscopy. 2008;40:664–70. 

The Anubis® platform from Karl-Storz is an advanced flexible natural orifice translumenal endoscopic surgery platform

Summery of the NOTES equipment

Ethics and acceptability NOTES indications and techniques should be practiced in non-human models followed by human research projects. Appropriate institutional and regional ethical committee approval before its role in clinical practice. Close collaboration with industry partners is key to the future development of NOTES. Annals of The Royal College of Surgeons of England 

Annals of The Royal College of Surgeons of England Research Although there are now rapidly increasing publications on NOTES, it is imperative to emphasize the importance of high-quality research which is adequately funded. For the investigator starting NOTES, it is essential that further knowledge on outcome in animal research is available before this technique can be applied directly into human clinical studies. Annals of The Royal College of Surgeons of England 

Annals of The Royal College of Surgeons of England Training Training in NOTES will be a key issue in the future and will improve the surgeon’s experience. Mandatory animal laboratory training would be a prerequisite of any training course and accreditation programme. Annals of The Royal College of Surgeons of England 

Annals of The Royal College of Surgeons of England Conclusion NOTES is an entirely novel method of surgical therapy that needs more research and training on animal models before its application on human. Although there are many reasons for scepticism, there is undoubted interest in this field from both the medical profession and the general public. Annals of The Royal College of Surgeons of England 

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