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SECTION 2 Current Clinical Applications and Techniques
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Figure 12.21 Laparoscopic view to the incoming endoscope beside a
trocar transvaginally.
Figure 12.23 Cutting of the appendix with a transvaginal inserted
stapler.
Figure 12.22 Elavation and preparation of the appendix under
endoscopic view: 1, transumilically inserted laparoscopic grasper; 2,
transvaginally inserted laparoscopic forceps; 3, endoscopic grasper.
Figure 12.24 Exposed mesoappendix after cutting of the appendix.
Figure 12.25 Cutting of the mesoappendix with a stapler. Figure 12.26 Endoscopic view to the staplerline and a laparoscopic clip.
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all cases, histologic examination of the appendix confi rmed
the presence of infl ammation. The patients were discharged
after an average of 1.3 days, range 1 –3 days, with the fi rst
two patients being purposely retained in hospital for 3 days
for observation. All patients had a pre -operative gynecologic
examination, and a further postoperative examination was
performed after 10 –14 days. There were no intraoperative
or postoperative complications. One patient developed gastroenteritis three weeks after the operation, but in the mini laparoscopy performed in order to be on the safe side the
local area was found to be free of irritation and the vaginal
incision had healed without adhesions.
In 2008 Palanivelu et al. [24] reported on an initial study
on hybrid NOTES appendectomy involving six patients. A
Veress needle was introduced via the umbilicus and a
pressure-controlled pneumoperitoneum established. In fi ve
cases a 3 mm laparoscope was used to control the transvaginal positioning of the endoscope. In three cases it was necessary to convert to laparoscopic appendectomy, in two cases
owing to the retrocecal position of the appendix and in one
case because of bleeding from the mesoappendix following
dislocation of the endoscopic clip. In two further cases additional laparoscopic instruments were required. In the sixth
case endoscopic resection and recovery of the appendix were
performed successfully after establishing the capnoperitoneum by means of a Veress needle and open gynecologic
colpotomy. Apart from the transcutaneous Veress needle,
which makes this operation a hybrid procedure, this surgery
corresponded to a pure NOTES procedure, with the appendix being removed using a snare. The age of the patients
ranged from 25 to 34 years. The mean operating time was
103.5 min (range 72 –135 min), with the laparoscopic and
hybrid NOTES procedures being counted together. Two
patients reported vaginal complaints on the second postoperative day. No postoperative complications arose. The
patients were discharged after 1 –2 days.
In March 2009 Tabutsadze and Kipshidze [25] reported on
two transvaginal appendectomies performed in Tbilisi. The
authors used a single -channel gastroscope (Karl Storz GmbH,
Tuttlingen, Germany). The operating method used was
based, inter alia, on the pure NOTES appendectomy procedures described by our working group and presented in the
above [19]. A detailed method report on their own operating technique has not yet been published. The patients were
22 and 28 years old and of normal body weight. The operating times were 76 and 88 min. The base of the appendix was
ligated using endoloops and detached using scissors. No
complications occurred and the patients were discharged 30
and 36 hours after surgery. Diagnostic imaging and follow up checks were performed by computer tomography. In
general, these were evidently pure NOTES operations, even
though in one case the photographic representation of the
patient’s abdomen immediately after surgery reveals unidentifi able metallic material in the umbilicus.
In addition to ten other hybrid NOTES procedures, Horgan
et al. reported in 2009 on a transvaginal hybrid NOTES
appendectomy [26]. The operating time was 78 min.
Shin et al. operated on a 74 -year old patient using the
hybrid technique involving insertion of a coloscope through
a 15 mm trocar introduced transvaginally [27]. The preparation of the mesenteriolum and the detachment of the appendix were conducted using an ultrasound dissector, and the
base of the appendix ligated by means of laparascopic loops.
Intake of food began on the fi rst postoperative day, and on
the third day the patient was released to outpatient status.
Transgastric appendectomy
The advantage of transgastric access is undoubtedly the fact
that it can be applied with patients of both genders. The
disadvantage consists, for one thing, in the greater distance
required to reach the access organ, and hence the effector
organ, as well as in the diffi culty of decontamination.
Transgastric surgery can again be subdivided into pure
NOTES procedures and hybrid operations.
Transgastric pure NOTES appendectomy
In this method, the incision in the anterior gastric wall is
made using the technique that is customarily used for the
insertion of a PEG tube. After the incision is made by a
needle-knife and a guidewire inserted, a balloon is used to
dilate the opening to 20 mm to allow the instruments to be
introduced. For operations on the lower abdomen, introduction into the upper corpus in mid -position is reported to
be advantageous [28]. However, this area has a greater concentration of blood vessels than the anterior wall of the
gastric antrum. Preparation via the endoscope can be performed as described above. Recovery of the specimen is
conducted transgastrically as the instruments are withdrawn. The OTSC clip system (Ovesco Endoscopy AG,
Tübingen, Germany) and the g -Prox device (USGI Medical,
USA) are available for the ligation of the gastric wall. The
use of an overtube is advantageous, in particular when withdrawal of instruments is necessary. Ideally, it extends as far
as the gastric access port, which also leads to stabilization of
the endoscope.
Transgastric hybrid NOTES appendectomy
Access via the stomach is achieved either as described above,
an auxiliary trocar being introduced with endoscopic visualization following establishment of the capnoperitoneum,
or alternatively, a laparoscopy can be performed fi rst and
the endoscope then be inserted through the gastric wall. The
appendix is then exposed using laparoscopic graspers. Preparation is carried out with fl exible instruments and the ligation of the base performed with a detachable snare or
endoloop.
The fi rst written report concerning a series of eight transgastric appendectomies performed in pure NOTES technique
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was published by Rao et al. [28]. As well as administering
peri-operative antibiotics, a local gastric lavage was performed. Immediately after the initial penetration of the
gastric wall, the authors used a needle -knife to establish a
pneumoperitoneum, with the insuffl ator being connected to
the catheter of the needle -knife after withdrawal of the
needle. Apart from this, no reports have so far been produced concerning insuffl ation in such small lumina. Access
was then established as described above, using a dual channel device. Through one channel a grasper was introduced in order to elevate the appendix and through the
other a hot biopsy forceps was used to prepare the mesoappendix. The ligation of the base of the appendix was fi nally
performed with an endoloop and the appendix detached
using a snare. The incision in the gastric wall was closed
using normal hemostatic clips: the authors believe that the
sides of the access port in the gastric wall will return to their
normal position after balloon dilatation and that a mucosal
clip is suffi cient. No information was given regarding operating times. In two further cases, it was necessary to convert
to laparoscopy owing to the retrocecal position of the appendix, and one patient had a needle -knife injury to the abdominal wall. Antibiotics were administered for up to 48 h after
the operation. There is no further information regarding
patient outcomes and the duration of their stay in hospital,
nor is there any report on the patients ’ follow -up care. In
particular, there is no information about the degree of histologic infl ammation of the appendixes. Especially in cases
of advanced infl ammation with severe swelling and adhesion of the mesoappendix, lifting the appendix with parallel
fl exible graspers would appear to be problematic, in particular because a good preparation angle is required for the
second, parallel grasper.
In 2009 Horgan et al. reported on a transgastric appendectomy among a series of other hybrid NOTES procedures.
In this fi rst transgastric appendectomy by the authors, they
were assisted by two transabdominal needlescopic instruments. The gastric wall was closed using the g -Prox device.
Since this was the fi rst of all the transgastric operations
performed by this working group, the transumbilical access
port was dilated and the closure of the gastric wall additionally secured with a stapler. The patient was discharged on
the fi rst postoperative day and outpatient follow -up care
continued for one month [26].
Park and Bergstr öm performed transgastric peritoneoscopy on three patients with suspected appendicitis [29]. For
additional support, a 2 mm transcutaneous instrument was
employed. In one case the appendix could not be exposed
and so it was necessary to convert to laparoscopy. In another
case, the appendix was found to be in a retrocecal position
and so conversion to open appendectomy again took place.
In the third patient it was possible to perform an appendectomy endoscopically using the technique described. In all
cases, a T -tag was used to close the gastric wall. The NOTES
patients were discharged on the fourth postoperative day
and antibiotics were administered for ten days owing to a
temporary elevation of CRP levels. On the second postoperative day, the patient who had undergone open surgery
developed a pneumothorax, which was caused by a T -tag
placed through the pleurasinus. Thoracic drainage was performed, followed by a laparoscopy in which the T -tag was
removed.
In a joint study, Horgan et al. [30] performed several
hybrid NOTES procedures using the Incisionless Operating
Platform (IOP) transport device (USGI Medical, San Clemente, CA, USA). These included two transgastric appendectomies. The safe penetration of the stomach by the transport
device was guided by a 5 mm laparoscopic camera placed
in the umbilicus. The transport device permitted a stable
position in the abdomen. The resection of the appendix
was performed using the hybrid technique, the mesoappendix being prepared with the ultrasound dissector. The
stump was secured with endoloops and the appendix
detached by means of an endoscopic snare. Following transgastric recovery of the specimen, the gastric wall was closed
using the g -Prox device (USGI). The operating time was
273.5 ± 54.4 min. The pain score reported by patients at the
time of discharge was 2.5 ± 0.7 on a scale from 1 to 10. The
patients were discharged within 24 h, and no complications
occurred.
The largest study on transgastric appendectomy of which
we are aware, but which is as yet unpublished, is that undertaken by Kaehler et al. [31]. So far, ten patients have been
included in this monocentric study. Exclusion criteria for
transgastric surgery were four -quadrant peritonitis, suspected perforation, a BMI of more than 30, pregnancy, cirrhosis of the liver, and previous operations. The procedure
was performed with a gas -sterilized dual -channel gastroscope (Karl Storz GmbH, Tuttlingen, Germany) following
gastric lavage. The location of the incision in the gastric wall
was selected in accordance with the PEG technique, and
access to the abdominal cavity was achieved by means of
balloon dilation, as described above. In all ten patients, a
3 mm trocar was placed in the umbilicus after the performance of a diagnostic peritoneoscopy under endoscopic vision.
Owing to the presence of an abscess as well as appendicitis,
in one case it was decided to convert to a laparoscopic resection. The trocar could be used to tension the appendix and
preparation was conducted endoscopically with the needle knife or coag -grasper. Ligation was performed centrally and
with a double suture using an absorbable NOTES snare
(Serag-Wiessner, Germany). The appendix was detached
using scissors and extraction took place transorally. After
attaching the OTSC clip system (Ovesco Endoscopy AG,
Germany) onto the gastroscope, the gastric wall was closed
with the aid of the twin -grasper (Ovesco). There were no
postoperative complications, and the patients were discharged between the fi rst and the third postoperative day.
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The fi rst multicentric study on the performance of NOTES
procedures was initiated by Zorron and the reports published by 18 participating centers [32]. Among the 362 operations, 37 were transvaginal (10.2%) and 14 (3.87%) were
transgastric appendectomies. The approaches used and the
techniques applied seem to have been very varied, and
as well as fl exible endoscopes, rigid transvaginal cameras
were employed. In the transvaginal cases, access was usually
established with laparoscopic control; in the transgastric
procedures, this was always the case. The incision in the
gastric wall was closed using laparoscopic stitching with the
aid of an additional pararectal trocar. Dissection was usually
conducted endoscopically, but sometimes also with rigid
instruments. The operating times for transvaginal procedures were 60.50 ± 31.33 min and for transgastric proce-
dures 135.50 ± 9.25 min. The intra -abdominal pressures
ranged from 12.38 to 13.75 mm Hg. The complication rate
was 6.67% for transvaginal operations and 24.14% for
transgastric procedures. In four cases (three transvaginal and
one transgastric), bleeding from the arteria appendicularis
had to be staunched laparoscopically or endoscopically
during the operation. In one case, the abdominal wall was
injured during the establishment of transgastric access, so
that it was necessary to convert to laparoscopy. Among all
the patients, it was decided six times to convert to laparoscopy and three times to open surgery, the latter all being
cases of cholecystectomy. The precise number of conversions
in appendectomy cannot be determined. Postoperatively,
prolonged ileus was reported after transgastric appendectomy, which was treated conservatively. Hospital stays following surgery ranged from 31 to 78 h.
Endolumenal appendectomy
The idea of invaginating the appendix during the performance of a coloscopy and thus being able to resect it without
incision into the abdominal cavity is a fascinating one and
is at the lowest possible level of invasiveness. There are no
clinical data concerning this procedure, but an experimental
study has been conducted. Unger et al. performed a total
coloscopy on 11 cadavers. In all cases it was possible to
advance a guidewire to the tip of the appendix. This was
then used to introduce newly designed instruments for
inversion, and the appendix was inverted into the cecum.
In ten out of eleven cases, this was at fi rst partially successful, the main obstacle being a thickened mesentery. After an
intralumenal incision, which was not described in detail, at
the base of the mesentery, it was then possible to conduct
complete inversion in ten cases. The ligation of the base of
the appendix was performed using an endoloop or clips, and
resection was conducted using a diathermy loop [33].
Unfortunately, with an infl amed appendix, this procedure
presents a number of diffi culties, such as the problem
described by the authors of the blocking effect of the mesoappendix, which is even thicker and more distended when
infl ammation is present. Also, the lumen is often displaced
and intubation is hindered. Finally, the swollen wall of the
appendix is more diffi cult to invaginate.
Single-incision appendectomy
Single-incision operations performed via the umbilicus are
not NOTES procedures but rather forms of laparascopic
surgery through a single access port. However, the techniques were developed after the inauguration of the term
NOTES and the performance of the fi rst NOTES operations,
when it became evident that the technical developments for
operations using fl exible endoscopes were not yet fully
mature and that a long path of development would be
required before they could be routinely employed. With
regard to invasiveness, these operations are mid -way
between conventional laparoscopy and NOTES procedures.
It should be noted, however, that establishing the necessary
access requires considerable stretching of the transumbilical
incision, which may be equivalent to a mini -laparotomy.
There are now as many pseudonyms for these procedures
as there are publications, and so these will not be listed here.
One variant of this procedure is the introduction of a fl exible
endoscope through a peri -umbilical incision.
The fi rst laparoscopic operations using only a single incision were reported by Ng in 1997 [34], with the incision
being made not in the umbilicus but in the right lower
abdomen. The appendix was located and mobilized laparoscopically, although in three cases an additional Veress
needle was used to assist in preparation. The main instrument was a laparoscope with a working channel (Karl Storz
GmbH, Tuttlingen, Germany). After release of the pneumoperitoneum, the appendix was pulled forward in front of
the abdominal wall and detached in the conventional
manner. The procedure was followed by a second peritoneoscopy, involving inspection and irrigation where necessary.
Fifteen patients were treated in this way without complications, and were discharged 1.3 days after the operation.
In 2008 Palanivelu et al. reported on the performance of
transumbilical fl exible endoscopic appendectomies on eight
out of twelve patients [35]. Exclusion criteria were previous
operations, abscesses, and perforations. In four cases (33.3%)
it was necessary to convert to laparoscopic surgery. The
umbilical incision permitted better handling of the fl exible
endoscope compared with the translumenal procedure. The
average age of the patients was 32.5 years. Discharge took
place between the fi rst and the third postoperative day.
Follow-up examinations were conducted after 7, 30, and 90
days and again after eight months. Six patients underwent
the entire procedure and no problems occurred.
Using three transumbilically placed single trocars
(1 × 12 mm and 2 × 5 mm), Chow et al. performed 12
appendectomies [36]. The mean age of the patients was 28.7
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years (range 12 –42), and the mean operating time was
61.6 min (range 24 –86). The operating time decreased as the
number of procedures rose. The patients were discharged
1.1 days after the operation and no complications were
found in a postoperative follow -up examination after eight
weeks.
Mofi d and Zornig used only two 5 mm trocars and a
curved grasper placed between them, which was possible
without loss of gas. The curved instruments also enabled
improved triangulation [37].
Under study conditions, Chouillard et al. operated on 55
patients using two umbilical 5 mm trocars [38]. Conversions
took place owing to diffi culty in exposing the appendix or
to advanced infl ammation with abscesses or peritonitis in 15
cases (25.5%); 14 times the conversion was to laparoscopy
and once to laparotomy. The mean operating time was
39 min (range 14 –111). The postoperative complication rate
was 5.4% (three patients), two of these being converted
patients. One patient had an umbilical abdominal wall infection, which was probably due to the extraction of the appendix through the wound without a recovery bag. Discharge
took place on average after 36 hours. The authors conclude
that this procedure may become a standard technique in the
surgical treatment of uncomplicated appendicitis.
Using a wound retractor for the introduction of instruments in single -port operations, Cho et al. compared 23
patients who had undergone this type of surgery with 20
appendectomies performed using customary laparoscopic
techniques [39]. The gender and age distribution and the
clinical symptoms of the two groups were comparable. The
mean operating times of 61.5 min for the single -port technique and 67.5 min for conventional laparoscopy were not
signifi cantly different. Similarly, there was no signifi cant
difference in the length of the postoperative stay in hospital
(4.2 compared with 3.8 days) nor in the postoperative pain
score (3.4 versus 3.1). A complication was a postoperative
abscess following a single -site operation on a perforated
appendix. Only the total wound length was signifi cantly
shorter with the single -port technique.
Summary
The original idea of NOTES was to perform the operation
with a fl exible endoscope in the abdominal cavity [1]. If we
consider the appendectomies conducted in this way and
reported on in monocentric publications (Table 12.1), out of
48 planned NOTES procedures they were only actually performed in 39 cases. Since the multicentric study published
by Zorron et al. [32] overlaps with at least one study, is relatively heterogeneous, and has already been presented in
detail, its fi ndings will not be discussed again here. Possible
congress reports on other cases or current studies are not
available to us at present, but they probably exist.
Table 12.1 Summary of NOTES appendectomies in single -center
publications.
Access Method
Pure
NOTES
Transvaginal 3 15 3 1
Transgastral 8 13 5
Hybrid
NOTES
Primary
conversion
Secondary
conversion
The few pure NOTES procedures that have been reported
are mainly individual case descriptions, with the exception
of the series conducted by Rao et al. [28]. However, that
publication fails to include information about the severity of
the infl ammation and the histologic examination of the
specimens. Unfortunately, no detailed information is provided regarding preparation and any diffi culties encountered. In cases of advanced infl ammation with considerable
swelling and adhesion of the mesoappendix, exposure and
preparation using two parallel instruments placed close
together must be rendered signifi cantly more diffi cult. Similarly, Tabutsadze et al. [25] also fail to provide details about
their preparation technique.
The transvaginal hybrid operations all begin with a mini laparoscopy. The transgastric access port was used by two
authors [29,31] without laparoscopic supervision in pure
NOTES technique, with an auxiliary trocar only being
inserted after a fl exible peritoneoscopy.
In all working groups, the operating times were considerably longer than is usual in laparoscopic procedures.
However, if we consider our own patients, a tendency
toward the shortening of operating times is evident, depending on the type of preparation and on the learning curve
[23]. This learning curve was also experienced with laparoscopy, which initially required much longer operating
times than open appendectomy.
The primary conversion rate after initial peritoneoscopy
revealed that endoscopic resection was not possible was
16.66%; the secondary conversion rate following an intraoperative complication was 2.5%.
The complication rate for all the cited operations was
7.5% and included one case of intraoperative bleeding with
subsequent conversion owing to the loss of a clip on the
mesenteriolum, as well as one case each of complications
with penetration and closure of the gastric wall, although
re-laparoscopy was only necessary in the latter case. There
were no cases of mortality.
In none of the cases demonstrated were there any septic
complications in the abdominal cavity or in the translumenal access ports. Information on the sterilization of instruments is only provided in a few of the publications [23,29,31];
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in cases of transgastric access, some of the authors performed a gastric lavage [28,31]. In order not to promote the
development of unnatural gastric fl ora, patients should not
be given any acid -blocking medications prior to transgastric
procedures.
Is it possible for NOTES appendectomy to reduce the
wound infection rate, which is already very low in laparoscopic surgery owing to the use of recovery bags? In abdominal surgery, accompanying infections occur in 5 –20% of
cases and their treatment always entails additional effort and
expense [40]. In these cases, the skin is regarded as the most
signifi cant source of bacteria, and these types of infection
could possibly be minimized through NOTES surgery [41].
However, with 1.4 × 10
bacteria per cm
2
, the concentration of germs on the skin in
3
aerobic and 2.4 × 102 anaerobic
the region of the umbilicus is rather lower than on the interior surfaces of the body. The stomach has a concentration
2
of 10
to 10 5 CFU pro ml, depending on the acid concentration. However, on the gingiva, i.e., on the way to the
stomach, there is a germ concentration of 10
11
to 10 12 CFU
per ml [42]. The vaginal fl ora of a sexually mature woman
contains 10
7
to 10 8 germs per g [43]. Infections in the area
of the abdominal wall are therefore obviously associated
with other factors, such as the thickness of the subcutaneous
fatty tissue and the resulting inferior blood circulation, as
well as mechanical, and hence traumatic, impacts on the
abdominal wall. These are factors that speak in favor of
translumenal access.
Comparison of the two forms of access employed so far is
diffi cult in view of the small number of cases. The advantage
of the transvaginal approach is the short distance that the
instrument has to travel in order to reach the effector organ
and the better maneuverability that this provides. The
advantage of the transgastric approach is that it can be
applied in patients of both genders. In their multicentric
study, Zorron et al. [32] demonstrated signifi cantly longer
operating times and a signifi cantly higher complication rate
for transgastric appendectomies.
What advantages are offered, in particular, by a fl exible
dual-channel endoscope in the abdominal cavity during
appendectomy? In contrast to the laparoscope, the endoscope is a multifunctional instrument. The optical resolution
and the illumination of the operating site are very similar.
With an endoscope it is possible to perform insuffl ation,
irrigation, and suction, and to leave at least one transendoscopic instrument in situ while doing so. A particular advantage is the irrigation function for the camera, which has not
yet been achieved by the manufacturers of laparoscopes. The
disadvantage is in the fl exibility that is required for intralumenal movement. Controlled movement to a specifi c point
in the abdominal cavity is therefore considerably limited.
The retention of stability after reaching a position is another
weak point. Forces exerted during manipulation can lead to
undesirable shifts in the position of the endoscope, which in
turn prevents proper exposure and precise preparation.
Using the transport system, Horgan et al. were able to demonstrate a much more stable platform for the preparation of
the appendix [30]. However, operating with fl exible endoscopes obviously requires lower intra -abdominal pressure of
10–12 mm Hg, as is refl ected in some publications [23,32].
The choice of (additional) instruments is currently heavily
dependent on the clinical severity of the diagnosis. For the
performance of appendectomies in pure NOTES technique
to become a standard procedure, further development will
be required of both the endoscopes and the fl exible instruments. Appendicitis with perforation, abscess formation, or
peritonitis is currently still a contraindication for NOTES
surgery.
Chapter video clips
Video 12.1 Pure NOTES appendectomy.
Video 12.2 Flexible hybrid NOTES appendectomy, assisted by
rigid instruments.
Video 12.3 Rigid transvaginal appendectomy, assisted by
fl exible instruments.
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24 Palanivelu C, Rajan PS, Rangarajan M, et al. Transvaginal endo-
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Introduction
NOTES Applications in Colorectal Surgery
Joël Leroy , Michele Diana, James Wall , & Jacques Marescaux
IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
5 Our red line from bench to bedside in NOTES colonic
resections.
Benefi ts of a minimally invasive surgical approach in
complex surgical procedures including colorectal resections
have been demonstrated in prospective clinical trials [1–4].
In the continuing evolution toward less -invasive surgery,
natural orifi ce translumenal endoscopic surgery (NOTES) is
an evolving fi eld that pushes the technical limits of minimally invasive surgery.
The common focus of minimally invasive techniques is to
minimize abdominal wall trauma in gaining access to the
peritoneal cavity and/or extracting the surgical specimen.
The goal is ultimately to reduce incisional complications of
pain, infections, and hernia [5,6].
NOTES in digestive surgery involves the use of the transgastric, transvaginal, transanal, or transvesical route to
access the peritoneal cavity and perform the entire procedure avoiding any incision in the abdominal wall [7].
A pure NOTES approach has been shown as feasible in
experimental settings but, due to several technical issues,
current clinical experiences are limited to “hybrid” procedures involving some degree of laparoscopic assistance.
Aspects and challenges of colorectal NOTES are discussed
as follows:
1 Transrectal approach is preferred for colorectal NOTES.
2 Current available platforms for colorectal NOTES
procedures.
3 Transrectal viscerotomy closure: experiences in literature.
4 Natural orifi ce specimen extraction (NOSE): a bridge to
NOTES.
Transrectal approach is preferred for colorectal
NOTES
Each NOTES access presents specifi c advantages and drawbacks. The transvaginal approach is the better studied with
already large series of cholecystectomies [8,9] and reports of
nephrectomies [10], sleeve gastrectomies [11], and appendectomies [12]. The intrinsic drawback of the transvaginal
route is its applicability to the female population only.
The transgastric route has also been employed in cholecystectomies [13,14] and peritoneoscopies [15] but this technique is limited by the lack of a secure means to close the
gastrotomy.
The use of the transrectal/colonic access has been recently
assessed in a number of different experimental procedures
such as peritoneoscopy [16], cholecystectomy [17], ventral
hernia repair [18], and distal pancreatectomy [19].
Transrectal access allows direct access to the peritoneal
cavity with in -line vision and allows large specimen retrieval,
but there are some concerns regarding possible intra abdominal infectious complications with also a lack of a
secure closure of the viscerotomy. Colorectal surgery is the
best indication for transrectal NOTES for at least two reasons.
First, there is a routine risk of some contamination during
colorectal laparoscopic procedures that is not necessarily
increased by using transanal access [20]. Second, making a
surgical wound into an otherwise healthy viscus to operate
on a second organ is probably less logical than directly
opening the diseased organ. In fact, the ideal situation in
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
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colorectal NOTES is to resect the viscerotomy with the
specimen.
Current available platforms for colorectal NOTES
procedures
The ultimate aim of NOTES is to offer less -invasive, incisionless surgery that may even be performed on an outpatient
basis. This revolutionary concept is partially driven by public
demand [21], and has benefi ted from industry investment
in the design of new surgical tools. We currently lack a good
operating platform to perform effective complex surgical
procedures such as colonic resections in the setting of pure
NOTES. The basic requirements for NOTES platforms are:
the ability to provide a safe access to the peritoneal cavity
and suffi cient stability; good visualization of the operating
fi eld; triangulation of the instruments; and the ability to
provide traction and counter -traction to expose the tissues.
Current fl exible endoscopes are becoming more robust for
endolumenal interventions, but do not yet have the capability of advanced suturing, fl exible stapling, and forceful
dissection.
No current platform addresses all of these issues but
important progress has been made. Partial solutions have
been provided by endoscopes with steerable tips and operating channels able to offer the advantages of fl exible scopes
and a rigid strong support.
Our group is currently working on the development of
two fl exible endoscopic platforms (Anubiscope
®
cope
, Karl Storz, Tuttlingen, Germany) that create angulation between the instruments and allow the endoscopic
surgeon to work with both hands, recreating in the endolumenal environment the basic principles of triangulated surgical manipulation. The endoscope is provided with a bivalve
tip that opens once in the peritoneal cavity with fl exible
instruments passing through the working channels and
exiting in a triangulated fashion. A robotic integrated version
of this platform is currently under development at our Institute. An experimental trial of NOTES colonic resections
using this platform on a porcine model is currently ongoing
at our Research Institute.
An existing stable platform to perform certain transrectal
NOTES procedures has been discovered in the transanal
endoscopic microsurgery (TEM ™) instrumentation. TEM is
a minimally invasive technique introduced by Buess [22]
and may be considered an ancestor of NOTES. It was
developed to perform full -thickness excision of mid - to high rectum lesions not amenable to standard colonoscopic or
transanal resection. The Transanal Endoscopic Operation
(TEO™, Karl Storz, Germany) device is a modifi cation of
TEM with dedicated instrumentation composed by a special
rectoscope (8 cm or 15 cm in length and 4 cm in diameter)
equipped with an ordinary laparoscopic imaging system that
allows precise manipulation of tissue, full -thickness resection, and suturing of the defect [23].
®
and Isiss-
Feasibility of transrectal radical sigmoid colectomy using
the TEM platform was assessed by Whiteford et al. [24] in
2007 in a cadaveric model.
Transrectal viscerotomy closure: evidences in
literature
In cases in which the colorectal viscerotomy is not included
in the specimen, full -thickness closure may be challenging
and time consuming. The SAGES/ASGE Working Group on
NOTES identifi ed the secure closure of viscerotomy as one
of the leading barriers that needed to be surmounted for the
development of translumenal surgery [25].
Several methods to close transcolonic access have been
reported.
Manual suture with TEM instruments of peritoneal defects
after full -thickness tumor resections has been used since the
introduction of the technique and has been proven safe even
in the upper rectum [26,27]. Furthermore, a low rate of
post-TEM rectal stenosis has been reported [28].
Wilhelm et al. proposed the closure of the viscerotomy by
closing a previously placed purse string around the incision
and then excising the slight elevation resulting after closure
with a linear stapling device [20].
Endoloops have additionally been shown to adequately
close planned colonic visceral perforations [29]; however,
endoclips seem to be inadequate for primary closure, though
they may be useful as adjunctive closure modality [29,30].
Natural orifi ces specimen extraction: a bridge
to NOTES
The concept of NOSE is not new. Franklin et al. [31] described
a fully laparoscopic colectomy with transanal specimen
extraction and transanal anvil introduction in 1993. Current
research into the development of NOTES procedures has
prompted the re -exploration of NOSE in many recent publications [17,32–35].
An expected benefi t of NOSE in laparoscopic surgery is to
prevent the need for an enlarged port site or mini -laparotomy,
especially in procedures with a large specimen, Furthermore, transanal placement of the anvil in the NOSE procedure is a good solution to avoid exteriorization of bowel to
perform the anastomosis. In fact, it has been reported that
intracorporeal anastomosis construction is superior in terms
of return of bowel function, postoperative narcotic use, and
length of stay and morbidity in comparison to the extracorporeal technique [36].
This issue is expected to be even more important in
laparo-endoscopic single -site (LESS) procedures in which
the bowel to be resected would have to be exteriorized
through the single -site wound with the mesocolon under
tension and the bowel beneath the abdominal wall at risk
for ischemia. In reviewing the current state of the art of
single port in colorectal surgery [37] incisions of up to
6–8 cm have been reported to construct the anastomosis
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extracorporeally and to extract the specimen. This leads to
increased risk of parietal morbidity such as hernia, pain, and
infection.
Smaller single -port devices or mini -laparoscopic instruments passed in multiple fascia incisions as per Curcillo ’s
single-port access technique could enhance interest in
NOSE [38].
We recently performed a systematic review of the literature concerning transvaginal [39] and transanal (submitted
to Surgical Innovation) specimen extraction applied to colon
resections in both malignant and benign diseases. Worldwide experience with this technical adjunct in colorectal is
still very limited and study quality quite low to support the
potential advantages.
The only published case -control study comparing the
clinical outcomes of totally laparoscopic right colectomy for
cancer with transvaginal NOSE and the standard laparoscopic approach found a statistically signifi cant decrease in
postoperative pain score and a shorter hospital stay in the
NOSE group [40] and a comparable oncologic outcome.
Briefl y, the results of our reviews raise several critical
issues:
1 The risk evaluation of peritoneal bacterial contamination
secondary to the natural orifi ce opening.
2 The risk of anal sphincter impairment.
3 The adequacy of NOSE application to oncologic cases.
Peritoneal contamination risk in colorectal NOSE
Contamination of the peritoneal cavity in colorectal surgery
in conventional non -NOSE colorectal surgery has been
recently assessed by Saida et al. [41]. They reported a rate
of bacterial contamination of the abdominal cavity during
surgical treatment for rectal cancer of 28% versus 49% in
laparoscopic and open procedures, respectively.
This risk is present while performing the colotomy to bring
the anvil intra -abdominally or while gaining access to the
abdominal cavity through the natural orifi ces. In our experience on transanal NOSE sigmoidectomies 100% of cultures
were positive; however, no patients developed signifi cant
intra-abdominal infections [42].
No study has assessed the peritoneal contamination by a
fl uid collection for microbial analysis in colorectal procedures with transvaginal NOSE. While some authors have
mentioned this risk, no specifi c prospective evaluation has
yet been published [43–46]. A prospective systematic peritoneal fl uid collection to provide the pattern of contamination in NOSE and non -NOSE colorectal resections might
address this issue.
Anal sphincter dysfunction
Anal sphincter dysfunction secondary to the extraction of a
bulky specimen is another signifi cant concern for transanal
extraction. Few authors have investigated this to date. Akamatsu et al. [47] reported no clinical anal dysfunction after
this procedure in 16 patients. However, no objective evaluation of anal dysfunction has been published. Anal sphincter
function has been studied in TEM techniques that require a
bulky 4 cm rigid transanal device. Studies have not revealed
major postoperative dysfunction with TEM and a full recovery of continence within 3 months [48–51]. In a study on
sigmoid colectomy using TEM microsurgery, Whiteford et al.
speculated that rectal compliance is what allows the passage
of the surgical specimen without causing any kind of laceration, at least in the rectum [24]. Many authors using this
surgical approach emphasize that the size of the specimen
to be extracted, could be predicted on the basis of the body
mass index of the patient and on the type of resection.
Thus, during this initial feasibility phase for this technique, there is a tendency to select non -obese patients with
benign diseases, which theoretically decreases the risk of
laceration, fi stula, or anal sphincter damage.
Despite no reports of clinical incontinence in both the
literature and our experience, it would be appropriate to
assess this issue with a prospective functional anal manometry evaluation.
NOSE application to oncologic cases
The reduction of surgical stress and infl ammatory response
offered by the laparoscopic approach could translate into
better oncologic outcomes [52,53]. The further reduction of
surgical trauma using NOSE could conceivably be advantageous for oncologic cases providing the accuracy of the
tumor clearing, but this remains to be demonstrated. Oncologic cases also raise concerns for NOSE, given a presumed
risk of metastatic seeding, as was perceived at the beginning
of laparoscopy with port -site metastasis [54].
Resection margins and number of harvested lymph nodes
for both transrectal and transvaginal NOSE seem to show
adequate oncologic resection without reports of extraction
site metastasis. Some authors have reported extraction
without a protective barrier [55,56]. Although the use of a
protection is not a guarantee to avoid cancer cells seeding
at the extraction site [57], we promote the use of at least a
single-layer specimen bag while performing NOSE even for
benign pathologies [45]. The sleeve can additionally provide
mucosal protection and mechanical lubrication to ease specimen delivery.
Hybrid NOTES colonic resections: experiences
in literature
A combination of laparoscopic and natural orifi ces approach
can provide advantages in colorectal surgery by sparing
major incisions to extract the specimen or to insert stapling
devices. This hybrid approach is currently the safest way to
develop techniques that may ultimately enable pure NOTES.
A few pioneering groups have reported hybrid NOTES
colonic resections [58,59].
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