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and mediastinitis and sepsis in one pig. A different approach
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to the thoracic cavity was evaluated by De Palma and
colleagues [10]. They reported the feasibility of a transgastric
transdiaphragmatic route for lung biopsy in four pigs without
postoperative complications. Although many of these experiences are still anecdotal, they represent potential areas
for future study in this new emerging fi eld. Further exploration and feasibility of these approaches will need to be
examined.
Transesophageal thoracic surgery
Choosing an access site
The transesophageal access route to the mediastinum and
thorax represents the most widely used and accepted
approach to thoracic NOTES procedures. The anatomy of the
thoracic esophagus and its relationship to the great vessels
and other organs in the mediastinum, however, remains one
of the biggest challenges of the transesophageal approach.
The use of endoscopic ultrasound (EUS), as a guide for
determining an ideal access site and as a tool to improve the
visualization and localization of targets such as lymph nodes,
has been evaluated by Fritscher -Ravens and colleagues in
the swine model [11]. In their experience, there were 3
complications in 14 animals without the use of EUS and
none in 14 animals with EUS guidance. They also evaluated
the use of EUS in abdominal transgastric procedures, and
although there were no differences in these, it appeared to
be especially useful in mediastinal and thoracic procedures
where the anatomy may be more complex and where the
mediastinum is enclosed by delicate structures with no
virtual space to work within. EUS is a promising guidance
tool in transesophageal surgery to help identify either the
site of entrance, specifi c targets, or both, especially in
humans, where the mediastinum may be anatomically even
more complex than in animal models. Nevertheless, there
are several reports documenting successful NOTES procedures with few complications when transesophageal access
to the thoracic cavity is performed in the absence of
endosonographic guidance [12,13]. Therefore, although
EUS appears to be as an interesting tool, its absolute necessity in transesophageal procedures remains unclear based on
animal studies to date.
Access technique
Once the site of entrance has been chosen, the esophagus
must be opened to gain access into the mediastinum and
thorax. Different approaches have been described to traverse
the esophageal wall. One approach is to incise the mucosa
and muscular layer of the esophagus with a needle -knife
to create a full -thickness linear defect in the esophageal
wall (Figure 22.1). This provides direct and straightforward
CHAPTER 22 Thoracic Cavity Application of NOTES
Figure 22.1 Full-thickness transesophageal technique. (Reproduced
from Fritscher -Ravens et al. [16], with permission from Georg Thieme
Verlag KG.)
access to the mediastinum, but requires a reliable closure
technique to prevent leaks and potential subsequent
infection.
A second approach to open the esophagus requires the
creation of a submucosal tunnel and has been widely
described by different authors (Figure 22.2) [12,14,15]. In
this technique, the mucosa is fi rst separated from the underlying muscle layer using injection of a saline solution or a
multiband mucosectomy device to incise the esophageal
mucosal layer (Figure 22.2). Once the mucosa is divided, a
5–10 cm long tunnel is created using air and blunt dissection
with the aid of the endoscope and closed graspers (Figure
22.3). Finally, the muscle layer is incised at the distal end of
the tunnel using a needle -knife (Figure 22.4). The main
advantage of this tunneling technique appears to be the
relative ease of closure, decreased necessity for special
sutures and devices, and reduced risk of esophageal leak and
infection, which is a major concern with this transesophageal approach (Video 22.1).
Closure
Another major challenge of transesophageal NOTES procedures is the safety of the esophageal closure to prevent
esophageal leak and mediastinal infection. For full -thickness
esophageal wall incisions, Fritscher -Ravens and colleagues
used two alternatives for closure, stitches or clips, in a small
animal series [16]. The necropsy revealed good macroscopic
and histologic healing using full -thickness sutures. However,
with the use of clips the closure of the muscular layer
was incomplete, suggesting clips may not be enough to
secure full -thickness closure of the esophageal wall. Perhaps
unexpectedly, the use of a submucosal tunnel without the
use of closure device has demonstrated excellent results
with no evidence of infection [17]. Recently, a prospective,
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SECTION 3 Perspectives on NOTES
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(a) (b)
(c) (d)
Figure 22.2 Tunneling transesophageal technique. (Reproduced from Turner BG, Gee DW. Natural orifi ce transesophageal thoracoscopic surgery: a
review of the current state. World J Gastrointest Endosc 2010; 2(1):3–9, with permission.)
(a) (b)
(c)
Figure 22.3 Endoscopic view of the tunneling technique: (a) mucosa opening, (b) submucosal space, and (c) muscular defect.
randomized trial in the animal model compared the submucosal tunnel closure with (fi ve animals) and without (fi ve
animals) the use of a covered esophageal stent as an adjunctive method of closure [18]. Complete closure of the entrance
site was observed in both groups although interference with
246
mucosectomy site healing was observed in four out of fi ve
of the stented animals. There were two stent migrations to
the stomach and a longer mean procedure time was observed
in this group. Contrary to what would be expected, the addition of a stent to the submucosal tunnel technique did not
Lymph node
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CHAPTER 22 Thoracic Cavity Application of NOTES
Sympathetic chain
Figure 22.4 Endoscopic view of the thoracic sympathectomy.
improve esophageal mucosectomy site healing and appears
to be unnecessary in animal models.
Applications of thoracic NOTES
Video -assisted thoracic sympathectomy is one of the current
surgical alternatives for the treatment of palmar hyperhidrosis. Turner et al described the feasibility of the transesophageal approach for thoracic sympathectomy in a
non-survival swine model [12]. The resection of the sympathetic chain was confi rmed by biopsy in seven of eight
animals with a mean procedure time of 61 minutes (Video
22.2, Figure 22.5). Similarly, endoscopic transesophageal
lymphadenectomy of the subcarinal, para -aortic and para tracheal lymph nodes has been described in non -survival
and survival swine models [13,19]. These studies demonstrate the feasibility of en bloc resection of lymph nodes in
an animal model, providing an intact specimen for histologic
examination (Video 22.3). Transesophageal thoracic sympathectomy and lymphadenectomy are interesting alternatives to evaluate in human trials based on their simplicity
and good results in animal studies.
While the majority of transesophageal research has
focused on pleural or mediastinal procedures, Fritscher Ravens et al. and Sumiyama et al. have evaluated the feasibility of the transesophageal approach to the pericardium
[16,20]. Using a pericardial window to gain access to the
pericardial cavity, they performed a spot coagulation of the
epicardium in fi ve pigs. The procedure was successfully performed in four of fi ve animals without evidence of complications at necropsy. This work opens more areas of NOTES
applications in the fi eld of cardiovascular surgery with new
opportunities and challenges.
Recently, Rolanda and colleagues reported an interesting
and innovative experience of segmental esophagectomy
using a hybrid approach in an ex vivo and in vivo animal
model [21]. In this preliminary experience, the combination
of a rigid transthoracic and oral fl exible endoscopic approach
Figure 22.5 Endoscopic view of the lymph node dissection.
was used to resect a short segment of esophagus and
then to perform an end -to-end anastomosis. The procedure
was completed in fi ve ex vivo and fi ve in vivo animals.
The patency and impermeability of the anastomosis was
evaluated in all the procedures and a leak was detected
and corrected in three animals. The complexity of the procedure required the use of a combination of endoscopic and
thoracoscopic approaches. However, this study represents a
fi rst step toward the “hybrid” procedure, which has been
used in human NOTES studies thus far and will likely be
necessary as a bridge to pure thoracic NOTES procedures as
well [22].
Perhaps the most exciting advancement in transesophageal NOTES techniques has been the endoscopic esophagomyotomy. In patients with achalasia, surgical management
has traditionally been the laparoscopic Heller myotomy.
This technique creates a surgical interruption of the lower
esophageal sphincter (LES) to alleviate the hypertonicity at
the LES. Although the fi rst endoscopic approach for Heller
myotomy was described over 30 years ago [23], the development of the NOTES concept and new endoscopic tools has
raised new interest in this area.
In 2007, Pasricha et al. described a transesophageal
approach for Heller myotomy in four pigs using a submucosal tunnel technique [24]. Manometric evaluation demonstrated a signifi cant reduction in LES pressure at fi ve days
and absence of infection at necropsy. Three years later,
Inoue et al. in 2010 described the fi rst human experience,
in the era of NOTES, of transesophageal myotomy for achalasia [25]. This report describes a transesophageal myotomy
using a submucosal tunnel technique in 17 patients. A signifi cant improvement of symptoms and reduction in resting
LES pressures was observed in all cases at short -term follow up, fi ve months. There were no postoperative complications,
but one patient developed refl ux esophagitis controlled with
the use of proton pump inhibitors (PPIs). The authors termed
the procedure per -oral endoscopic myotomy (POEM). A
second study, of posterior myotomy, published by the same
group reproduces the same results in 43 patients [26]. The
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promising results of this preliminary clinical experience in
terms of safety and effi cacy provide compelling evidence to
continue this area of development, evaluate its reproducibility in different centers, and determine its effi cacy at longer
follow-up [27]. Additionally, although this technique of
endoscopic esophagomyotomy may not be considered an
extralumenal procedure, it provides preliminary evidence in
humans regarding the safety of the submucosal tunneling
technique, lending support to its use in extralumenal transesophageal procedures in humans.
Flexible endoscopic thoracic procedures
Although NOTES implies entry via a natural orifi ce, the
development of this fi eld has introduced other novel uses of
fl exible endoscopy, similar to what occurred at the beginning of the laparoscopic surgery revolution with laparoscopic assisted open surgery. Indeed, the use of fl exible scopes in
more complex translumenal surgical procedures has driven
its utilization in thoracic and abdominal procedures, often
replacing standard rigid scopes [28,29]. Using a fl exible
scope, Spaun et al. described a transcervical approach to
circumferentially dissecting the thoracic esophagus, performing a LES myotomy, and resecting mediastinal lymph
nodes in both swine and human cadavers [30]. Using a small
cervical incision and blunt dissection, the fl exible scope was
introduced to the mediastinum. The dissection then continued using a pretracheal or pre - or post -esophageal approach
depending on the procedure. A second scope in the esophagus was used to facilitate its recognition and also monitor
mucosal integrity after LES myotomy. Lymph nodes were
marked using transoral EUS guidance with black dye or
methylene-blue. Overall, 16 out of 16 lymph nodes were
successfully harvested in pigs and 2 of 2 in the cadaver with
completion of Heller myotomy in all cases. A second article
by the same group describes in detail their experience with
transcervical Heller myotomy in a survival series of ten pigs
and also in two human cadavers [31]. Myotomy was performed in all animals and cadavers; it was successfully
extended 2 cm to the stomach in all of the four posterior
myotomies (three pigs and one cadaver), but only in 25%
of the anterior myotomies (two pigs).
A similar concept with a different intended purpose has
been described using a subxiphoid approach in animal
models and also in patients. Zenati et al. describe a new
platform for video pericardioscopy named the FLEXview
system (Boston Scientifi c Cardiac Surgery, Santa Clara, CA,
USA), which allows visualization and electronic mapping of
the epicardium in patients [32]. Manca and colleagues
described the use of a subxiphoid approach in patients with
pericardial effusion for diagnostic purposes [33]. Recently,
Gee and colleagues presented their experience using a subxiphoid approach for endoscopic pulmonary vein dissection
in a cadaver model [34]. This group successfully performed
pulmonary vein dissection in six cadavers using endoscopic
instruments as a fi rst step for pulmonary vein isolation. This
approach could potentially be a new alternative for the
treatment of atrial fi brillation. Inspired by the concept of
NOTES, the use of fl exible endoscopy in transcervical and
subxiphoid approaches represents new alternatives in the
growing fi eld of endoscopic surgery.
Barriers to practice
One of the main concerns among surgeons and endoscopists
regarding transesophageal procedures is related to the risk
of leak, infection, and mediastinitis. Bacterial contamination
and infection in transgastric procedures appears to be avoidable using standard conditions of asepsis and antibiotic
prophylaxis [35–37]. The use of PPIs may increase the bacterial load without a signifi cantly higher risk of infection
[35,37]. Surprisingly, the incidence of infections as postoperative complications in transesophageal NOTES procedures
appears to be low in animal models but it remains to be
evaluated in human studies.
One of the diffi culties observed in mediastinal and thoracic NOTES procedures is related to the insuffl ation of air
and its hemodynamic consequences. Unlike the abdominal
cavity, the rigidity of the thorax may produce physiological
changes resulting in pneumothorax or compression of
greater vessels, with fatal consequences. Von Delius et al.
evaluated the cardiovascular effect of transesophageal mediastinoscopy in a pig model. They found a signifi cant but
minor fall in cardiac index, and, most importantly, tension
pneumothorax in three of eight animals with one fatality
[38]. This highlights the importance of developing preventive strategies to avoid or decrease the deleterious effect of
the insuffl ation in the thoracic cavity and monitoring its
consequences.
Certainly, the transition of animal experience to human
studies is diffi cult. The thoracic anatomy of most animal
models is different to human anatomy [39]. The right lung
in pigs consists of cranial, middle, caudal, and accessory
lobes whereas the left lung is divided into a cranial and
caudal lobe. The cranial lobe of the right side is ventilated
by the tracheal bronchus, which arises proximal to the
main bifurcation of the trachea. The distal portion of
the esophagus is located in a virtual space surrounded by
the accessory lobe of the right lung. This difference compared to human anatomy, combined with a smaller heart in
pigs (0.3% of body weight versus 1% in dogs) in relation to
its size, provides more space to work in and may artifi cially
simplify the performance of distal esophageal procedures in
animals. At the same time, this anatomic difference may also
allow more risk of communication between the right and
left thorax, increasing the risk for signifi cant cardiovascular
248
complications based on increased air pressure in a rigid
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cavity [38].
Finally, another diffi culty experienced in NOTES procedures is related to the relative absence of instruments, technology, and platforms specifi cally designed for this purpose.
Conventional fl exible scopes and endoscopic instruments
are designed for diagnostic or therapeutic upper gastrointestinal endoscopy or colonoscopy. The current design accounts
for diameter and length of scopes, degrees of fl exibility,
angle of vision, and number and diameter of working channels, among other specifi cations. The concept of NOTES has
allowed the development of new instruments and platforms.
Nevertheless, this development is still in its early stages and
most of the new technologies are prototypes that are not
widely available [40].
The future of thoracic NOTES
Transesophageal Heller myotomy represents, in many ways,
the beginning of the era of human NOTES applications in
the thoracic cavity [25]. This procedure demonstrates the
safety of transesophageal procedures in humans and breaks
some of the main barriers and concerns about the NOTES
approach. The successful demonstration of the Heller
myotomy in a human model also validates previous work
in animal models and provides the foundation for advancement of other transesophageal NOTES applications [24].
As discussed in this chapter, there are other applications
of NOTES in the thoracic cavity that have been evaluated in
animal models and these represent the next areas for human
study. As was described for the subxiphoid approach, some
of these procedures are very specifi c and may require special
instruments or platforms. The transition to human studies
has been slow but remains encouraging.
Conclusion
Transesophageal NOTES is a new surgical platform that
provides a less invasive alternative to accessing the mediastinum and thoracic cavity. Studies in animal models demonstrate its safety and feasibility. Preliminary data on human
studies shows promising results in endoscopic esophagomyotomy, which provides a reliable platform for extralumenal transesophageal procedures. Continued technological
advances and new instruments are needed to make transesophageal NOTES a viable approach in humans.
Chapter video clips
Video 22.1 Transesophageal tunneling technique.
Video 22.2 Transesophageal thoracic lymph node dissection.
Video 22.3 Transesophageal thoracic sympathectomy.
CHAPTER 22 Thoracic Cavity Application of NOTES
References
1 Gopaldas RR, Bakaeen FG, Dao TK, et al. Video -assisted thora-
coscopic versus open thoracotomy lobectomy in a cohort of
13,619 patients . Ann Thorac Surg 2010;89:1563–70.
2 Anraku M, Miyata R, Compeau C, Shargall Y. Video -assisted
mediastinoscopy compared with conventional mediastinoscopy:
are we doing better? Ann Thorac Surg 2010;89:1577–81.
3 Park BJ. Is surgical morbidity decreased with minimally invasive
lobectomy? Cancer J 2011;17:18–22.
4 Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric
peritoneoscopy: a novel approach to diagnostic and therapeutic
interventions in the peritoneal cavity . Gastrointest Endosc
2004;60:114–17.
5 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural
Orifi ce Translumenal Endoscopic Surgery. October 2005 . Surg
Endosc 2006;20:329–33.
6 Yang C, Liu HP , Chu Y, et al. Video. Natural orifi ce transtracheal
evaluation of the thoracic cavity and mediastinum . Surg Endosc
2010;24:2905–7.
7 Liu YH, Chu Y, Liu CY , et al. Feasibility of the transtracheal
approach for the thoracic cavity in a large animal model . Surg
Endosc 2011;25:1652–8.
8 Liu YH, Liu HP , Wu YC, Ko PJ. Feasibility of transtracheal surgi-
cal lung biopsy in a canine animal model . Eur J Cardiothorac Surg
2010;37:1235–6.
9 Liu YH, Liu HP , Wu YC, Ko PJ. Feasibility of transtracheal tho-
racoscopy (natural orifi ce transluminal endoscopic surgery) . J
Thorac Cardiovasc Surg 2010;139:1349–50.
10 De Palma GD, Siciliano S, Addeo P, et al. A NOTES approach for
thoracic surgery: transgastric thoracoscopy via a diaphragmatic
incision in a survival porcine model . Minerva Chir 2010;65:
11–15.
11 Fritscher -Ravens A, Ghanbari A, Cuming T, et al. Comparative
study of NOTES alone vs. EUS -guided NOTES procedures . Endos-
copy 2008;40:925–30.
12 Turner BG, Gee DW , Cizginer S, et al. Feasibility of endoscopic
transesophageal thoracic sympathectomy (with video) . Gastroin-
test Endosc 2010;71:171–15.
13 Turner BG, Gee DW , Cizginer S, et al. Endoscopic transesopha-
geal mediastinal lymph node dissection and en bloc resection by
using mediastinal and thoracic approaches (with video) . Gas-
trointest Endosc 2010;72:831–5.
14 Sumiyama K, Gostout CJ, Rajan E, Bakken TA , Knipschield MA.
Transesophageal mediastinoscopy by submucosal endoscopy
with mucosal fl ap safety valve technique . Gastrointest Endosc
2007;65:679–83.
15 Willingham FF , Gee DW , Lauwers GY , Brugge WR, Rattner DW .
Natural orifi ce transesophageal mediastinoscopy and thoracoscopy . Surg Endosc 2008;22:1042–7.
16 Fritscher -Ravens A, Patel K, Ghanbari A, et al. Natural orifi ce
transluminal endoscopic surgery (NOTES) in the mediastinum:
long-term survival animal experiments in transesophageal
access, including minor surgical procedures . Endoscopy 2007;39:
870–75.
17 Turner BG, Cizginer S, Kim MC, et al. Stent placement provides
safe esophageal closure in thoracic NOTES
Endosc 2011;25:913–18.
(TM)
procedures . Surg
249
SECTION 3 Perspectives on NOTES
https://t.me/med1917
18 Turner BG, Kim MC, Gee DW , et al. A prospective, randomized
trial of esophageal submucosal tunnel closure with a stent versus
no closure to secure a transesophageal natural orifi ce transluminal endoscopic surgery access site . Gastrointest Endosc 2011;73:
785–90.
19 Woodward T, McCluskey D, 3rd, Wallace MB, et al. Pilot study
of transesophageal endoscopic surgery: NOTES esophagomyotomy, vagotomy, lymphadenectomy . J Laparoendosc Adv Surg Tech
A 2008;18:743–5.
20 Sumiyama K, Gostout CJ, Rajan E, et al. Pilot study of trans-
esophageal endoscopic epicardial coagulation by submucosal
endoscopy with the mucosal fl ap safety valve technique (with
videos). Gastrointest Endosc 2008;67:497–501.
21 Rolanda C, Silva D, Branco C, et al. Peroral esophageal
segmentectomy and anastomosis with single transthoracic
trocar: a step forward in thoracic NOTES . Endoscopy 2011;43:
14–20.
22 Lehmann KS, Ritz JP , Wibmer A, et al. The German Registry for
natural orifi ce translumenal endoscopic surgery: report of the
fi rst 551 patients . Ann Surg 2010;252:263–70.
23 Ortega JA, Madureri V, Perez L. Endoscopic myotomy in the
treatment of achalasia . Gastrointest Endosc 1980;26:8–10.
24 Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic
esophageal myotomy: a novel experimental approach for the
treatment of achalasia . Endoscopy 2007;39:761–4.
25 Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic
myotomy (POEM) for esophageal achalasia . Endoscopy 2010;42:
265–71.
26 Inoue H, Kudo SE. [Per -oral endoscopic myotomy (POEM) for
43 consecutive cases of esophageal achalasia] . Nippon Rinsho
2010;68:1749–52.
27 Dotai T, Katagiri T, Nijhawan S, et al. The steps and outcome of
transesophageal endoscopic myotomy . In 2011 Scientifi c Session
of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), San Antonio, Texas, USA, 2011 .
28 Parker M, Pfl uke JM, Shaddix KK, et al. Video: transcervical
videoscopic esophageal dissection in minimally invasive
esophagectomy . Surg Endosc 2011;25:941–2.
29 Swanstrom LL, Dunst CM, Spaun GO. Future applications
of fl exible endoscopy in esophageal surgery . J Gastrointest Surg
2010;14(suppl 1 ):S127–32.
30 Spaun GO, Dunst CM, Martinec DV , et al. Mediastinal surgery
in connective tissue tunnels using fl exible endoscopy . Surg
Endosc 2010;24:2120–27.
31 Spaun GO, Dunst CM, Arnold BN, et al. Transcervical Heller
myotomy using fl exible endoscopy . J Gastrointest Surg 2010;14:
1902–9.
32 Zenati MA, Shalaby A, Eisenman G, et al. Epicardial left ven-
tricular mapping using subxiphoid video pericardioscopy . Ann
Thorac Surg 2007;84:2106–7.
33 Manca G, Codecasa R, Valeri A, et al. Totally endoscopic subxi-
phoid pericardioscopy: early steps with a new surgical tool . Surg
Endosc 2009;23:444–6.
34 Gee D, Escalona A, Briggs KH, et al. Endoscopic pulmonary vein
ablation for atrial fribrillation: a giant step forward . In 2011
Scientifi c Session of the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES) San Antonio, Texas, USA,
2011.
35 Giday SA, Dray X, Magno P, et al. Infection during natural orifi ce
transluminal endoscopic surgery: a randomized, controlled
study in a live porcine model . Gastrointest Endosc 2010;71:
812–16.
36 Eickhoff A, Vetter S, von Renteln D, et al. Effectivity of current
sterility methods for transgastric NOTES procedures: results of a
randomized porcine study . Endoscopy 2010;42:748–52.
37 Memark VC, Anderson JB, Nau PN, et al. Transgastric endo-
scopic peritoneoscopy does not lead to increased risk of infectious complications . Surg Endosc 2011;25(7):2186–91.
38 von Delius S, Wilhelm D, Feussner H, et al. Natural orifi ce
transluminal endoscopic surgery: cardiopulmonary safety of
transesophageal mediastinoscopy . Endoscopy 2010;42:405–12.
39 Sack WO. Essentials of Pig Anatomy, 1st edn . Veterinary Text-
books, Ithaca, New York , 1982.
40 Karimyan V, Sodergren M, Clark J, Yang GZ, Darzi A. Navigation
systems and platforms in natural orifi ce translumenal endoscopic surgery (NOTES) . Int J Surg 2009;7:297–304.
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Designing the NOTES Procedure Room
Mouen A. Khashab & Anthony N. Kalloo
The Johns Hopkins Hospital, Baltimore, MD, USA
Introduction
Natural orifi ce translumenal endoscopic surgery (NOTES)
has evolved as a legitimate alternative technique to traditional surgery and laparoscopy for the work -up and treatment of various mediastinal [1,2], abdominal [3], and pelvic
pathologies [4] since its introduction in 2000 [5]. The
improvement in the endoscopic and laparoscopic imaging
and technology has made the performance of NOTES surgery
become the next logical step. Although multiple challenges
have yet to be overcome before the widespread adoption of
NOTES [6], the recent immense interest in this technique
has led to an increasing number of publications [7], including well -designed randomized controlled trials [8–11]. Furthermore, human NOTES procedures have already been
performed and multiple exciting papers detailing this exigent
work have also been published [12–16]. Researchers, endoscopists, and surgeons working in the NOTES fi eld have to
toil diligently together for NOTES to move forward.
Most reported human NOTES procedures had been performed in conventional operating rooms. Marks et al.,
however, performed bedside transgastric NOTES to successfully treat a dislodged percutaneous gastrostomy tube (PEG)
in the early postoperative period [17]. Performing NOTES
procedures in the endoscopy suite is a new concept and may
help expand the scope of NOTES and its widespread use.
Hoffman et al. recently showed that mini -laparoscopyguided liver biopsy performed in an endoscopy unit is a safe
technique for the evaluation of patients with liver disease
[18]. In this chapter, we propose a design for a modern
NOTES room in the endoscopy suite.
General principles
The design and construction of an advanced and minimally
invasive NOTES room is a signifi cant undertaking. It is fi rst
important to determine the number of NOTES procedures
rooms necessary to accommodate the caseload of the unit.
This will also be determined by whether these rooms will be
dedicated for NOTES procedures only or whether other
advanced endoscopic procedures will be performed in these
rooms. Approximately 300 sq ft is an adequate space for a
traditional endoscopy room [19]. However, ample space is
needed for NOTES rooms to accommodate endoscopic,
laparoscopic, and radiologic equipment and a minimum of
360 sq ft is likely needed. Strategic equipment placement
within this space is essential to optimize the effi ciency and
the safety of the unit. (Figure 23.1, Video 23.1).
Power cables from electrosurgical units, IV lines, suction
tubing, etc., crowd endoscopy rooms, block access to
patients, and may pose a hazard to the endoscopy unit personnel moving about the darkened endoscopy room.
Ceiling-mounted equipment booms are being increasingly
used in modern operating rooms to eliminate the above
shortcomings of the “low tech ” designs. These booms
use the space above the false ceiling and consist of articulating arms that support different equipment, such as light
source, endocamera, anesthetic gas connections, electrocautery, and electric plug points. Ceiling -mounted booms
enhance sterile set -up and decrease the risk of cable leakage
since they are hidden above the false ceiling. The above ceiling space should be of adequate height to include air
conditioning pipelines, data relay wires, and cables for
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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SECTION 3 Perspectives on NOTES
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(a) (b)
Figure 23.1 Spacious NOTES room with the ability to accommodate endoscopic, laparoscopic, and radiologic equipment. Ceiling -mounted booms
enhance sterile set -up, decrease clutter, and ease personnel movement.
various equipment booms (e.g., electrical wires, vacuum,
oxygen, etc.).
Lighting
Effective and successful performance within the operating
room is enhanced by having lighting that does not cause
visual, operational, and environmental diffi culties such as
glare, shadowing, or visual stress. The operating room environment requires a combination of satisfactory ambient
lighting and effective direct and indirect task lighting. The
ability to adjust these lighting levels and change their characteristics allows room staff to be more effi cient. An on demand voice -activated lighting system may be ideal.
Poor lighting can impact on the patient, through poor
performance and impaired effectiveness, which may cause
lengthened procedures through uncertainty, or even errors.
A backup electric system should be available in the case
of power failure. There are typically three basic types of
lamps used within an operating room environment: incandescent, gas discharge, and light emitting diodes (LED).
Incandescent and gas discharge lamps have traditionally
been the main lamp type, utilizing halogen, tungsten,
xenon, and quartz. However, other types of lighting are now
emerging onto the market in several forms, particularly
LEDs. LED -based surgical lights are quickly replacing halogen
models in operating rooms, due to advantages such as
superior lighting characteristics, cooler operating temperatures, and unlimited life span. Equipment booms for lighting
are mostly preferred. In the operative area, the overhead
light should be shadowless and be freely moveable in both
horizontal and vertical ranges. The light should provide
50 000 to 100 000 lux at the center and 15 000 lux at the
periphery [20].
Equally important is the ability to dim the lights since
endoscopic procedures require a dimly lit room. Large
windows would not be preferred.
Fluoroscopy
A NOTES room may be used for other advanced endoscopic
procedures that necessitate the use of fl uoroscopic guidance
(e.g., endoscopic retrograde pancreatography, stricture dilation, enteral stent placement, etc.). Fluoroscopy is also occasionally needed during NOTES procedures for assistance in
spatial orientation or other specifi c instances, such as use of
NOTES for anterior spinal procedures [21].
Radiation protection necessitates a wall thickness in all
directions equivalent to 2 mm of lead. A mobile imaging
scanner intensifi er, or C -arm, is needed. The C -arm must be
compact and lightweight to allow easy positioning with
adequate space to work around and a wide range of motion.
The X -ray equipment should satisfy the regulatory standards
under clinical use conditions. These include presence of
adequate total fi ltration, presence of fl uoroscopy timer,
which terminates the exposure or produces an audible signal
at the end of a fi ve minute accumulative time interval, and
fl uoroscopic exposure rates that do not exceed the regulatory standards. The C -arm should have a high quality image
for quick and precise diagnosis. Image display should be on
a high -resolution thin -fi lm transistor (TFT) screen monitor.
The data output of the C -arm is best transmitted to a hanging
screen monitor to optimize visualization by the operating
endoscopist.
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NOTES ( operating room) table
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The NOTES (operating room) table should be mobile, with
electronically controlled hydraulic drive, and with adequate
width and weight bearing capability. It must allow for patient
positioning in both supine and prone positions, with signifi cant amounts of longitudinal or transverse tilts. The table
should allow tilt in different directions to be able to move
the bowels or other organs out of the “fi eld of view ’ using
gravity. The tabletop is divided into multiple sections, including leg plates for the lithotomy position (for transvaginal
NOTES procedures). In addition, the tabletop should be
without crossbars for it to be compatible with fl uoroscopy.
Sterilization
There is a basic difference between disinfection and sterilization. While sterilization is a process that destroys all forms
of microbial life, disinfection is a process that eliminates
most pathogenic microorganisms, with the exception of
some bacterial spores and infectious proteins [22]. Maximally aseptic conditions should be used during NOTES procedures [23]. This requires sterilization of endoscopes and
all endoscopic accessories, including the use of sterile overtubes during the passage of the endoscope through the gastrointestinal tract or other hollow organs [23]. Non -sterile
conditions invariably lead to intraperitoneal infection.
Aseptic techniques during NOTES prevent intra -abdominal
infections [24,25].
A sterilization unit should be in close proximity to the
NOTES room. Sterilization techniques for human use include
prolonged soaking in high -level sterilant, automated liquid
sterilization, gas sterilization using ethylene oxide, and
hydrogen peroxide gas vapor sterilization (e.g., STERRAD,
Ethicon, Inc., Somerville, NJ, USA). This latter system provides a high level of sterilization within a half an hour
processing time and is advisable for units with high -volume
load of procedures [20].
NOTES room air pressure
The Centers for Disease Control (CDC) recommends maintenance of a positive air pressure in operating rooms so that
airborne contaminants will not fl ow into the surgical site.
To minimize entry of airborne microbes into the NOTES
room, systems that maintain air pressure in the room higher
by at least 0. 002 inches of water column (0.5 Pascals) than
the air pressure in the corridor are used. These systems fi lter
the air before delivery with a high effi ciency particulate air
(HEPA) fi lter and then pump it into the operating room at
high pressure, which forces air from the operating room out
CHAPTER 23 Designing the NOTES Procedure Room
into the hallway. To maintain positive pressure, the room
should be well sealed without any loopholes. Excessive positive air pressure is unnecessary because it is energy ineffi cient and may push enough moist air into cool wall cavities
during cold weather to result in hidden mold growth in the
walls.
Laparoscopic equipment
Many advances are needed for pure NOTES procedures to
become routine. Hybrid surgery, or laparoscopically assisted
NOTES, allows judicious implementation of NOTES techniques in patients [26]. As we learn more about NOTES and
as the experience with NOTES techniques grows, hybrid
operations will likely rely less on laparoscopy and more on
pure endoscopy, serving as a transition to broad application
of pure clinical NOTES [26].
Laparoscopic equipment should be handy in the NOTES
room to assist in hybrid procedures. In addition, laparoscopy
is potentially needed to assist in treatment of unexpected
complications, such as bleeding and iatrogenic visceral
perforation. Laparoscopy can also be used for access
closure. Needed laparoscopic surgical equipment can be classifi ed into two broad categories: equipment for access and
exposure, and hand instruments for the actual operative
procedure.
Laparoscopic equipment for access and exposure
1 A telescope: usually a 10 mm diameter, 25 cm long rod
lens for viewing with additional parallel optic fi bers to allow
light from an external source. The telescope has an eyepiece
for direct viewing or fi xing of a camera and a “side branch ”
at right angles to allow the attachment of a light -transmitting
cable carrying light from a light source.
2 A laparoscopic “camera”: this is a special lightweight
attachment that is fi xed to the eyepiece of the telescope and
is able to pick up a video image of whatever is seen in the
telescope. The video signal is transmitted to a special video
monitor.
3 A high -performance halogen or Xenon light source with
a fi ber -optic cable to transmit the light from the light source
to the telescope, which has a special attachment point for
the light cable.
4 Video monitor: high resolution “medical” monitors display
colors more accurately, but are more expensive. However,
the less expensive ordinary TV sets can be used for most
routine operative work.
5 An insuffl ator: delivers carbon dioxide gas from a high pressure cylinder to the patient at a low and accurately
controlled pressure and at a high rate if necessary.
6 Cylinder of carbon dioxide gas.
7 Ancillary equipment: cables to connect the monitor to the
camera control unit, a tube to transmit carbon dioxide from
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the insuffl ator to the patient, and minor items such as
brushes to clean the equipment and telescope anti -fog
solution.
Hand instruments for laparoscopic surgery
Hand instruments in laparoscopic surgery include graspers,
scissors, needle holders, retractors, clip applicator, trocars,
and cannulas. Since most instruments are either 5 –5.5 mm
or 10 –11 mm in diameter, 5.5 mm and 11 mm trocars, along
with a “reducer” that allows the use of a 5 mm instrument
in a 10 mm or 11 mm cannula are needed. A Veress needle
may also be used. This is a spring -loaded needle that is used
to make a blind fi rst puncture for laparoscopic access into
the abdominal cavity. There is a small but unavoidable incidence of injury to bowel or great vessels as the insertion of
this needle is blind. The use of a Veress needle can be
avoided by use of the “open entry ” technique, in which the
peritoneal cavity is entered under vision.
Conversion from NOTES to laparoscopic or
open procedures
NOTES room should have the necessary provisions to allow
conversion of a NOTES procedure to laparoscopic or even
an open surgical procedure. This is potentially needed in
cases of failed NOTES, unexpected complications, or unexpected fi ndings. NOTES room staff must be prepared for
such conversions without delay. Open retractors and extra long open instruments must be available in the room for this
possibility. Ideally, an open instrument tray should be available in anticipation of possible urgent open conversion. Conversion to a laparoscopic or open procedure will be part of
the learning curve for NOTES operators.
Ergonomics of a NOTES room
Endoscopists report a high rate of injury related to the repetitive use of endoscopic equipment. Relatively large numbers
of reporting endoscopists, ranging from 37% to 89%, have
expressed experiencing musculoskeletal complaints most
commonly affecting the left thumb, right wrist, neck, and
back [27]. It has been shown that performing NOTES is
signifi cantly more challenging for surgeons than laparoscopy [28]. The greater amount of muscular exertion required
is linked to higher ergonomic risks. Monitor position is an
important ergonomic factor during NOTES and other minimally invasive surgeries [29]. Functional laparoscopic studies
point out that laparoscopic tasks are performed signifi cantly
quicker and more precisely when the monitor is placed in
the proximity of the surgeon ’s hands, in line with the surgeon’s forearm –instrument motor axis [29]. Studies on eyestrain recommend avoidance of elevated monitor positions
above eye level. A downward viewing direction of 15 ° is the
most neutral viewing direction for the extraocular musculature. The distance to the monitor should be 80 –120 cm for
avoidance of excessive accommodation, convergence, and
staring [30]. This distance is based on a regular 19 -in. laparoscopic monitor and is dependent on the screen size and
image resolution. With 21 -in. high -defi nition monitors, a
viewing distance of 80 cm may be considered too close [29].
Future thoughts
It is possible that NOTES in the future will not have to be
performed in an operating room but could be done anywhere. Laparoscopy can be performed safely in an endoscopy unit, as demonstrated by Hoffman et al. in over one
thousand patients [18]. Second, NOTES has been performed
at the bedside for “rescue” of a dislodged gastrostomy tube
[17]. In this case report, a high -risked patient had a dislodged PEG tube in the early postoperative period with evidence of incomplete gastrocutaneous tract formation and
intra-abdominal leakage. Transgastric NOTES was performed
at the bedside with peritoneal exploration, evacuation of
intra-abdominal fl uid, and re -establishment of the PEG tube
through the original gastrotomy tract. This leads to the
notion that NOTES with the right tools and accessories could
be portable for appropriate indications.
Conclusion
NOTES has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000 [5]. Breaching the gastrointestinal boundary
opened the realm for new endoscopic techniques, innovative endoscopic instruments, and pioneering treatment
modalities. For the widespread use of NOTES and for NOTES
to be the real next frontier in endoscopy, endoscopists have
to gain the ability to perform this minimally invasive technique in their usual working environment, the endoscopy
suite. The dedicated NOTES room design is an essential
requirement for effi cient, safe, and state -of-the-art performance of NOTES procedures. Provisions should be made for
conversion to laparoscopic or open surgery. The proposed
“high-tech” design decreases clutter, eases personnel movement, maintains sterile fi eld, improves ergonomics, and
allows the use of fl uoroscopy and laparoscopic equipment
when needed.
Disclosures
Mouen Khashab is a consultant for Boston Scientifi c.
Anthony Kalloo is a founding member, equity holder, and
consultant for Apollo Endosurgery.
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