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SECTION 1 Development of the NOTES Concept
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Table 5.6 Main determinants for transvaginal access.
Advantages
Longest history of use
Does not require the use of a special platform for creating the point
of entry or closure
Easiest closure, favorable healing
Easily accessible for disinfection
No high -volume secretion of fl uids
Favorable access to peritoneal cavity
Disadvantages
Access available to only 50% of population
Possible cause of pelvic adhesions, fertility problems?
Temporary postoperative sexual abstinence, sexual dysfunction?
Lower preference among younger reproductive females
Cultural barriers?
a
Contraindications (same as described as for culdoscopy
Obliterated or frozen rectouterine space
Fixed retroverted uterus
Laterally deviated uterus/cervix
Pelvic mass
Pelvic infection
Bleeding
Narrow vagina
Several prior abdominal/pelvic operations
No prior ultrasonography
a
Christian J, Barrier BF, Schust D, et al. Culdoscopy: a foundation for
natural orifi ce surgery – past, present, and future. J Am Coll Surg
2008;207(3):417–22.
):
superior third of the vagina to avoid pelvic muscles and surrounding structures.
After incising the vaginal mucosa, the superior margin of
the incision is grasped by an Allis forceps, and sharp dissection is performed with scissors. The posterior cul -de-sac peritoneum is identifi ed and opened (Figure 5.17c). The
endoscope or surgical platform is inserted through the
vaginal opening and CO
is insuffl ated into the peritoneal
2
cavity as the instruments are directed up out of the pelvis.
Transvaginal hydroperitoneum access [55]
This technique comprises pre -instillation of saline solution
into the pouch of Douglas in order to reduce the risk of rectal
injury. A radially expandable sleeve and a blunt -tip dilating
trocar are sequentially inserted to create the access using a
Veress needle as a stylet. The procedure is initiated using a
5 mm radially expandable sleeve and Veress needle assembly
by direct midline puncture into the posterior vaginal fornix,
5–10 mm below the posterior lip of the cervix, between the
uterosacral ligaments (Figure 5.18). The axis of entry is
horizontal and it is necessary to avoid insertion of the needle
between the vaginal vault and the peritoneum. For this
maneuver it is important to stabilize the cervix with a Pozzi
tenaculum fi xed at 8 o ’clock position of the cervix. Then,
150–200 ml of saline solution is instilled into the pouch of
Douglas. Hydropelvoscopy is then performed using a small
30 degree endoscope to verify the feasibility of the procedure. Subsequently, the blunt -tip dilating trocar (a 12 mm
diameter dilator) is gently inserted into the radially expandable sleeve. As soon as the dilating trocar is inserted, the
fl exible endoscope can be inserted. Pneumoperitoneum
using CO
dilating trocar.
insuffl ation is then easily created through the
2
Patients are kept under overnight fasting before the procedure. Bowel preparation is not a requisite for this procedure. The procedure is done under general anesthesia with
the patient intubated endotracheally. The patient is positioned in a Lloyd –Davies position, which also includes the
patient inclined in Trendelenburg fashion to facilitate pelvic
organ retraction. Disinfection of the vagina is achieved by
topical povidone -iodine solution or chlorhexidine solution.
A urinary catheter is placed and kept solely for the peri operative period.
Transvaginal access under direct vision ( classical
approach) [8] (Figure 5.17)
After proper retraction of the vaginal walls, the cervix is
grasped and retracted upwards. For usual peritoneal access,
the vaginal mucosa in the posterior cul -de-sac is opened
5–10 mm below the cervix by a semilunar 2.5 cm incision
(Figure 5.17a). Alternatively, for accessing to the retroperitoneum, a lateral incision at the vaginal wall is performed.
For this type of access, the incision must be made at the
52
Transvaginal access under laparoscopic
assistance [8]
This is probably the most popular NOTES access procedure
worldwide, in which preliminary pneumoperitoneum is
advocated. The surgeon is positioned between the legs of the
patient; the fi rst assistant stands behind for holding the
controls of the endoscope. If laparoscopic assistance is
needed, a second assistant stands on the left side of the
patient. Pneumoperitoneum is maintained by using a laparoscopic insuffl ator to provide control of the pressure, either
by a multilumen transvaginal trocar or through a Veress
needle.
The procedure begins with a Veress puncture in the left
subcostal abdomen or the umbilicus for the pneumoperitoneum. After inserting a 5 mm trocar in the umbilicus, a
laparoscope is used to inspect the abdominal cavity and the
pouch of Douglas.
After confi rming the feasibility of using the pouch of
Douglas, a 10 –12mm laparoscopic trocar is inserted in the
vaginal posterior cul -de-sac under laparoscopic guidance
Area of access
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(a)
CHAPTER 5 NOTES Access Techniques
Cervix
Bladder
Uterosacral
ligaments
Uterus
Vagina
Peritoneal cavity
Rectum
(c)
Figure 5.17 Transvaginal access. (a) Schematic of vaginal retraction
exposing the cul -de-sac area. The area of access is 5 –10 mm below the
cervix, between uterosacral ligaments. (b) Schematic of a sagittal view of
posterior transvaginal access. Access is gained by entering the Douglas
pouch. Note the proximity of the rectum. (c) Picture of direct (classical)
using steady and gentle pressure. An intrauterine manipulator may be used to retract the uterus anteriorly to improve
the view of the posterior fornix. After extraction of the
trocar stylet, the endoscope is inserted. A disposable single
port access system can be a more advantageous substitute
for the laparoscopic trocar. Advantages of using a single -port
access system include multiple access ports, reliable pneumoperitoneum, and use of fl exible endoscopes and instruments ranging from 5 mm to 12 mm.
After gaining access to the peritoneal cavity, the endoscope is gently pushed forward. Initial orientation in the
cavity and navigation of the endoscope up and out of the
pelvis is made possible by localization of the abdominal wall
and abdominal organs using a reverse Trendelenburg posi-
(b)
transvaginal access. Note the cervix being retracted upwards to expose
the mucosal and peritoneal opening. (Parts a and c adapted from
Watrelot A, Wattiez A, Transvaginal access. Epublication: eats.fr, 2007
Jun;7(6). At www.eats.fr/doi -lt01enwatrelot001.htm. Accessed April
2011. Copyright © IRCAD -WeBSurg -EATS. Reproduced with permission.)
tion. The vaginal wound is closed using absorbable running
or interrupted sutures under direct vision. Patients are
advised to avoid sexual intercourse for 2 weeks. Postmenopausal patients occasionally receive topical estrogen applications for up to 4 weeks.
Anal route: transrectal/ transcolonic access
Initially used for transrectal removal of laparoscopic colectomy specimens, the anal natural orifi ce route has regained
attention for enabling rectosigmoidectomy [56]. This novel
NOTES technique is mainly based on the transanal endoscopic microsurgery (TEM) platform, a system designed for
53
SECTION 1 Development of the NOTES Concept
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complex endolumenal surgical intervention allowing full thickness removal of non -invasive rectal tumors. The TEM
approach has technical components that can be considered
a translation of laparoscopic surgery into an endolumenal
environment. A rigid port inserted transanally provides fi eld
visualization by using CO
insuffl ation and the use of cus-
2
tomized surgical instruments capable of suturing, dissecting,
and coagulating. Apart from its original use for rectal tumor
local resection, the TEM platform has now been applied for
NOSE procedures and for laparoscopic -assisted transanal
rectosigmoidectomy in humans (Table 5.7).
Bladder
Uterus
Vagina
Peritoneal cavity
Rectum
Figure 5.18 Hydroperitoneum access, posterior vaginal approach.
Schematic showing water instillated into the Douglas pouch to avoid
inadvertent rectal lesion. (Based on Watrelot A, Nassif J, Law WS,
Marescaux J, Wattiez A. Safe and simplifi ed endoscopic technique in
transvaginal NOTES. Surg Laparosc Endosc Percutan Tech
2010;20(3):e92–4.)
Transanal sigmoidectomy with rectal mobilization
using TEM
The current NOTES transanal access for rectosigmoidectomy
uses an adaptation of the TEM technique, as described below
[56]. After full mechanical bowel preparation, the patient is
then placed in lithotomy position. The rectum is irrigated
with diluted povidone -iodine solution. A Veress needle is
inserted through the umbilicus and the abdomen is insuffl ated to a pressure of 12 mmHg. A 5 mm port for the laparoscope is inserted through the site for future ileostomy
creation in the right lower quadrant. The Veress needle is
then replaced for a 2 mm needle port used for insertion of a
laparoscopic grasper, which is used for peritoneal inspection.
After confi rming that the sigmoid colon is redundant with
no evidence of pelvic adhesions, the laparoscopic camera
and instrument are removed and transanal dissection is
initiated.
The patient is then placed in a lithotomy position and the
anoscope used for Procedure for Prolapse and Hemorrhoids
(PPH, Ethicon Endo -Surgery, Cincinnati, OH) is inserted
transanally and sutured to the peri -anal skin. A purse string
suture is placed 4 cm from the anal verge to tightly occlude
the rectum. The 7.5 cm TEM proctoscope (Karl Storz, Tuttlingen, Germany) is inserted and sealed with the faceplate,
and CO
the rectal mucosa circumferentially just distal to the purse
string, full -thickness rectal transection is initiated circumferentially using the Harmonic scalpel (Ethicon) and TEM dissecting instruments (Storz). Posteriorly, care is taken to
avoid dividing residual internal sphincter muscle fi bers.
After gaining further access to the mesorectum, the shorter
proctoscope is replaced with the 15 cm proctoscope to
improve exposure. The rectosigmoidectomy procedure is
then carried out as described in Chapter 14.
of a fl exible operating platform for operating in distant
organs within the peritoneal or retroperitoneal cavity. This
access is achieved by using an anterior or posterior (retro-
is insuffl ated to a pressure of 9 mmHg. After scoring
2
Transrectal access may also be used for enabling insertion
Table 5.7 Anal route human NOTES-assisted procedures (excluding natural orifi ce specimen extraction procedures).
Author Year Country Technique
Abbas et al. 2008 USA Abdominopelvic abscess drainage
Velhote and Velhote 2009 Brazil Transanal assisted sigmoid vessel ligature (transanal colectomy pull -through for Hirschprung)
Sylla et al. 2010 USA Transanal port -assisted rectosigmoidectomy + total mesorectal excision
Donatelly et al. 2011 France Paraortic abscess drainage
Tuech et al. 2011 France Transanal port -assisted rectosigmoidectomy + total mesorectal excision
Horgan et al. 2011 USA Peri-rectal peritoneoscopy
Zorron et al. 2011 Brazil Transanal port -assisted rectosigmoidectomy + total mesorectal excision
54
rectal) approach. The anterior approach is created by incis-
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ing the rectum at the point of the peritoneal fl exion, with
direct access to the peritoneum (Figure 5.19a). The posterior
transrectal approach encompasses creating a retrorectal
tunnel allowing access to retroperitoneal organs such as the
pancreas (Figure 5.19b) [46]. By using a low rectal incision,
this access can be done using conventional instruments, as
for transvaginal access.
Transcolonic ( trans-sigmoid) access
The concept of developing a transcolonic access is to provide
another in -line access option to the upper abdomen. The
usual entry point is the sigmoid, for it is also called trans sigmoid access. Purse string sutures may be placed prior to
viscerotomy to facilitate closure. As for most NOTES procedures, the fi rst model using transcolonic access was the
cholecystectomy procedure in a pig survival model using
standard fl exible endoscopic instruments [57]. For the fi rst
two experimental studies, transcolonic access provided a
good approach to the gallbladder; however, technical limitations that prevailed were the presence of residual stool and
endoscopic colotomy closure (one failure in eleven closure
attempts). Although survival pigs were given postoperative
antibiotics, postoperative adhesions and microabscesses
were a constant fi nding. Since the anal route is among the
most contaminated routes, in order to avoid peritoneal
infection and fi stula, safer transcolonic access to the peritoneum may require specifi c colon irrigation and disinfection
and use of special ports.
CHAPTER 5 NOTES Access Techniques
Bladder
Uterus
Vagina
Peritoneal cavity
Rectum
(a)
Bladder
Uterus
Vagina
Urethral route: Transvesical access
In 2006, the fi rst report on transvesical access was a diagnostic peritoneoscopic procedure using a fl exible endoscope
in pigs [58]. In this successful procedure the authors could
reach the upper quadrant and also perform liver biopsy. In
2007, human NOTES transvesical peritoneoscopy was
carried out during a robotic -assisted radical prostatectomy
[59]. Again, successful abdominal exploration was possible
using a fl exible endoscope. Several potential advantages of
the transvesical access approach have been listed [60]: (i) it
is naturally and usually sterile, (ii) its location is ergonomically advantageous, allowing in -line upper abdomen access
and access above the bowel loops, (iii) like the transvaginal
approach, it is possible to introduce rigid instruments, (iv)
pneumoperitoneum is easily achieved and maintained, and
(iv) the procedure can be performed on both genders.
Despite initial efforts on developing the transvesical technique, this access has not been further explored clinically.
Limitations for the technique are the diameter of the urethra,
which limits the size of surgical platforms used and the size
of specimens to be removed. Another limitation is reliable
closure of the vesical defect to avoid urinary peritoneal spill-
Peritoneal cavity
Rectum
(b)
Figure 5.19 Transrectal access. (a) Anterior rectal access into
peritoneum. (b) Posterior (retrorectal) access. Note the lower posterior
incision. This access allows entrance into the retroperitoneal space.
age with risk for fi stula, peritonitis, and infection. To avoid
this problem a postoperative indwelling catheter has been
needed, which carries a risk of infection. Usage of non absorbable closure devices may lead to obstructive foreign
body if intravesical migration occurs. Some patients may
55
SECTION 1 Development of the NOTES Concept
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3
1
4
2
4
Figure 5.20 Transvesical access to the peritoneum. See text for
discussion. (Reproduced with permission from Gettman MT [59],
© 2007 Elsevier.)
require urethral dilation and be exposed to complications
inherent to this procedure. Finally, urethral instrumentation/
dilation can cause secondary transient or long -term postoperative urinary incontinence.
Transvesical access technique
A method has been described for the only human published
case to date [59,61]. With the patient in a steep Trendelenburg position, pneumoperitoneum is created, and laparoscopic ports are placed in the standard fashion for
robot-assisted prostatectomy. A standard rigid cystoscope is
advanced transurethrally, and peritoneal access is gained by
inserting an endoscopic injection needle through the bladder
wall under simultaneous laparoscopic and endoscopic guidance. A guidewire is inserted through the needle to maintain
the access. A balloon dilator is used to dilate the cystotomy
tract. A fl exible ureteroscope is inserted through the cystostomy and peritoneoscopy is performed (Figure 5.20). After
removing the ureteroscope, the cystotomy site is closed with
2-0 polyglactin fi gure -of-eight sutures.
Conclusion
Due to signifi cant technical advances the past 5 years, several
NOTES procedures using the oral, vaginal, and anal routes
became feasible in humans. However, there are still technical, logistic, and economic issues deterring widespread use.
Moreover, randomized trials comparing NOTES to gold
standard procedures (e.g., laparoscopy) are needed to
confi rm its advantages for it to fi nally be considered as a
standard-of-care option. Nevertheless, NOTES has already
changed the future of surgery for preserving patients from
visible scars and parietal somatic pain. For the fi rst time in
surgical history the surgeon will probably be able to propose
to the patient at least one additional choice of access for
some commonly performed surgical procedures, such as
cholecystectomy.
Chapter video clips
Video 5.1 Transgastric access. Transmural drainage of organized
infected pancreatic necrosis.
Video 5.2 Transesophageal access. Endoscopic submucosal
esophageal myotomy in a porcine model.
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peritoneoscopy: a novel 5 mm port for intra -abdominal scarless
surgery . J Urol 2006;176(2):802–5.
59 Gettman MT , Blute ML. Transvesical peritoneoscopy: initial
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60 Branco F, Pini G, Osório L, et al. Transvesical peritoneoscopy
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61 Granberg CF , Frank I, Gettman MT . Transvesical NOTES: current
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6
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NOTES Closure Techniques
Erwin Rieder1& Lee L. Swanstrom
1
Legacy Health System, Portland, OR, USA
2
The Oregon Clinic, Portland, OR, USA
Introduction
More than 25 years ago Erich M ühe reported the fi rst laparoscopic cholecystectomy [1]. Since then surgical procedures
have continuously evolved along the direction of less invasiveness. Today, minimally invasive surgery (MIS) has
mostly replaced traditional laparotomy for many procedures. Although laparoscopy has defi nite patient advantages, any breach of the cutaneous barrier has inherent
complications such as herniation, wound infection, and
chronic pain. A fairly novel concept to enter the abdominal
cavity by traversing a gastrointestinal organ has evolved
since 1998 when Pasricha et al. fi rst postulated the use of
fl exible endoscopy to perform laparoscopic procedures [2].
Later labeled as natural orifi ce translumenal endoscopic
surgery (NOTES) [3], the basic aim of these “scar -less” novel
interventions through natural orifi ces (e.g., mouth, vagina,
and anus) is to reduce the surgical impact on the patient
and, at least theoretically, improve outcomes. Since the fi rst
report on the feasibility and safety of a per -oral transgastric
endoscopic access to the peritoneal cavity in a long -term
survival porcine model by Kalloo [4,5], it has been shown
that access to essentially all organs can be performed by a
translumenal approach. From what was only a conceptual
or laboratory -based approach a few years ago, multiple
centers have now progressed to human NOTES procedures
[6].NOTES involves a completely novel route into the peritoneal cavity. The creation and closure of an intentional
viscerotomy is one of the fundamental differences between
it and open or laparoscopic surgery. Additionally, breaching
an otherwise unharmed gastrointestinal organ challenges
long-established surgical paradigms. While today, complications from conventional surgical access (wound infections,
scarring, pain, hernias, etc.) are more or less accepted, any
2
failure of transenteric closure techniques could have a life threatening impact for the patient. Therefore, failure rates
of viscotomy closure in NOTES have to approach 0%. This
important requirement was clearly stated and discussed in
the SAGES and ASGE NOTES working group paper [3] and
has subsequently initiated tremendous work on specifi c
closure devices and procedures. The following gives a short
summary of current closure technologies as well as developing attempts to accomplish secure closure of diverse translumenal access routes.
No closure
Early in the experimental NOTES experience, multiple
authors proposed that it might not be necessary to close
small enterotomy defects at all. In a survival pig study,
where small gastrotomies were created and then dilated
with a through -the-scope balloon, Jagannath and colleagues
reported no signs of intra -abdominal infection after two
weeks when the transmural approach was simply left open
to contract and heal [7]. Additionally, Ryou et al. observed
that a control gastrotomy, which was left open, achieved air
leak pressures of 15 mmHg [8]. This observation could indicate that a full -thickness tissue closure is not an absolute
necessity. However, it is known that the pig stomach is not
comparable to that of humans, and tissue tolerance and
healing of the porcine stomach may be different from that
of the human stomach.
Transvesical approaches to the peritoneal cavity have been
reported in both animal and clinical studies. It was hypothesized that bladder access would be simplifi ed as the urinary
tract is sterile and catheterization alone will allow healing
of the viscerotomy. A group from Portugal used a Foley
catheter, placed four days for bladder drainage, and achieved
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.
59
SECTION 1 Development of the NOTES Concept
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Figure 6.1 An enteric exit technique is to tunnel under the mucosa for
a distance before exiting.
of the endoscope due to the submucosal tunnel would make
endoscope movement and maneuvering more diffi cult compared to a direct translumenal access route. Several other
quick and simple techniques to “not close ” viscerotomies
have been proposed, but clinical feasibility remains questionable in most. Therefore any eventual “overtreatment”
for the closure of access sites for NOTES currently appears
to be more than justifi ed.
Traditional closure techniques
closure of vesicotomy after transvesical thoracoscopy in a
pig survival model [9]. In 2007 a group from the Mayo Clinic
demonstrated the clinical feasibility of transvesical peritoneoscopy [10]. The procedure was performed with a fl exible
ureteroscope under laparoscopic control prior to a planned
robotic prostatectomy. The authors observed that after
removal of the ureteroscope the cystotomy immediately
decreased to a smaller size, but was not watertight. In this
case the iatrogenic hole in the bladder was closed by standard fi gure -of-eight sutures performed with the robot.
A mucosal fl ap technique with an offset mucosotomy has
been proposed as a way to both access the submucosal for
therapeutic reasons (e.g., Heller myotomy [11]) as well as
provide a “fl ap ” to avoid the need to close NOTES viscerotomies [12]. This technique involves an initial mucosal “lift”
created with submucosal saline injection and a subsequent
small mucosal incision to insert the fl exible endoscope into
the submucosal space. The submucosal tunnel is then
mechanically dissected with a dilating balloon, high -pressure
CO
or with needle knife cautery (Video 6.1). After a vari-
2
able length of tunneling, the muscle and serosal layers can
be breached for access to the mediastinum or abdomen
(Figure 6.1). The overlying mucosa serves as a biologic safety
fl ap valve, to control contamination and provide secure
closure. Maximum security is typically provided by clipping
the mucosotomy closed with endoscopic clips, but other
innovative ways without closure have been described.
In the esophagus, the use of covered esophageal stents has
been proposed as an alternative to closing mucosotomies
with the tunneling technique. One animal survival study of
mediastinal access with the “fl ap ” technique compared no
closure to no closure and a covered stent [13]. Interestingly,
it was observed that the stent actually signifi cantly interfered with mucosectomy site healing. On the other hand,
the unstented group achieved complete re -epithelialization
and healing. This indicates that, at least hypothetically, the
submucosal tunnel itself might act as a secure closure and
would not require to be closed by clips or suturing devices.
The mucosal fl ap technique described above has also been
evaluated for the transgastric access [14]. Although certainly
an appealing method to handle the closure of the gastric
viscotomy, it is a concern that the resulting additional bends
A method of gastrotomy access and closure using a conventional percutaneous endoscopic gastrostomy (PEG) tube has
been described, but leakage rates were observed to be high
[15]. Both intra -abdominal abscesses and peritoneal contamination were observed, rendering this method unappealing. A gastropexy closure technique has been reported in a
survival animal model [16]. Using three translumenal percutaneous stay sutures to mark the site of access (placed
under endoscopic visual control), the sutures were tied to
the abdominal wall to close the gastric hole. Although partly
successful in the animal as well as easy and inexpensive, it
certainly needs further evaluation as to its appropriateness
as a clinical closure technique for transgastric NOTES. In
their discussion, the authors discussed that adhesions resulting from gastrotomy tubes do not typically cause any long term complications.
NOTES was initially conceived as a fl exible endoscopic
approach via a transgastric route. However, due to a number
of reasons the most frequently used and published natural
orifi ce route currently appears to be the gynecological transvaginal access [6,17]. The primary reason for this is that safe
and simple direct suture closure of the culpotomy [18],
which can be managed by using open instruments, is well
established. Transvaginal access has a long history of use for
intraperitoneal surgical procedures. Transvaginal appendectomies at the time of hysterectomies were described as early
as 1949, and the gynecological community has an even
longer experience with transvaginal procedures and safe and
well-tolerated closure of the culpotomy.
Closure of the 1 –2 cm culpotomy incision is done with
exposure by a vaginal speculum and with traditional open
surgical instruments. Absorbable sutures are used and either
an interrupted or running suture technique can be used.
A recently published large case series has described the
fi rst 551 patients within the German NOTES registry [17].
Nearly all patients were operated transvaginally and the
resulting culpotomies were sutured with resorbable sutures.
Two cases of bleeding and one abscess in the pouch of
Douglas were reported in this series (0.6% complication rate
for closure). Another international multicenter trial of 362
patients also reported the majority of cases (88%) to be
performed via a transvaginal route with closure also accom-
60
plished by direct suturing [6]. One vaginal granuloma was
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described in this case series (0.3% closure complication).
Both reports observed that primary vaginal closure was safe
and simple.
Another well -documented “standard” surgical technique
is closure of rectal and rectosigmoid full -thickness excision
sites using transanal access. While transcolonic access initially received little attention – most likely due to a perceived
infection risk – recently it has become more interesting,
particularly for NOTES colon resections [19]. One particular
benefi t of a transanal/transrectal approach is the delivery of
substantially large specimens compared to other NOTES
access sites (Video 6.2). Incorporating the viscotomy into the
subsequent anastomosis simultaneously avoids the necessity
to breach an otherwise uninvolved organ.
With specialized retractors, it is possible to close a rectotomy, or perform an anastamosis, with standard surgical
instruments. This ability is limited to the distal 8 cm of the
rectum, which is almost always extraperitoneal. This makes
it suitable only if the rectum is being dissected out as part
of the primary procedure (e.g., low anterior resection) as it
otherwise subjects the patient to higher risks than more
proximal divisions. Sylla et al. have described this approach
– transanal rectal dissection with a subsequent traditional
hand-sewn coloanal anastamosis – in survival animals and
a human case with favorable results [20].
At a level of 12 –15 cm above the anal verge, the rectum
and recto -sigmoid are intraperitoneal, allowing easy access
to the peritoneal cavity. While this level is too high for
closure with standard surgical tools, there is a well established and validated surgical closure method available
in many larger hospitals. Transanal Endoscopic Microsurgery (TEM) (Richard Wolf, T übingen, Germany) is a surgical
platform that has been available for more than 30 years and
has been used for the resection of rectal polyps and early
rectal cancer [21]. This operating proctoscope permits a
surgeon to perform full -thickness suture repairs under direct
vision using laparoscopic like instrumentation (Figure 6.2,
Video 6.3). The safety of these transanal closures has been
well documented [22]. The use of TEM or related devices in
NOTES in both laboratory and clinical cases is described as
well [20,23–25].
While transanal suturing by TEM is possible, it is technically demanding and, optimally, standard end -to-end anastomosis (EEA) staplers would be used. This has been
described in cadaver NOTES studies for transanal rectosigmoid resections. As described by Whiteford and colleagues,
after transanal delivery and resection of the rectosigmoid, a
stapler anvil was subsequently sutured into the proximal
colon using a purse string suture with the suture tail left
long for later manipulation and connection to the EEA
stapler. After the bowel was returned into the abdomen the
proctoscope was reinserted and the pneumoperitoneum/ rectum was re -established. An additional purse string suture
CHAPTER 6 NOTES Closure Techniques
Figure 6.2 The TEM system allows laparoscopic -like suturing abilities
transanally up to 20 cm.
was placed at the proximal end of the open rectum and the
previously placed anvil was delivered into the rectal stump
using the long suture tails as a handle. The rectal purse string
suture was tightened intracorporeally, keeping the anvil in
place and the anvil shaft and center rod were joined and
fi red [23] (Video 6.4). Although certainly feasible, a more
recent study has found one insuffi cient anastomosis in four
cadaver specimens while using this closure approach [26].
However, having the possibility to re -establish the pneumorectum by the TEM rectoscope allows direct inspection and
potential suture salvage of the anastomosis.
Endoscopic clips
One of the fi rst descriptions of closing an intentional gastric
viscotomy for NOTES was given by Kalloo and colleagues
[4]. Conventional endoscopic clips were used for the closure
of gastric wall incisions, after transgastric examination of
the abdominal cavity in an experimental animal survival
model. Four to six clips were necessary to suffi ciently close
the dilated gastric incision. No failure or complication was
observed after a two -week survival period. Rao and Reddy
also reported the use of this method for closure of the
transgastric fl exible endoscopic access during their fi rst
reported clinical NOTES appendectomies and liver biopsies.
Although apparently feasible, the use of endoclips, which
were designed for intralumenal hemostasis, only approximates the mucosa rather than a full thickness closure including muscularis propria and serosa (Video 6.5). Closing the
access site with clips alone is therefore expected to be inferior to standard closures.
Some groups have developed and evaluated novel ways
of adding to endoclip closures to hopefully make them more
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