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Natural orifice transluminal endoscopic surgery (NOTES)

Pankaj J Pasricha, MD
Homero Rivas, MD, MBA, FACS
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editors
Kristen M Robson, MD, MBA, FACG
Wenliang Chen, MD, PhD


Natural orifice transluminal endoscopic surgery (NOTES) is an emerging field within gastrointestinal surgery and interventional gastroenterology in which the surgeon accesses the peritoneal cavity via a hollow viscus and performs diagnostic and therapeutic procedures. NOTES is evolving rapidly, presenting seemingly limitless possibilities for innovation, technique, and device development.


The concept of flexible transluminal endoscopy, a term used before NOTES was coined, was first developed by a multicenter team of investigators (the Apollo Group) in the late 1990s [1]. The publication of the initial animal studies generated a wave of enthusiasm, and many centers began experiments of their own, using the NOTES approach for a variety of operations [2]. These have ranged from diagnostic explorations of the peritoneal cavity to complex organ resections including pancreatectomy, splenectomy, and nephrectomy [3-5].

The initial approach was transgastric, but more recently NOTES has been performed through several other orifices, resulting in transcolonic, transvaginal, and transurethral/transcystic approaches. The approach has also been extended from the peritoneum to other compartments in the body, such as transesophageal approaches to the mediastinum and heart, transgastric intrauterine interventions in pregnant animals, and novel approaches to the vertebral column [6-9].

Given this flurry of activity and mounting enthusiasm, in 2005 the American Society of Gastrointestinal Endoscopy and the Society of Gastrointestinal Endoscopic Surgeons came together in a consortium (the Natural Orifice Surgery Consortium for Assessment and Research) to provide consensus and guidelines on how best to bring this procedure to the clinical mainstream. In the last few years, an increasing number of NOTES procedures in humans have been performed. However, technological limitations of the current flexible platforms have been a major challenge, limiting the adoption of this approach (to date) to a few major medical centers. Nevertheless, while it is still too early to predict its ultimate role and value, it is clear that NOTES has dramatically altered our perceptions of how to approach gastrointestinal surgery.

A strong argument can be made that NOTES has been instrumental in the resurgence of lesser invasive surgical techniques such as single-incision laparoscopic surgery, which for some may represent a bridge to NOTES [10-14]. Furthermore, developmental efforts in NOTES have resulted in numerous advanced surgical and endoscopic technologies that are now being applied in conventional laparoscopic and endoscopic techniques.

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Literature review current through: Nov 2017. | This topic last updated: Jul 10, 2017.
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