Natural Orifices Trans-lumenal Endoscopic Surgery

NOTES: innovative surgical technique. Surgical operations without opening the abdomen – natural openings in the body are used for access – Europe's first gallbladder removal performed in France

(Paris, 30 October 2007)- "In future it may be possible to perform gastroenterological operations, for example on the gallbladder or the appendix, without the need for abdominal incision. The new technique is called NOTES (Natural Orifices Trans-lumenal Endoscopic Surgery). It is still under trial, and makes use of the natural body orifices such as the mouth, rectum or vagina to access the surgery area in the abdominal cavity. Europe's first gallbladder removal using this technique was recently performed at Strasbourg University Hospital, France, said scientists at the United European Gastroenterology Week (UEGW) in Paris, the largest European convention of its kind."

"'NOTES has the potential to refute the old rule that surgery always involves anatomical damage,' said Prof. Jacques Marescaux from Strasbourg. And the statement by Prof. Paul Fockens from Amsterdam, Netherlands, was similar: 'NOTES is a brand new development, with great potential.' He went on to explain that the procedure, which is currently undergoing testing and has so far only been used a few times on humans, eliminates external scars, reduces pain from surgery, and shortens healing time.

NOTES is regarded as the logical development from open surgery, via minimally invasive laparoscopic surgery (also known as 'keyhole surgery'), to a form of treatment which permits surgical procedures in the abdominal cavity without external injury. Prof. Marescaux and his team are among the pioneers in development of this new surgical technique. 'We have performed more than 225 operations of this kind on living pigs between 2005 and 2007. The procedures included removal of the gallbladder, adrenal glands, pancreas, spleen, and sections of the colon. We inserted the necessary surgical instruments into the abdominal cavity through high-performance, very flexible endoscopes, using natural body orifices'."

First operation conducted without complications
"The experience gained by the physicians in these tests was extremely valuable for Europe’s first NOTES operation on a human being – removal of the gallbladder from a female patient in Strasbourg in May 2007, with insertion of the surgical instruments through the vagina, piercing of the rear surface and thus penetration into the abdominal cavity. 'The operation was performed by a multidisciplinary team, including a gastroenterologist and a gynaecologist,' explained Prof. Marescaux. The operation was completed with no complications – all the principles applied in conventional laparoscopic gallbladder removal (cholecystectomy) were strictly applied; at no time in the operation was additional access by abdominal incision considered. 'The patient had no post-operative pain, no externally visible scars, and was able to go home as early as the second day after the operation'."

Rapid development, but not all questions have been answered
"Since then, a similar procedure has also been performed in Hamburg, and a little later an appendectomy was successfully performed in Rostock, Germany. It is thought that around 100 NOTES procedures have now been performed worldwide. Development is moving very fast, but not all the questions have been completely answered – firstly, many experts fear greater risk of infection if the wall of the stomach is pierced following access via the mouth, or if the colon has to be perforated in the case of rectal access. That could allow bacteria to get into the abdominal cavity, with the risk of dangerous peritonitis (inflammation of the lining of the abdominal cavity). And secondly, new technical devices are needed, for example to close wounds or for better visualisation of the operating area."

UEGF has initiated research programme EURO-NOTES Foundation:
"There are now various research programmes which are working intensively on the new surgical technique. The European Association for Endoscopic Surgery (EAES) and the European Society of Gastrointestinal Endoscopy (ESGE), both partnering in the UEGF, have launched the EURO-NOTES Foundation, headed by Prof. Fockens. It held its first convention in Göteborg, Sweden, in September 2007. Like the American gastroenterologists and surgeons, the European experts are also calling for intensive training of operating staff, for the establishment of national and international registers of all NOTES operations, and for comparative studies between laparoscopic operations and NOTES. 'These measures are intended as a precaution,' said Prof. Fockens, 'to prevent over-hasty introduction of this surgical method, which undoubtedly offers great hopes, but is still at the research stage'."

"NOTES could be used for the majority of gastroenterological procedures"
"'In parallel, intensive work is being done on technical improvements,' said Prof. Marescaux. New computer-aided systems, which provide 3D images from the inside of the body and automatically control the endoscope, are currently undergoing clinical trials. He is optimistic about the results: 'We know from trials that the majority of gastroenterological operations that are done by laparoscopy could also be done with NOTES. That will become apparent in the course of time in clinical practice, too. The future lies in the development of endoscopic computer and robot systems which make the operator’s work easier, and give the patient even more reliable results'."


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