NOTES is the complicated medical acronym for what is otherwise known as scarless surgery and includes revolutionary surgical procedures to the abdomen. Initial steps were taken in the late 1990’s and, after a long period of research, it is now finding its way into the daily practice of surgeons operating in the abdominal cavity.
NOTES stands for Natural Orifice Transluminal Endoscopic Surgery.
Natural Orifice because the technique avoids making visible scars by using natural orifices (such as mouth, vagina, anus, urethra,…) to gain access to the abdominal cavity.
Transluminal because the access is not directly through the abdominal wall, as it is in classical laparoscopic surgery, but goes through the lumen ,or cavity,of another organ (eg stomach, vagina, rectum, bladder,…).
Endoscopic because the surgeon does not touch the organs with his hands under direct vision as in open surgery, but uses a camera that projects the image on a screen and uses long and fine instruments.
Interventions in the abdomen have traditionally been performed by laparotomy (i.e. by making a large incision in the abdominal wall). In the 1980’s and 1990’s the first major paradigm shift occurred in abdominal and pelvic surgery, laparoscopic surgery was introduced. Operations could be performed through several very small incisions, instead of through one large incision, using a camera and long fine instruments. This less invasive approach allowed quicker recovery and a cosmetically more appealing result. After a period of skepticism, it has now become commonplace in all disciplines of abdominal and pelvic surgery (gynaecology, gastro-intestinal surgery, urology,…).
NOTES is now the next paradigm shift. After a period of thorough research, it has now become a realistic alternative for open and laparoscopic surgery for multiple abdominal procedures, mainly in gynaecological and gastro-intestinal surgery. Besides the obvious aesthetic advantage of not creating any visible scars, other potential advantages include less surgical wound infection, fewer abdominal wall hernias and less abdominal wall pain, all leading to a quicker recovery and shorter hospitalisation.
In addition to no visible scarring, potential advantages of NOTES surgery include:
NOTES procedures can be performed via different access routes.
Transgastric (gNOTES): via the mouth, the peritoneal cavity is accessed by making a small hole in the stomach
Transvaginal (vNOTES): the peritoneal cavity is accessed by making a small opening in the top of the vagina
Transanal (aNOTES or TAMIS): via the anus by opening the large intestine
Transurethral (uNOTES): the peritoneal cavity is accessed by making a small opening in the bladder.
Currently the transvaginal approach is most commonly used as it provides the easiest access and has thus far proved to be the safest. This approach has the disadvantage of only being possible in women.
NOTES procedures were first performed in 2007 and are currently mostly used for simple to moderately complex operations, such as appendectomy (removal of appendix), cholecystectomy (removal of gallbladder), adnexectomy (removal of ovary and Fallopian tube), ovarian cystectomy (removal of ovarian cyst), treatment of ectopic pregnancy, fertility exploration, hysterectomy (removal of the uterus),…
In a research setting, more complex organ resections have been reported, such as colon resections, sleeve gastrectomy (removal of part of the stomach), abdominal wall hernia repair, nephrectomy (removal of kidney), splenectomy (removal of spleen), pancreatectomy (removal of pancreas), adhaesiolysis (removal of adhaesions), …
NOTES initially started out as a technique for operations in the peritoneum (abdominal cavity), but the approach is now also being researched for other compartments in the body. For example, operations to the vertebral column, approach to the mediastinum and heart via the esophagus, transgastric approach for intrauterine interventions in pregnant animals,...
As with any open or laparoscopic operation, NOTES operations do have potential complications. These vary depending on the operation and we would advise you to discuss these thoroughly with your experienced NOTES surgeon before the procedure.