Natural Orifice Translumenal Endoscopic Surgery: Current Status

Abstract

A lthough laparoscopy has been performed for over three decades, the field of minimally invasive surgery did not blossom until the introduction of the charge coupled device chip, which enabled videoendoscopy. Shortly after laparoscopic cholecystectomy was introduced in the late 1980s, surgeons and patients rapidly appreciated the benefits conferred by smaller incisions and minimal tissue trauma. Within 4 years of the first laparoscopic cholecystectomy, nearly every minimally invasive abdominal surgical procedure in use today had been attempted. Currently, laparoscopic surgery is the method of choice for treating most common intra-abdominal conditions. While the laparoscopic surgical revolution was occurring, similar progress was made in therapeutic flexible endoscopy. The introduction of percutaneous endoscopic gastrostomy (PEG) by Ponsky and Gauderer [1] in 1981 established the principle that the lumen of the gastrointestinal tract could be safely violated with a flexible endoscope to perform a surgical procedure. Just as few would have predicted that nearly all common duct stones and many pancreatic pseudocysts would one day be treated nonsurgically, few would have foreseen the PEG technique as an access route to the peritoneal cavity. Once Baron and others [2–4] showed that even complex pancreatic fluid collections could be managed transgastrically, the potential of flexible endoscopes to do more than simple endoscopy was further appreciated. These advances paved the road for an emerging field with possibilities beyond even the most sophisticated therapeutic endoscopic techniques. Natural orifice translumenal endoscopic surgery (NOTES) was introduced as a new approach that might help eliminate the pain and morbidity associated with abdominal wall trauma in laparoscopic surgery. In 2004, Kalloo and colleagues [5] published the first description of this technique. The Hopkins group demonstrated the feasibility of performing transgastric peritoneoscopy with a flexible endoscope. Using a porcine model, they created a gastrotomy with a needle knife sphincterotome, dilated the gastrotomy with an 18-mm balloon, and performed peritoneoscopy. On completion of the