Scarless endoscopic surgery: NOTES or TUES

Abstract

Dear editor, It has been three years since Kalloo et al. [1] published their experimental report on natural orifice transluminal endoscopic surgery (NOTES). The author concluded that peroral transgastric approach to the peritoneal cavity was feasible and offered the potential for a wide range of endoscopic surgery with the possible advantage of improved patient recovery, reduced need for anesthesia, and better cosmetic results. In recent years, several more studies have been performed including tubal ligation, gastrojejunostomy, cholecystectomy, splenectomy and so on. Almost all the published data are based on animal surgeries [2]. Marescaux et al. from Strasburg completed the world first transvaginal endoscopic cholecystectomy on April 2 2007 (http://www.websurg.com), which is the first typical clinical NOTES surgery. Many endoscopic physicians are showing great interest in this new technique. New instruments specially designed for NOTES surgery have been developed which include suturing devices, the R scope, transport, the cobra [3], minirobots [4], and so on. However, few clinical reports have appeared to date. The major barriers that limit clinical application include access, closure, infection, suturing technology, orientation [5]. Considering the limitations to NOTES mentioned above, we develop a new access technique, known as transumbilical endoscopic surgery (TUES), according to the NOTES principle. On May 21 2007, we successfully completed our first TUES surgery: transumbilical endoscopic liver cyst fenestration using a standard flexible endoscope, followed by endoscopic abdominal exploration and appendectomy. The TUES technique we have developed needs only one 12-mm trocar in the umbilicus similar to standard laparoscopic surgery. The flexible endoscope is inserted through the trocar and surgery is performed using the instruments through the working channels in the endoscopy. The incisions were sutured with no visible scars on the abdomen except for a small incision if drainage was necessary after operation. Compared with the NOTES technique, TUES can obtain similar scarless results on the abdomen, and theoretically has the same advantages of rapid recovery, less need for anesthesia, and better cosmetic results. The orientation in TUES surgery is easily controlled by an assistant so the operators can get better images similar to with standard laparoscopic surgery. Almost all the present barriers to NOTES surgery such as access, infection, closure of the stomach, incision, and orientation can be resolved by using this TUES technique. TUES is much simpler and safer than the standard NOTES technique. Undoubtedly, TUES will be a hopeful option for scarless abdominal surgery.