Purpose: Natural orifice translumenal endoscopic surgery (NOTES) is a novel concept that provides the potential for performance of incisionless imaging and operations. The method of accessing the abdominal cavity through a natural orifice under endoscopic visualization might offer advantages over open and laparoscopic surgery. The purpose of this study is to develop novel endoscopic technology and procedure to overcome the limitations of intra-abdominal and retroperitoneal imaging and surgery that is used to be invisible. Methods: We performed NOTES intra-retroperitoneoscopy in 2 human cadaver and 12 survival porcine and canine studies. After perforation of the gastric, colonic, and vaginal wall, a flexible double-channel scope was advanced into the peritoneal cavity and retroperitoneal space under endoscope-induced carbon dioxide insufflation. After performing observations and surgical procedures, the wall was closed using a suturing system or endoscopic clips. Results: The endoscope could visualize each objective organ in all 14 attempts. Following liver biopsy or lymph node removal, GI anastomosis or intestinal resection were also accomplished using a standard flexible endoscope without laparoscopic assistance. Animal NOTES cholecyctectomy was completed in 6 transgastric, 2 transcolonic, and 2 transvaginal access. Transgastric intestinal resection was performed in 4 procedures. No acute complications were recorded. The submucosal, intramuscular and retroperitoneal imaging could be allowed histological diagnosis. Human cadaver NOTES transvaginal cholecystectomy and appendectomy were also completed within 90 and 40 minutes without major complications. Conclusions: Our study described the use of translumenal endoscopy to accomplish intra-abdominal surgeries. This could reach to the invisible space using standard modalities. Scarlesss intra- and retroperitoneal imaging of NOTES is technically feasible and safe in either human or animal study. CLINICAL RELEVANCE/APPLICATION: NOTES procedure is enormously advantageous to the patient. This would break the physical barrier between bodily trauma and surgery, representing the revolution in surgery.
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