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Published on: August 29, 2025
NOTES: a review of the technical problems encountered and their solutions
Yoav Mintz1, Santiago Horgan, John Cullen
1Department of Surgery, University of California-San Diego, San Diego, California 92103-8400, USA. ymintz@ucsd.edu
Summary
Natural orifice translumenal endoscopic surgery (NOTES) faces technical challenges. A hybrid approach using laparoscopic vision in pigs overcame issues like incision, vision, and suturing, paving the way for future NOTES development.
Area of Science:
- Minimally Invasive Surgery
- Surgical Innovation
- Gastrointestinal Endoscopy
Background:
- Natural orifice translumenal endoscopic surgery (NOTES) is a developing field with significant technical hurdles.
- Current limitations in NOTES include uncontrolled pneumoperitoneal pressure, inadequate visualization, and complex suturing.
- Existing endoscopic tools pose challenges for safe and effective NOTES procedures.
Purpose of the Study:
- To review the technical problems encountered in Natural orifice translumenal endoscopic surgery (NOTES).
- To propose temporary solutions and novel techniques to overcome these challenges.
- To evaluate the feasibility of a hybrid approach for advancing NOTES.
Main Methods:
- Acute and survival studies were conducted on 15 farm pigs.
- A hybrid technique combining endoscopic surgery with laparoscopic vision was employed.
- Procedures included liver biopsy, tubal ligation, oophorectomy, cholecystectomy, splenectomy, and small bowel resection with anastomosis.
Main Results:
- All surgical procedures were successfully completed.
- Novel methods were developed to address technical difficulties in NOTES.
- Gastrotomy closure utilized T-bar sutures and stapling; small bowel anastomosis was achieved via a dual-lumen NOTES technique.
Conclusions:
- The hybrid technique provides a temporary solution to facilitate NOTES development.
- Utilizing rectal or vaginal entry ports with laparoscopic instruments aids gastrointestinal NOTES.
- While common laparoscopic operations may be feasible with NOTES, safety requires further determination.
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