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Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique whereby "scarless" abdominal operations could be performed with an endoscope passed through a natural orifice (mouth, anus, etc.) then through an internal incision in the stomach or colon, thus avoiding any external incisions or scars.^[1]

This technique has been used for diagnostic and therapeutic procedures in animal models, including transgastric (through the stomach) organ removal. Most recently, a transcolonic approach has been advocated by some researchers as being more suited to access upper abdominal structures that are often more difficult to work with using a transgastric approach. ^{[2] [3]} NOTES was originally described in animals by researchers at Johns Hopkins University (Dr. Anthony Kalloo et al.), and was recently used for transgastric appendectomy in humans in India (by Drs. G.V. Rao and N. Reddy). Thus far there have been no published reports of its use in human patients in the United States.

Proponents and researchers in this field recognize the potential of this technique to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions. NOTES could be the next major paradigm shift in surgery, just as laparoscopy was the major paradigm shift during the 1980s and 1990s. Potential advantages include the need for reduced anesthesia requirements, faster recovery and hospitalization stays, avoiding potential complications of transabdominal wound infections (i.e. "hernias"), less immunosuppresion, better post operative pulmonary and diaphragmantic function, and the potential for "scarless" abdominal surgery. Critics challenge the safety and advantage of this technique in the face of effective minimally invasive surgical options such as laparoscopic surgery.

Contents 1 NOSCAR 2 NESA/NOS 3 External links 4 References

Senior leadership from the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal Endoscopic Suregons (SAGES) organized a working group of surgeons and gastroenterologists in 2006 to develop standards for the practice of this emerging technique. This group is known as NOSCAR or Natural Orifice Surgery Consortion for Assessment and Research. A White Paper on NOTES was released by NOSCAR simultaneously in two medical journals in May 2006. This paper identified the major areas of research needed to be addressed before NOTES can become a viable clinical application for human patient. These areas included development of a reliable closure technique for the internal incision, prevention of infection, and creation of advanced endoscopic surgical tools.

Parallel to the NOTES (Natural Orifice Translumenal Endoscopic Surgery) working group which looks beyond existing horizons and concentrates on the transgastric peritoneal access, the New European Surgical Academy (NESA) founded the NOS (Natural Orifice Surgery) working group which is exploring another surgical route, the Transdouglas one. The term difference is not accidental. "T" in NOTES stands for Transluminal. NOS includes NOTES because it refers to all surgical procedures performed through natural openings like mouth, nose, urethra and vagina. The NESA designed a new surgical device, the TED (Transdouglas Endoscopic Device) adapted to pelvic anatomy. The TED is a wide multi-channel flexible instrument enabling surgical procedures in the upper abdomen (cholecystectomy, liver biopsy, splenectomy etc.) as well as in the pelvis (hysterectomy, cystectomy, etc.) by using a single entry. The members of the European NOS working group are internationally renowned scientists, physiologists, pharmacologists and surgeons from various disciplines. The first meeting was on June 23, 2006 in Berlin. The planned procedures have already been simulated and preclinical studies will start soon. The NESA strongly believes that in the future, this new approach using the body natural openings and “traditional” endoscopic operations will complement one another.

• NOSCAR
• ASGE
• SAGES
• NOTES White Paper

• NESA
• NOS/SLO: Natural Orifice Surgery/Scarless Operations working group

1. ^ Baron, TH (2007 Jan). "Natural orifice transluminal endoscopic surgery.". Br J Surg 94 (1): 1-2.. PMID 17205508 DOI:10.1002/bjs.5681. Retrieved on 2007-02-24. 
2. ^ Fong, DG; Pai RD Thompson CC (Feb 2007). "Transcolonic Abdominal Exploration: A NOTES survival Study". Gastrointestinal Endoscopy 65 (2): 312-8. PMID 17173916. 
3. ^ Pai, RD; Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (Sept 2006). "Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model". Gastrointestinal Endoscopy 64 (3): 428-34. PMDI 16923495.