Direct target NOTES: prospective applications for next generation robotic platforms



A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative.


During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy.


Feasibility was demonstrated in all cases using the Flex® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min.


A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.

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Correspondence to S. Atallah.

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Conflict of interest

S. Atallah is a paid consultant for ConMed, Inc, Applied Medical, Inc, THD, America, and has an ongoing consultant relationship with Medicaroid Robotics and MedRobotics, Inc. This research was supported by MedRobotics, division of Colorectal Surgery, Research and Development. The other authors declare that they have no conflict of interest.

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This research was performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was not applicable as the work represented herein did not involve human subjects. Cadaveric research was conducted in accordance with the standards set forth by ethics and scientific laboratory regulations.

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Atallah, S., Hodges, A. & Larach, S.W. Direct target NOTES: prospective applications for next generation robotic platforms. Tech Coloproctol 22, 363–371 (2018) doi:10.1007/s10151-018-1788-z

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  • Minimally Invasive Surgical Procedures
  • Surgical Procedures, Robotic
  • Natural Orifice Endoscopic Surgery
  • Hysterectomy, Vaginal
  • TaTME
  • Appendectomy