NOTES: Transvaginal Endoscopic Appendectomy

Abstract

Natural orifice transluminal endoscopic surgery (NOTES) (Halim and Tavakkolizadeh, Int J Surg 6:273–276, 2008) is an surgical technique whereby “scarless” abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, urethra, anus, etc.) then through an internal incision in the stomach, vagina, bladder (Lima et al., J Urol 176:802–805, 2006) or colon, thus avoiding any external incisions or scars (Baron, Br J Surg 94:1–2, 2007).

This technique has been used for diagnostic and therapeutic procedures in animal models, including transgastric (through the stomach) organ removal. Most recently, the transvesical and the transcolonic approaches have 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 (Fong et al., Gastrointest Endosc 65:312–318, 2007; Pai et al., Gastrointest Endosc 64:428–434, 2006).In this sequence, a group from Portugal used transgastric and transvesical combined approach to increase the feasibility of moderately complex procedures such as cholecystectomy (Rolanda et al., Gastrointest Endosc 65:111–117, 2007). 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). Auyang ED and colleagues reported human cholecystectomy using hybrid NOTES technique in 2009 (Auyang et al., J Gastrointest Surg 13:1149–1150, 2009). Totally transvaginal cholecystectomy has been described in experimental model without using laparoscopic assistance (Sánchez-Margallo et al., Minim Invasive Ther Allied Technol 17:361–364, 2008). In late 2008, surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. The surgery was called transvaginal donor kidney extraction (Surgeons remove healthy kidney through vagina. InfoNIAC.com. http://www.infoniac.com/health-fitness/remove-healthy-kidney-through-vagina.html).

The transvaginal access to NOTES seems to be the most safe and feasible for clinical application. In early March 2007, the NOTES Research Group in Rio de Janeiro, Brazil, led by Dr. Ricardo Zorron, performed the first series of transvaginal NOTES cholecystectomy in four patients, based in previous experimental studies. With fewer potential complications, the procedure has a disadvantage of being possible only in women.

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 lower anesthesia requirements, faster recovery and shorter hospital stays, avoidance of the potential complications of transabdominal wound infections (e.g. hernias), less immunosuppression, better postoperative pulmonary and diaphragmatic function, and the potential for “scarless” abdominal surgery. Critics challenge the safety and advantages of this technique in the face of effective minimally invasive surgical options such as laparoscopic surgery.