A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery - Experimental models, techniques, and applicability to the clinical setting

Objective: Evaluation of models, techniques, outcomes, pitfalls, and applicability to the clinical setting of natural orifice translumenal endoscopic surgery (NOTES) for performing intra-abdominal surgery through a systematic review of the literature. Summary Background Data: NOTES has attracted much recent attention for its potential to allow traditional surgical procedures-to be performed entirely through a natural orifice. Amid the excitement for potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated. Methods: Studies were identified by searching MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Library, Entrez PubMed, Clinical Trials Database, National Health Services Centre for Reviews and Dissemination (NHS CRD) databases, and National Research Register from 2000 to June 2007. Studies identified in September 2007 were included if they were performed in live human subjects. Results: Of the 34 studies included for review, 30 were experimental studies conducted in animals, thus the evidence base was very limited. Although intra-abdominal access could be achieved reliably via oral, anal, or urethral orifices, the optimal access route and method could not be established. Viscerotomy closure could not be achieved reliably in all cases and risk of peritoneal infection has not been adequately minimized. Although the majority of interventions could be performed in animals using NOTES, a number of technical problems were encountered that need to be resolved. Conclusions: NOTES is still in early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-managed human studies need to be conducted to determine the safety and efficacy of NOTES in a clinical setting.