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| '''For the WikiPatient page for this topic, click [[Natural orifice translumenal endoscopic surgery (NOTES) (patient information)|here]]''' | | '''For the WikiPatient page for this topic, click [[Natural orifice translumenal endoscopic surgery (NOTES) (patient information)|here]]''' |
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| '''Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@perfuse.org] | | '''Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:moh_sbeih@hotmail.com]Phone: 617-849-2629; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu] |
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| '''Related Key Words and Synonyms:''' Natural Orifice Translumenal Endoscopic Surgery, Single Incision Laparoscopic Surgery, Minimally Invasive Surgery, Transanal Endoscopic Microsurgery, Natural Orifice Surgery Consortium for Assessment and Research. | | '''''Synonyms and keywords:''''' Natural orifice translumenal endoscopic surgery, Single incision laparoscopic surgery, Minimally invasive surgery, Transanal endoscopic microsurgery, Natural orifice surgery consortium for assessment and research, Society of american gastrointestinal and endoscopic surgeons. |
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) overview|Overview]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) overview|Overview]]== |
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) potential applications|Potential Applications]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) potential applications|Potential Applications]]== |
| NOTES procedures have been performed through different natural orifices. So far, transvaginal approach is the most commonly used and has the highest success rate for certain procedures.
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| ===Transvaginal NOTES===
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| This is the most common apprach to be used in NOTES procedures. This approach has been used for cholecystectomy, appendectomy, colon resections, abdominal wall hernia repair, and sleeve gastrectomy <ref name="pmid20620259">{{cite journal |author=Chukwumah C, Zorron R, Marks JM, Ponsky JL |title=Current status of natural orifice translumenal endoscopic surgery (NOTES) |journal=Curr Probl Surg |volume=47 |issue=8 |pages=630–68 |year=2010 |month=August |pmid=20620259 |doi=10.1067/j.cpsurg.2010.04.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0011-3840(10)00075-4 |accessdate=2012-02-27}}</ref>. Transvaginal fertility procedures and oocytes procurement transvaginally has been performed for years <ref name="pmid3103035">{{cite journal |author=Schulman JD, Dorfmann AD, Jones SL, Pitt CC, Joyce B, Patton LA |title=Outpatient in vitro fertilization using transvaginal ultrasound-guided oocyte retrieval |journal=Obstet Gynecol |volume=69 |issue=4 |pages=665–8 |year=1987 |month=April |pmid=3103035 |doi= |url= |accessdate=2012-03-06}}</ref>. Transvaginal cholecystectomy and transvaginal appendectomy have been performed in humans. Around 85% of the Notes procedures that have been reported in Germany is transvaginal cholecystectomy (the most common) <ref name="pmid20585238">{{cite journal |author=Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ |title=The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients |journal=Ann. Surg. |volume=252 |issue=2 |pages=263–70 |year=2010 |month=August |pmid=20585238 |doi=10.1097/SLA.0b013e3181e6240f |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181e6240f |accessdate=2012-02-27}}</ref>. There are many advantages for this approach which include:
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| :*The organ (Gallbladder, appendix or others) can be extracted easily outside the body through the flexible walls of the vagina even the large organs.
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| :*It is relatively easier and safer to perform the procedure through this approach. Vaginal wall closure is less complex than gastric wall closure and has less complications rate <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>. A single stitch can be easily used to close the incision.
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| :*In general, transvaginal NOTES has lower complications rates than other approaches.
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| :*Transvaginal rout is considered the best rout for performing minor uterine procedures for benign uterine diseases <ref name="pmid17493374">{{cite journal |author=McCracken G, Lefebvre GG |title=Vaginal hysterectomy: dispelling the myths |journal=J Obstet Gynaecol Can |volume=29 |issue=5 |pages=424–8 |year=2007 |month=May |pmid=17493374 |doi= |url= |accessdate=2012-03-06}}</ref>.
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| :*Sexual function is not affected by transvaginal extraction of the uterus or other organs <ref name="pmid15167858">{{cite journal |author=Roussis NP, Waltrous L, Kerr A, Robertazzi R, Cabbad MF |title=Sexual response in the patient after hysterectomy: total abdominal versus supracervical versus vaginal procedure |journal=Am. J. Obstet. Gynecol. |volume=190 |issue=5 |pages=1427–8 |year=2004 |month=May |pmid=15167858 |doi=10.1016/j.ajog.2004.01.074 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002937804001590 |accessdate=2012-03-06}}</ref>.
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| The drawback of this approach is that it can be used only in females. Also, the NOTES surgeon should have the basics of gynecological surgery before perform a transvaginal procedure. Women may present with dyspareunia and infertility after the procedure, also there is a potential risk for [[urinary tract infection]] after cannulation of the urinary bladder (required in transvaginal NOTES procedures). There is a risk for injury to nearby organs, the rectum and the sigmoid colon are at higher risk than other structures, that is why visualizing the pelvis directly by a laparoscope (through the trocar site) may be a safe method to ensure there are no injuries for pelvic organs.
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| Transvaginal approach may have higher incidence rates for certain complications (bladder injury and vaginal hematoma) than other surgical approaches <ref name="pmid11344430">{{cite journal |author=Milad MP, Morrison K, Sokol A, Miller D, Kirkpatrick L |title=A comparison of laparoscopic supracervical hysterectomy vs laparoscopically assisted vaginal hysterectomy |journal=Surg Endosc |volume=15 |issue=3 |pages=286–8 |year=2001 |month=March |pmid=11344430 |doi=10.1007/s004640000328 |url=http://link.springer-ny.com/link/service/journals/00464/bibs/1015003/10150286.html |accessdate=2012-03-06}}</ref>.
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| Transvaginal cholecystectomy are usually performed with a single 5mm umbilical port. An additional 3mm transabdominal port can be used as a safety precaution in few cases <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>. The average operating time to perform the procedure is 2 hours. Blood loss is less than 50 ml in most cases <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>. Using the laparoscopic hook which is inserted via the umbilical port to dissect the gallbladder from the liver is considered easier, quicker and safer than the dissection by using the smaller size endoscopic hook <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>. Currently, laparoscopic clipping of the cystic duct is the safest and most secured method for securing the duct <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>. More occlusive endoscopic clips and instrumentation should be developed.
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| In transvaginal NOTES (and most NOTES procedures), insufflation through a laparoscopic port (which can be used also for single laparoscopic instrument insertion) is better controlled than endoscopic insufflation <ref name="pmid17404796">{{cite journal |author=Meireles O, Kantsevoy SV, Kalloo AN, Jagannath SB, Giday SA, Magno P, Shih SP, Hanly EJ, Ko CW, Beitler DM, Marohn MR |title=Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery |journal=Surg Endosc |volume=21 |issue=6 |pages=998–1001 |year=2007 |month=June |pmid=17404796 |doi=10.1007/s00464-006-9167-7 |url=http://dx.doi.org/10.1007/s00464-006-9167-7 |accessdate=2012-03-05}}</ref>.
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| ===Transanal/Transrectal NOTES===
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| Transanal rectosegmoid resection using transanal endoscopic microsurgery (TEM) and laparoscopic assistance has been demonstrated to be feasible and safe in a swine survival model and in human cadavers <ref name="pmid20174948">{{cite journal |author=Sylla P, Sohn DK, Cizginer S, Konuk Y, Turner BG, Gee DW, Willingham FF, Hsu M, Mino-Kenudson M, Brugge WR, Rattner DW |title=Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model |journal=Surg Endosc |volume=24 |issue=8 |pages=2022–30 |year=2010 |month=August |pmid=20174948 |doi=10.1007/s00464-010-0898-0 |url=http://dx.doi.org/10.1007/s00464-010-0898-0 |accessdate=2012-02-28}}</ref>. Currently, there are clinical trials that aim to assess the oncological safety of this approach in treating benign and malignant colorectal tumors.
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| Transanal colorectal resection procedures requires a stable platform for endolumenal and direct translumenal access to the peritoneal cavity. The first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance has been performed successfully by a team of surgeons from Barcelona and Boston in 2009 <ref name="pmid20186432">{{cite journal |author=Sylla P, Rattner DW, Delgado S, Lacy AM |title=NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance |journal=Surg Endosc |volume=24 |issue=5 |pages=1205–10 |year=2010 |month=May |pmid=20186432 |doi=10.1007/s00464-010-0965-6 |url=http://dx.doi.org/10.1007/s00464-010-0965-6 |accessdate=2012-02-28}}</ref>. The progression and substantial improvement in NOTES instrumentation may optimize this approach to be widespread applied in humans, and may ultimately permit completely NOTES transanal colorectal resection instead of abdominoperineal resection (APR), low anterior resection (LAR) and laparoscopic colorectal resection procedures.
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| ===Transgastric NOTES===
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| Initially, there were difficulties in achieving orientation and navigation based on retroflection of the endoscopes to visualize the upper abdomen and perform upper abdominal procedures. Better results had been achieved for lower abdominal surgeries, such as pelvic surgery, tubal ligation, and appendectomy.
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| This NOTES approach is more sophisticated than the transvaginal one, especially in terms of gastric wall closure after extracting the organ (requires laparoscopic assistance <ref name="pmid20541750">{{cite journal |author=Nikfarjam M, McGee MF, Trunzo JA, Onders RP, Pearl JP, Poulose BK, Chak A, Ponsky JL, Marks JM |title=Transgastric natural-orifice transluminal endoscopic surgery peritoneoscopy in humans: a pilot study in efficacy and gastrotomy site selection by using a hybrid technique |journal=Gastrointest. Endosc. |volume=72 |issue=2 |pages=279–83 |year=2010 |month=August |pmid=20541750 |doi=10.1016/j.gie.2010.03.1070 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(10)01369-6 |accessdate=2012-02-27}}</ref>. Also, the complications rate is higher in this rout compared with transvaginal route. Trials in the field (on animal and cadaver models) are trying to create a new devices and techniques to simplify the stomach incision closure.
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| Appendectomy, cholecystectomy and cancer staging have been performed via this approach <ref name="pmid18614547">{{cite journal |author=Zorrón R, Soldan M, Filgueiras M, Maggioni LC, Pombo L, Oliveira AL |title=NOTES: transvaginal for cancer diagnostic staging: preliminary clinical application |journal=Surg Innov |volume=15 |issue=3 |pages=161–5 |year=2008 |month=September |pmid=18614547 |doi=10.1177/1553350608320553 |url=http://sri.sagepub.com/cgi/pmidlookup?view=long&pmid=18614547 |accessdate=2012-02-27}}</ref>. Retrieval of dislodged endoscopic gastrostomy tube via this approach has been reported as well <ref name="pmid17404790">{{cite journal |author=Marks JM, Ponsky JL, Pearl JP, McGee MF |title=PEG "Rescue": a practical NOTES technique |journal=Surg Endosc |volume=21 |issue=5 |pages=816–9 |year=2007 |month=May |pmid=17404790 |doi=10.1007/s00464-007-9361-2 |url=http://dx.doi.org/10.1007/s00464-007-9361-2 |accessdate=2012-02-27}}</ref>. however, all cases require Some degree of hybridization is required for all transgastric NOTES procedures. This approach can be used in all patients (males and females) but the extracted specimen (through the oral cavity) needs to be relatively smaller than those extracted by other routs.
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| In general, the following steps should be considered for most NOTES transgastric procedures:
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| *The patient should be in an overnight fasting state. General anesthesia is inducted and single dose intravenous antibiotics are administered (amoxicillin and metronidazole). The position of the patient is usually Lloyd-Davies position.
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| *Gastric lavage should be done before the procedure using chlorhexidine solution.
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| *The puncture site is chosen for adequate visibility to perform the procedure. The best areas of entry are the proximal body and the distal antrum (both are relatively avascular) <ref name="pmid18381176">{{cite journal |author=Rao GV, Reddy DN, Banerjee R |title=NOTES: human experience |journal=Gastrointest. Endosc. Clin. N. Am. |volume=18 |issue=2 |pages=361–70; x |year=2008 |month=April |pmid=18381176 |doi=10.1016/j.giec.2008.01.007 |url=http://linkinghub.elsevier.com/retrieve/pii/S1052-5157(08)00008-1 |accessdate=2012-03-05}}</ref>.
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| *A flexible endoscope is inserted via the oral cavity to the stomach, the puncture is made by a needle knife. The puncture site is dilated by an endoscopic balloon and and the scope is inserted into the peritoneal cavity.
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| *Intraperitoneal pressure is controlled using laparoscopic carbon dioxide insufflator and the procedure is performed. Usually 2 to 3mm trocars are used in the procedure.
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| *The puncture site is closed by a suturing device after extracting the specimen or the organ via the oral cavity.
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| Peritonitis and esophageal rupture may occur after transgastric procedures. In general, complications are more common in transgastric procedures than in transvaginal procedures.
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| ===Transesophageal NOTES===
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| This approach can be used for the management of achalasia (failure of relaxation of the lower esophageal sphincter that cause dysphagia). Many cases of per oral endoscopic myotomy (POEM) have been performed successfully to treat achalasia <ref name="pmid17703382">{{cite journal |author=Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ |title=Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia |journal=Endoscopy |volume=39 |issue=9 |pages=761–4 |year=2007 |month=September |pmid=17703382 |doi=10.1055/s-2007-966764 |url=http://www.thieme-connect.com/DOI/DOI?10.1055/s-2007-966764 |accessdate=2012-02-27}}</ref>.
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| Esophageal injuries could be prevented during performing the procedure by using gastroesophageal overtubes. The instruments and ports for transesophageal NOTES have more restrictions in their size and shape compared with other approaches.
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| Large organ (specimen) extraction is not suitable for this approach (a maximal diameter of 2 cm) according to the relatively smaller size of esophageal lumen compared with other hollow organs.
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| ===Transurethral/Transcystic NOTES===
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) future directions|Future Directions]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) future directions|Future Directions]]== |
| Operating on intensive care unit patients may be the future progression in NOTES procedures and may offer many benefits. Transgastric placement of diaphragm pacing for weaning the ICU patients from the ventilator may lead to several potential benefits over other methods of pacing <ref name="pmid17177078">{{cite journal |author=Onders R, McGee MF, Marks J, Chak A, Schilz R, Rosen MJ, Ignagni A, Faulx A, Elmo MJ, Schomisch S, Ponsky J |title=Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients |journal=Surg Endosc |volume=21 |issue=3 |pages=475–9 |year=2007 |month=March |pmid=17177078 |doi=10.1007/s00464-006-9125-4 |url=http://dx.doi.org/10.1007/s00464-006-9125-4 |accessdate=2012-02-22}}</ref>. This procedure could be performed at the bedside.
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| NOTES may become the preferred method to operate on selected patients (specific population). Morbidly obese patients and those with severe intra abdominal adhesions are good candidates for NOTES.
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| More studies should be conducted to find clear clarifications for the following issues <ref name="pmid18362621">{{cite journal |author=Flora ED, Wilson TG, Martin IJ, O'Rourke NA, Maddern GJ |title=A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting |journal=Ann. Surg. |volume=247 |issue=4 |pages=583–602 |year=2008 |month=April |pmid=18362621 |doi=10.1097/SLA.0b013e3181656ce9 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181656ce9 |accessdate=2012-02-29}}</ref>:
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| *The best and the safest way to traverse the wall of the lumen in order to get access to the organ.
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| *Controlling the complications of every single NOTES procedure.
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| *Improving spatial orientation to perform the procedure.
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| *The best closure for the translumenal incisional site. Methods of reliable full thickness, watertight closure for the puncture sites in different organs should be developed.
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| *Specific ways for organ extraction through the natural orifices.
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| *Methods to prevent infections during NOTES procedures.
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| *Anesthesia level requirement for every NOTES procedure.
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| *Optimal instrumentation and devices for every NOTES procedure.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) current technological developments|Current Technological Developments]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) current technological developments|Current Technological Developments]]== |
| The development of NOTES instruments is emerging to make these procedures feasible and safe. These instruments include platforms and many other tools, such as suturing devices and anastomotic (nonsuturing) devices <ref name="pmid18381169">{{cite journal |author=Mummadi RR, Pasricha PJ |title=The eagle or the snake: platforms for NOTES and radical endoscopic therapy |journal=Gastrointest. Endosc. Clin. N. Am. |volume=18 |issue=2 |pages=279–89; viii |year=2008 |month=April |pmid=18381169 |doi=10.1016/j.giec.2008.01.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S1052-5157(08)00006-8 |accessdate=2012-02-23}}</ref>. The new platform permits the performance of a large intraabdominal procedure in a faster and more accurate fashion.
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| University of California San Diego and Novare Endosurgical developed a new grasper that can be used in NOTES procedures through the same port of the endoscopes <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>. The grasper is long (around 75 cm) and can be articulated for flexible retraction even. In the same time, it is rigid enough to provide a stronger retraction than the endoscopic grasper <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-03-05}}</ref>.
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| The preferred way to gain access to the peritoneal cavity via a hollow viscus (lumen) is a very small incision (minimal) followed by a balloon expansion and dilatation. A tiny incision can be made using a sphincterotome or a needle knife.
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| Although a direct insertion of an endoscope and the NOTES instruments is possible, Overtube is usually used to permit multiple entries to the field the procedure and to perform complex maneuvers.
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| Current, there are many research studies by engineers which focuse on computer assisted imaging systems that provide additional 3-D information of the intervention site. Virtual off-axis view assists surgeons with a better visual depth perception during the intervention <ref>^ Hoeller, Kurt (2010). Novel Techniques for Spatial Orientation in Natural Orifice Translumenal Endoscopic Surgery (NOTES) (Ph.D.). Central Institute of Healthcare Engineering (ZiMT) at Friedrich-Alexander-Universitaet Erlangen-Nuernberg (FAU). ISBN 978-3-8322-9766-4</ref>. Video images can be rectified using the impact of gravity on a 3-axis accelerometer integrated in the tip of the endoscope <ref>^ WO application 2010105946, Gutiérrez Boronat, Javier; Jahn, Jasper; Schneider, Armin; Hoeller, Kurt, "Endoscope and Imaging Device", published 2010-09-23, assigned to Fraunhofer-Gesellschaft zur Foerderung der angewandten Forschung e.V.</ref>.
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| ==[[Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)|Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)]]== | | ==[[Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)|Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)]]== |
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| 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 who met in New York City on July 22 and 23, 2005 to develop standards for the practice of this emerging technique. This group is known as the Natural Orifice Surgery Consortion for Assessment and Research (NOSCAR). A White Paper on NOTES was released by NOSCAR simultaneously in two medical journals in May 2006 <ref name="pmid16427920">{{cite journal |author= |title=ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005 |journal=Gastrointest. Endosc. |volume=63 |issue=2 |pages=199–203 |year=2006 |month=February |pmid=16427920 |doi=10.1016/j.gie.2005.12.007 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(05)03412-7 |accessdate=2012-02-22}}</ref>. This paper identified the major areas of research needed to be addressed before NOTES can become a viable clinical application for patients. These areas included development of a reliable closure technique for the internal incision, prevention of infection, and creation of advanced endoscopic surgical tools <ref>[http://www.noscar.org/faq.php Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)<!-- Bot generated title -->]</ref>.
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| NOSCAR tasks include the following:
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| *Producing White Papers which focus on the challenges that need thought and research.
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| *Tracking the groups of similar research projects that address the previous challenges.
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| *Organizing the research projects, enhance collaboration and attract funding to key areas of study.
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| *Building a robust outcomes database by collecting submission of data.
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| *Fostering collaborative clinical trials.
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| The White Paper on NOTES and the guidlines for participation in NOSCAR can be found in the external links below <ref>
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| D. Rattner, A. Kalloo, and the SAGES/ASGE Working Group on Natural Orifice Translumenal Endoscopic Surgery</ref>.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) conclusions|Conclusions]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) conclusions|Conclusions]]== |
| Natural orifice transluminal surgery (NOTES) is a rapidly evolving field which may shift the minimally invasive surgery world from laparoscopic and video assisted thoracic surgery to procedures that can be done via the natural body orifices without any abdominal or thoracic incisions. NOTES may be a feasible, safe, and reasonable option for abdominal surgery. It may provide many advantages and lessen many surgical complications. New NOTES procedures should be experimental at the beginning, and they should be performed only in research labs in advanced institutions before applying NOTES clinically.
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| We are on the way for routine clinical applications of NOTES by the steady progression of the field. Patient safety and the research trials that ensure this safety is paramount. Innovative instruments are needed for the surgeons and gastroenterologists to perform safe NOTES procedures. The development of such therapeutic techniques and advanced endoscopic devices will allow the endoscopists to perform various procedures more easily, such as resection of large and deep mucosal lesions and taking full thickness biopsies <ref name="pmid19806084">{{cite journal |author=Jay Pasricha P, Krummel TM |title=NOTES and other emerging trends in gastrointestinal endoscopy and surgery: the change that we need and the change that is real |journal=Am. J. Gastroenterol. |volume=104 |issue=10 |pages=2384–6 |year=2009 |month=October |pmid=19806084 |doi=10.1038/ajg.2009.150 |url=http://dx.doi.org/10.1038/ajg.2009.150 |accessdate=2012-02-27}}</ref>.
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| International NOTES research groups, such as NOSCAR, EURO-NOTES, ASIA-NOTES, NOSLA (Natural Orifice Surgery Latin America), EATS (European Association of Translumenal Surgery) and others currently work to improve NOTES field and aim to provide registries for NOTES procedures worldwide.
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| Finally, enthusiasm and conducting laboratory studies and clinical trials are required for further improvements in the field in order to provide the best possible patient care for our patients.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) published trials|Published Trials]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) published trials|Published Trials]]== |
| *A transgastric debridement of necrotizing pancreatitis was performed using flexible endoscope in 2000 by Seifert et al <ref name="pmid10968442">{{cite journal |author=Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF |title=Retroperitoneal endoscopic debridement for infected peripancreatic necrosis |journal=Lancet |volume=356 |issue=9230 |pages=653–5 |year=2000 |month=August |pmid=10968442 |doi=10.1016/S0140-6736(00)02611-8 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(00)02611-8 |accessdate=2012-03-05}}</ref>. This was initial description for the transgastric access to perform procedures.
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| *In 2002, Gettman et al published a transvaginal nephrectomy in a porcine model <ref>Gettman MT, Lotan Y, Napper CA, Cadeddu JA. Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model. Urology 2002; 59: 446-450</ref>.
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| *A novel endoscopic peroral transgastric approach to the peritoneal cavity was tested in a porcine model in acute and long-term survival experiments at Johns Hopkins Medical Center in 2004 by Kalloo et al <ref name="pmid15229442">{{cite journal |author=Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV |title=Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity |journal=[[Gastrointest. Endosc.]] |volume=60 |issue=1 |pages=114–7 |year=2004 |month=July |pmid=15229442 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704013094 |accessdate=2012-02-16}}</ref>. He demonstrated the feasibility and safety of this approach to be an alternative to laparoscopy and laparotomy. The peritoneal cavity was examined, and a liver biopsy specimen was obtained. The gastric wall incision was closed with clips <ref name="pmid15229442">{{cite journal |author=Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV |title=Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity |journal=[[Gastrointest. Endosc.]] |volume=60 |issue=1 |pages=114–7 |year=2004 |month=July |pmid=15229442 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704013094 |accessdate=2012-02-16}}</ref>.
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| *A transgastric lymphadenectomy has been performed in a survival porcine model by Fritscher-Ravens et al and reported in 2004 <ref name="pmid16427939">{{cite journal |author=Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P |title=Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance |journal=Gastrointest. Endosc. |volume=63 |issue=2 |pages=302–6 |year=2006 |month=February |pmid=16427939 |doi=10.1016/j.gie.2005.10.026 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(05)03148-2 |accessdate=2012-03-01}}</ref>. This study showed that EUS (Endoscopic Ultrasonography) guided transgastric approach for lymph node selection and lymphadenectomy is feasible.
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| *A transgastric fallopian tube ligation has been reported in a porcine survival model in 2005 by Jagannath et al <ref name="pmid15758923">{{cite journal |author=Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN |title=Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model |journal=Gastrointest. Endosc. |volume=61 |issue=3 |pages=449–53 |year=2005 |month=March |pmid=15758923 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704028287 |accessdate=2012-02-29}}</ref>.
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| *A transgastric partial hysterectomy and oophorectomy in a porcine survival model has been reported in 2005 by Wagh et al <ref name="pmid16234027">{{cite journal |author=Wagh MS, Merrifield BF, Thompson CC |title=Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model |journal=Clin. Gastroenterol. Hepatol. |volume=3 |issue=9 |pages=892–6 |year=2005 |month=September |pmid=16234027 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S1542-3565(05)00296-X |accessdate=2012-02-29}}</ref>.
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| *A transgastric cholecystectomy and cholecystogastric anastomosis in a nonsurvival model has been reported in 2005 by Park et al <ref name="pmid15812420">{{cite journal |author=Park PO, Bergström M, Ikeda K, Fritscher-Ravens A, Swain P |title=Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos) |journal=Gastrointest. Endosc. |volume=61 |issue=4 |pages=601–6 |year=2005 |month=April |pmid=15812420 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510704027749 |accessdate=2012-02-29}}</ref>.
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| *A transgastric gastrojejunostomy procedure in a porcine survival model has been reported in 2005 by Kantsevoy et al <ref name="pmid16046997">{{cite journal |author=Kantsevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN |title=Endoscopic gastrojejunostomy with survival in a porcine model |journal=Gastrointest. Endosc. |volume=62 |issue=2 |pages=287–92 |year=2005 |month=August |pmid=16046997 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0016510705015658 |accessdate=2012-03-01}}</ref>.
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| *A transvesical liver biopsy has been performed on pigs (survival and nonsurvival models) and reported in 2006 by Lima et al <ref name="pmid">{{cite journal |author=Lima E, Rolanda C, Pêgo JM, Henriques-Coelho T, Silva D, Carvalho JL, Correia-Pinto J |title=Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery |journal=J. Urol. |volume=176 |issue=2 |pages=802–5 |year=2006 |month=August |pmid= |doi=10.1016/j.juro.2006.03.075 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5347(06)00816-0 |accessdate=2012-03-01}}</ref>. This study provided encouragement for additional preclinical studies of transvesical surgery to design new intra-abdominal scarless procedures in what seems to be third generation surgery.
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| *A transgastric splenectomy has been performed in a nonsurvival porcine model and reported in 2006 by Kantsevoy et al <ref name="pmid16432652">{{cite journal |author=Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN |title=Transgastric endoscopic splenectomy: is it possible? |journal=Surg Endosc |volume=20 |issue=3 |pages=522–5 |year=2006 |month=March |pmid=16432652 |doi=10.1007/s00464-005-0263-x |url=http://dx.doi.org/10.1007/s00464-005-0263-x |accessdate=2012-03-01}}</ref>.
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| *A new transgastric closure method for stomach incisions has been compared to other closure methods in 2007 by Ryou et al <ref name="pmid17160493">{{cite journal |author=Ryou M, Pai RD, Pai R, Sauer JS, Sauer J, Rattner DW, Rattner D, Thompson CC, Thompson C |title=Evaluating an optimal gastric closure method for transgastric surgery |journal=Surg Endosc |volume=21 |issue=4 |pages=677–80 |year=2007 |month=April |pmid=17160493 |doi=10.1007/s00464-006-9075-x |url=http://dx.doi.org/10.1007/s00464-006-9075-x |accessdate=2012-03-01}}</ref>. The study showed by using ex vivo porcine stomach model that prototype gastrotomy device yields the highest median air leak pressure (most leak-resistant gastrotomy closure) compared to the QuickClip closure method and the hand-sewn closure. This method also dramatically diminishes the time for incision and gastrotomy closure to approximately 5 min <ref name="pmid17160493">{{cite journal |author=Ryou M, Pai RD, Pai R, Sauer JS, Sauer J, Rattner DW, Rattner D, Thompson CC, Thompson C |title=Evaluating an optimal gastric closure method for transgastric surgery |journal=Surg Endosc |volume=21 |issue=4 |pages=677–80 |year=2007 |month=April |pmid=17160493 |doi=10.1007/s00464-006-9075-x |url=http://dx.doi.org/10.1007/s00464-006-9075-x |accessdate=2012-03-01}}</ref>.
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| *A transcolonic abdominal exploration in a swine survival model has been performed by Fong et al and reported in 2007 <ref name="pmid17173916">{{cite journal |author=Fong DG, Pai RD, Thompson CC |title=Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model |journal=Gastrointest. Endosc. |volume=65 |issue=2 |pages=312–8 |year=2007 |month=February |pmid=17173916 |doi=10.1016/j.gie.2006.08.005 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(06)02665-4 |accessdate=2012-03-01}}</ref>. In contrast to the transgastric method, a transcolonic approach provides more consistent identification of structures in the upper abdomen and provides better en face orientation and scope stability.
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| *A transgastric diaphragmatic pacing and peritoneal exploration procedure in a nonsurvival porcine model has been performed by Onders et al and reported in 2007 <ref name="pmid17177078">{{cite journal |author=Onders R, McGee MF, Marks J, Chak A, Schilz R, Rosen MJ, Ignagni A, Faulx A, Elmo MJ, Schomisch S, Ponsky J |title=Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients |journal=Surg Endosc |volume=21 |issue=3 |pages=475–9 |year=2007 |month=March |pmid=17177078 |doi=10.1007/s00464-006-9125-4 |url=http://dx.doi.org/10.1007/s00464-006-9125-4 |accessdate=2012-03-01}}</ref>. This study demonstrated the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation.
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| *A transgastric intraperitoneal pressure measurement procedure has been performed in a nonsurvival porcine model and reported in 2007 by Meirless et al <ref name="pmid17404796">{{cite journal |author=Meireles O, Kantsevoy SV, Kalloo AN, Jagannath SB, Giday SA, Magno P, Shih SP, Hanly EJ, Ko CW, Beitler DM, Marohn MR |title=Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery |journal=Surg Endosc |volume=21 |issue=6 |pages=998–1001 |year=2007 |month=June |pmid=17404796 |doi=10.1007/s00464-006-9167-7 |url=http://dx.doi.org/10.1007/s00464-006-9167-7 |accessdate=2012-03-01}}</ref>. This study demonstrated that the use of an on-demand unregulated endoscopic insufflator for translumenal surgery can cause large variation in intraperitoneal pressures, which may lead to hemodynamic compromise. Well-controlled intraabdominal pressures that is achieved with a standard autoregulated laparoscopic insufflator maybe much safer.
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| *Radical sigmoidectomy using a pure NOTES transanal approach was first described in 3 human cadavers in 2007 by Whiteford et al <ref name="pmid17705068">{{cite journal |author=Whiteford MH, Denk PM, Swanström LL |title=Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery |journal=Surg Endosc |volume=21 |issue=10 |pages=1870–4 |year=2007 |month=October |pmid=17705068 |doi=10.1007/s00464-007-9552-x |url=http://dx.doi.org/10.1007/s00464-007-9552-x |accessdate=2012-02-15}}</ref>. They used TEM as an endoscopic platform to perform the procedure without the need of any abdominal incisions <ref name="pmid17705068">{{cite journal |author=Whiteford MH, Denk PM, Swanström LL |title=Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery |journal=Surg Endosc |volume=21 |issue=10 |pages=1870–4 |year=2007 |month=October |pmid=17705068 |doi=10.1007/s00464-007-9552-x |url=http://dx.doi.org/10.1007/s00464-007-9552-x |accessdate=2012-02-15}}</ref>. This showed that NOTES sigmoid colon resection with en bloc lymphadenectomy and primary anastomosis can be performed successfully, and it is possible to complete the critical steps of NOTES sigmoid resection, en bloc lymphadenectomy, primary anastomosis, and retrieval of an intact specimen without any incisions by using transanal endoscopic microsurgery instrumentation.
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| *Completely NOTES transvaginal cholecystectomy has been reported by a team of surgeons in Philadelphia (USA). The patient was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up. Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans <ref name="pmid19474690">{{cite journal |author=Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M |title=Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique |journal=Ann. Surg. |volume=249 |issue=6 |pages=908–12 |year=2009 |month=June |pmid=19474690 |doi=10.1097/SLA.0b013e3181a802e2 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/SLA.0b013e3181a802e2 |accessdate=2012-02-28}}</ref>.
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| *The first series of transvaginal NOTES cholecystectomy has been performed by the NOTES Research Group in Rio de Janeiro (Brazil) in 2007, based in previous experimental studies. The first human transvaginal endoscopic cholecystectomy case was reported in 2007 <ref name="pmid17875836">{{cite journal |author=Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D |title=Surgery without scars: report of transluminal cholecystectomy in a human being |journal=Arch Surg |volume=142 |issue=9 |pages=823–6; discussion 826–7 |year=2007 |month=September |pmid=17875836 |doi=10.1001/archsurg.142.9.823 |url=http://archsurg.ama-assn.org/cgi/pmidlookup?view=long&pmid=17875836 |accessdate=2012-02-15}}</ref>.
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| *A transvaginal laparoscopically assisted endoscopic cholecystectomy has been reported by Marc Bessler <ref name="pmid17892873">{{cite journal |author=Bessler M, Stevens PD, Milone L, Parikh M, Fowler D |title=Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery |journal=Gastrointest. Endosc. |volume=66 |issue=6 |pages=1243–5 |year=2007 |month=December |pmid=17892873 |doi=10.1016/j.gie.2007.08.017 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5107(07)02553-9 |accessdate=2012-02-28}}</ref>.
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| *Transgastric appendectomy has been performed by Santiago Horgan in 2008 <ref name="pmid19343435">{{cite journal |author=Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P |title=Natural orifice surgery: initial clinical experience |journal=Surg Endosc |volume=23 |issue=7 |pages=1512–8 |year=2009 |month=July |pmid=19343435 |pmc=2695868 |doi=10.1007/s00464-009-0428-0 |url=http://dx.doi.org/10.1007/s00464-009-0428-0 |accessdate=2012-02-28}}</ref>. The patient's appendix was removed through the mouth. Dr. Horgan also applied the EndoSurgical Operating System (EOS) on pigs to perform the entire operation through the stomach without laparoscopic assistance or any abdominal incision.
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| *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.
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| *The first case of robotic-assisted laparoscopic live-donor transvaginal nephrectomy with the uterus in place has been performed by a multidisciplinary team of surgeons at University of Pavia (Italy) in 2010 <ref name="pmid21114647">{{cite journal |author=Pietrabissa A, Abelli M, Spinillo A, Alessiani M, Zonta S, Ticozzelli E, Peri A, Dal Canton A, Dionigi P |title=Robotic-assisted laparoscopic donor nephrectomy with transvaginal extraction of the kidney |journal=Am. J. Transplant. |volume=10 |issue=12 |pages=2708–11 |year=2010 |month=December |pmid=21114647 |doi=10.1111/j.1600-6143.2010.03305.x |url=http://dx.doi.org/10.1111/j.1600-6143.2010.03305.x |accessdate=2012-02-28}}</ref>. The initial experience with the combination of robotic surgery and transvaginal extraction of the donated organ has opened a new opportunity to minimize trauma in transplant surgery.
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| *A NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance has been performed in a 76-year-old woman at the Hospital Clinic in Barcelona by a team of surgeons from the Hospital Clinic in Barcelona and Massachusetts General Hospital/Boston in November 2009 <ref name="pmid20186432">{{cite journal |author=Sylla P, Rattner DW, Delgado S, Lacy AM |title=NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance |journal=Surg Endosc |volume=24 |issue=5 |pages=1205–10 |year=2010 |month=May |pmid=20186432 |doi=10.1007/s00464-010-0965-6 |url=http://dx.doi.org/10.1007/s00464-010-0965-6 |accessdate=2012-02-15}}</ref>.
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| *Transvaginal purely endoscopic appendectomies were reported in 2008 by investigators from Germany and by another group of investigators from India <ref name="pmid18256848">{{cite journal |author=Bernhardt J, Gerber B, Schober HC, Kähler G, Ludwig K |title=NOTES--case report of a unidirectional flexible appendectomy |journal=Int J Colorectal Dis |volume=23 |issue=5 |pages=547–50 |year=2008 |month=May |pmid=18256848 |doi=10.1007/s00384-007-0427-3 |url=http://dx.doi.org/10.1007/s00384-007-0427-3 |accessdate=2012-02-29}}</ref><ref name="pmid18347865">{{cite journal |author=Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M |title=Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES--world's first report |journal=Surg Endosc |volume=22 |issue=5 |pages=1343–7 |year=2008 |month=May |pmid=18347865 |doi=10.1007/s00464-008-9811-5 |url=http://dx.doi.org/10.1007/s00464-008-9811-5 |accessdate=2012-02-29}}</ref>.
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) videos|Videos]]== | | ==[[Natural orifice translumenal endoscopic surgery (NOTES) videos|Videos]]== |
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| ==[[Natural orifice translumenal endoscopic surgery (NOTES) external links|External Links]]== | | ==External Links== |
| *http://www.noscar.org/wp-content/uploads/2011/01/NOTES_White_Paper_Feb06.pdf | | *http://www.noscar.org/wp-content/uploads/2011/01/NOTES_White_Paper_Feb06.pdf |
| *http://www.noscar.org/ | | *http://www.noscar.org/ |
| *http://www.noscar.org/outcomes.php
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| *http://www.dgav.de/english/notes.html | | *http://www.dgav.de/english/notes.html |
| *http://www.euronotes.world.it/ | | *http://www.euronotes.world.it/ |
| *http://www.japan-medical-tourism.com/content/natural-orifice-translumenal-endoscopic-surgery-notes-japan | | *http://www.japan-medical-tourism.com/content/natural-orifice-translumenal-endoscopic-surgery-notes-japan |
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| ==References== | | ==Acknowledgments== |
| {{Reflist|2}}
| | Person who first created this page was '''Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:moh_sbeih@hotmail.com] |
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| [[Category:General surgery]] | | [[Category:General surgery]] |
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