Transgastric access techniques for NOTES

Abstract

Natural orifice translumenal endoscopic surgery (NOTES) has been the focus of extensive research since the first NOTES procedure was reported in 2004 by Kalloo and colleagues. Although a number of animal experiments and some human experiences of NOTES have been reported in the last few years, there are many issues that need to be addressed before this technique is adopted widely in clinical practice. Achieving a safe and effective access to the peritoneal cavity at an optimal location using most favorable techniques was the foremost barrier. So far, transgastric, transrectal, transvaginal, and transurethral approaches have been reported as potential access routes to the peritoneal cavity, of which the transgastric route has been one of the most widely studied. Although the transgastric route has advantages over other routes for lower abdominal and peritoneal organs given the straight approach from upper abdomen, it has its limitations as a route for organs located in the upper peritoneum, where retroflexion is required and the maneuverability is limited. With the development of new technologies and new devices, the potential limitations of each access route are being addressed. Moreover, the natural orifice surgery consortium for assessment and research (NOSCAR®) white paper pointed out that the optimal access route would vary with the nature of the intended procedure. Larger studies and randomized controlled trials are needed for setting guidelines regarding the optimal access routes for NOTES procedures. © 2009 Elsevier Inc. All rights reserved.