3. INTRODUCTION
• Minimally invasive surgical techniques have
been evolving since 100 yrs.
• First laparoscopic cholecystectomy was done
by ERICH MUHE in 1985.
• Kalloo et al given the initial description of
transgastric peritoneoscopy in 2004.
• Rao and Reddy have performed transgastric
appendicectomy in Hyderabad India 2007.
• ASGE,SAGES both came together and formed
NOSCAR in 2005 .
4. INTRODUCTION
• NOSCAR(Natural orifice surgery consortium
for assessment and research).
• NOTES includes diagnostic or therapeutic
interventions performed via existing orifices of
the human body(mouth,anus,urethra,vagina).
• Trans abdominal surgeries such as single port
surgeries are modification of laparoscopic
surgery ,it is not subset of NOTES.
5. INTRODUCTION
• HYBRID procedures include both endoluminal
and laparoscopic aproaches.
• Routes to do NOTES surgery are :
• Transvaginal
• Trans gastric
• Transvesical
• Transcolic
• Transesophageal.
8. TRANGASTRIC NOTES
• Pre op preparation:Overnight fasting,pre op
antibiotics and stomach and esophagus wash
with povidine iodine.
• Gastrotomy mostly done on ant wall to avoid
gastroepiploic arteries and its branches.
• In retroperitoneal surgeries post wall
gastrotomy is indicated.
9. TRANSGASTRIC NOTES
• Gastrotomy done by a needle knife by putting
2mm-4mm incision by electrocautery catheter
is guided through it.
• It is dilated by ballon dilator which is passed
over the catheter ,peritoneal cavity is entered.
• In hybrid procedures gastrotomy done under
vision via laparoscopic transabdominal port.
12. NOTES -CHOLECYSTECTOMY
1
• Transgastric entry into peritoneal cavity
• Scope is turned to right by 90 degrees to locate gall bladder.
2
• Dissection is done by dissector,monoplar cautery
• Cystic duct is ligated and cystic artery is clipped.
3
• Gallbaldder is cut and disected off from gallbladder bed .
• By using specimen retrieval bag specimen Is drawn into
stomach
13. Closure of access site
• Methods of closure include endoscopic
clips,over the scope clip system(OTSC),septal
occluders,T tags ,T bar,G-prox system,and
linear endoscopic staples.
• Laparoscopic closure is still the most common
method of closure in hybrid procedures.
• Reapir is tested by instilling methyline blue
saline monitored by laparoscope,or
pneumogastrium by gastroscope.
14. TG NOTES
• Post operative care is same as lap
cholecystectomy except for PPI for 1 month
after surgery.
19. TRANSVAGINAL APPROACH
• PRE OP PREPARATION:under GA patient
positioned in low lithotomy (Lloyd –
davies)with allen stirrups.shoulder holders
applied in steep trendelenburg position.
• Vagina is incised through the psoterior fornix
in the place of traingle of safety.
• In hybrid procedures vagina is incised under
vision from laproscope through umbilical port.
24. TV NOTES
• After removing the
specimen
pneumoperitoneum is
released.
• Colpotomy wound is closed
with running absorbable
sutures.
25. TRANSVAGINAL APPENDICECTOMY
• Through the colpotomy wound multichannel
port is inserted ,using laparoscopic
instruments .
• appendix is dissected ,mesoappendix is
clamped with ligasure.
• appendix is divided with endoscopic stapler.
27. TRANSVAGINAL NEPHRECTOMY
• Done in 2007.
• Done by 3 cm colpotomy incision,and one
umbilical port ,three trocars and standard
laparoscopic instruments.
• Specimen is removed through transvaginal
route .Operative time:420 min.
28. COMPLICATIONS OF TV NOTES
STUDY SURGERY MAJOR
COMPLICATION
MINOR
COMPLICATION
ZORING ET AL TVC ABSCESS WOUND INFECTION
HENSEL ET AL TVC BLADDER INJURY COLPOTOMY BLEED
LEHMAN ET AL TVC RECTAL
INJURY,BLADDER
INJURY,POST OP
BLEEDING,ABSCESS
VAGINAL BLEED
,UTI,VAGINAL
MYCOSIS,BACTERIAL
VAGINITIS.
LINKE ET AL TVC CVA ,UMBILICLA
HERNIA
PLEURAL
EFFUSION,BACTERAIL
VAGINITIS,COLPOTOM
Y DEHISCENCE.
ZORRON ET AL TVC BILIARY LEAK,GASTRIC
WALL PERFORATION,
CYSTIC ARTERY BLEED
,INTRA ABD
HTN,VAGINAL
DYSPAREUNIA.
TVA APPENDIX VESSEL
BLEED
29. TRANSRECTAL NOTES
• Appied to both genders.
• Direct visual/spatial access to upper abdomen.
• Size of lumen and anal orifice allows large
access colostomy enabling multiple
instrument introduction and specimen
extraction.
• Access and closure can be done with trans
anal endoscopic microsurgery instruments
(TEMS)
30. TRANS RECTAL NOTES
• Surgeries done
• 1)hybrid transanal resection of rectum and
mesorectum(TEMS-trans anal endoscopic
microsurgery)
• 2)pull through sugery for hirschprung disease.
• 3)trans rectal hybrid nephrectomy.
• PRE OP PREPARATION:bowel
prepaartion,lithtomy position,irrigation of
rectosigmoid with 10% povidine iodine.
31. TRANSRECTAL NOTES
• ACCESS :about 15cm from the anal verge an
anterior transverse rectotomy incision
(2cm)made with a harmonic scalpel.posterior
incision given for nephrectomy.
• CLOSURE:colostomy closure can be avoided by
incorporating into colo anal anastomosis.
• By applying endoloops ,endoclips.or by
endoscopic /laparoscopic suturing/stapling
devices..
33. • Higher bacterial load of colon is the
disadavntage ,need of reliable sterilisation
technique is key for future TR NOTES
34. TRANSVESICAL NOTES
• Applies to both males and females .
• provides a normally sterile tract .
• has adequate visualisation of majority of
abdominal cavity.
• No need of preop prophylactic antibiotics.
• ACCESS:needle knife to ant bladder wall.
35. TRANSVESICAL NOTES
• Passage of guide wire through the defect
followed by ballon dilator.
• Cystoscope is replaced with flexible
ureteroscope.
• CLOSURE:done by laparoscopic port with 2-0
vicryl sutures in figure of eight fashion.
• Reliable closure technique is necessary for
broader application of transvesical NOTES.
36. TRANSESOPHAGEAL/PERORAL
ESOPHAGEAL MYOTOMY(POEM)
• POEM done for achalasia patients endoscopic
myotomy done through a submucosal tunnel.
• Alternative to the lap heller myotomy.
• PREOP PREP:EGD to clean esophagus and rule
out other patholgies.pre op antibiotics.
• PROCEDURE:
• Submucosal injection of saline in ant mid
esophagus
37. POEM
• 2 cm longitudinal incision to create
submucosal plane.
• Dissection in submucosal plane to reach GE
junction.
• Inner circular muscle layer of distal esophagus
and LES is divided approx 2 cm distal to GEJ.
• Mucosal entry closed with hemostatic clips.
• P/o look for esophageal leak.,give double dose
PPI.
40. COMPLICATIONS
• Transmural dissection leading to
pneumomediastinum and
pneumoperitoneum.
• Advantage over lap heller myotomy is no need
of no need of antirefulx procedure (partial
fundoplication)as hiatus attachment ,and the
angle of his is maintained and surrounding
structures are not distrubed.
41. COMPLICATIONS OF NOTES
• Sec to increaed intrabdominal pressure
,decreased cardiac
output,tachycardia,decreased renal blood
flow.
• Infection (10-20%) sec to non sterile
endoscope,improper seal between wall of
access of organ and scope or improper
closure leading to leakage.
42. SUMMARY
• The field of minimal invasive surgery has
matured but continues to evolove with the
addition of technology and innovation.
• With adequate assessment ,research,protocol
development ,NOTES may demonstrate
improvement in patient care .
• Current level of investigation in technology
and development is insufficient to support the
concept of NOTES.
43. REFERENCES
• MASTERY OF ENDOSCOPY AND
LAPAROSCOPIC SURGERY BY LEE
L.SWANSTORM ,NATHANIEL J.SOPER ( 4TH
EDITION.)
• SURGICAL CLINICS OF NORTH AMERICA VOL
88
• MASTERY OF SURGERY BY FISCHER 5TH
EDITION.
