This document discusses Natural Orifice Transluminal Endoscopic Surgery (NOTES), a new surgical technique. NOTES involves performing surgery using an endoscope inserted through natural openings like the mouth, vagina, or anus without external incisions. The document provides a brief history of NOTES, describes some procedures that have been performed, and discusses potential advantages as well as challenges to further development and acceptance of the technique.

1. NOTES
Dr.Kamran Yousaf
Meeqat Gen Hospital
Madinah Munawwarah
Natural Orifice Transluminal
Endoscopic Surgery
The next generation of ‘Least Invasive
Surgical therapy’
Novel method of surg therapy

2. NOTES
 Scarless abd surgery
 Emerging field-GI surg & Interven
Gastroentrologists
 Evolving rapidly
 Presenting limitless possibilities for
innovation,tech & device development
 May revolutionize the surgical approach
 Proponents,Researchers believe it may
well be the next Paradigm shift in surg as
was laparoscopy in 80’s,90’s

3. SURGEONS WITHOUT
SCALPEL

4. NOTES: DEFINITION
 An experimental surg
tech,scarless abd
operation,performed by
introducing a multi-channeled
endoscope thru a natural
orifice(mouth,vagina,urethra,
anus),puncturing the hollow
viscus & doing a diag or
therapeutic procedure.

5. NOTES:A STEP FORWARD
 emerging surgical
approach 
‘viewed as a step
forward’
utilize the
body’s natural
openings.
History in the making????

6. NOTES
 Latest craze among todays
surgeons.
 Highest level of minimal invasiveness.
 Can be ‘Future of Surgery’
-Minimal invasive surgery
-Least invasive surgery
 SILS,,,,,NOTES

7. NOTES: HISTORY
 That endoscopy can be used
to do procedures beyond the
wall of the GIT was known
since 1980 when the first
transluminal feeding
gastrostomy was described by
Gauderer et al.

8. NOTES: HISTORY
 Kozarek et al. reported first of
successful endoscopic drainage of
pancreatic pseudocyst in 1985.
 The first report of oral
peritoneoscopy done in animals
was published by Kalloo et al. in
2004,John Hopkins,US

9. NOTES: HISTORY
 In September 2007,
Novare announced
the successful
completion of the first
NOTES gallbladder removal (TV) procedures.
 2007-Bessler et all,Marescaeux et all,,TV chol
 Same year,Swanstrom,colleagues reported TG chole
as well
 2008,,TV donor kidney extraction done in John
Hopkins

10. NOTES: HISTORY
•In March 2008, Dr Ricardo
Zorron, of Brazil,
performed the first series
of NOTES cholecystectomy
on four patients via
transvaginal route.

11. NOTES:
 Transgastric appendectomy in
humans in India By Dr. G V Rao
and Dr. N Reddy. (Hyderabad,
India),,,2007

12. NOTES:
 Famous bollywood actress
‘Shilpa Shetty’ and
south Indian actress ‘Khusboo’
have recently undergone
transgastric appendicectomy.

13. NOTES: HISTORY
 Since then, multiple investigators
have used transluminal endoscopy
in animal models to perform various
intraperitoneal surgical procedures,
ranging from tubal ligation to
splenectomy,oophorectomy,nephrect
omy,Gastro-jej etc

14. 
NOTES:
Abd cavity access thru natural
The technique
route,mouth,vagina,urethra,anus
 An adv endoscope with multiple channels is pushed
thru
 Hollow viscus is punctured from inside
 Periton insufflation is done to have wide working
space
 Conventional laparoscopic instruments are
advanced thru edosc for dissection
 Principles of safe access are,,,,minimal tissue
inj,,,good exposure,,,safety to avoid
vascular/visceral inj,,,maintain seal & manipulate
instruments
 ???Hybrid NOTES

15. 
NOTES: WHY???
Basic human nature to keep on
experimenting/research to improve the
qualityof life
 To get the max from mini
 Ultimate goal of med prof
is Patients welfare
 Advantages associated with
NOTES are numerous like
 Less physiolog insult
 No question of pain

16. NOTES: Why?Advantages
 Less hospital stay
 Less resources
 Bed occupancy,rapid turn over
 Early return to work
 NOTES can be done as an
outpatient
 Conscious sedation instead of
Gen Anaesth
 Cosmetic result is un-matched as no incision

17. NOTES: ADVANTAGES
 No wound,no infection
 No infection,no incisional hernia
 Minimal chance for intra-abd adhesions
 No post op intest obs
 Ideal for any surgery
on ICU patients
 Last but not the least
More public/pt
satisfaction

18. NOTES: THE CONCEPT
 NOTES - safe and feasible
- same efficacy
as traditional laparoscopic
procedures.

19. NOTES: INSTRUMENTS

20. NOTES: INSTRUMENTS

21. NOTES: INSTRUMENTS

22. NOTES: INSTRUMENTS

24. NOTES
 Result of active cooperation
between minimally invasive
surgeons and interventional
gastroenterologists.

27. NOTES
 Internal incision is over stomach,
vagina, bladder or colon, thus
completely avoiding any external
incisions or scars.

28. INTERNAL INCISION

31. NOTES
 Continued evolution of flexible
endoscopy + Growing awareness
about invasiveness of surgery having
impact on patient outcomes
Lead to
Endoscopy and Surgery - working
together as NOTES

32. NOTES: ROUTES
 NOTES has been
mostly practised
on animals, for diagnosis
and treatments, including
transgastric organ
removal.

33. NOTES: ROUTES

34. DEMONSTRATING
TRANSGASTRIC
ROUTE

38. DEMONSTRATING
TRANSVAGINAL
ROUTE

41. NOTES: ROUTES
 Acc. To some transvesical and
transcolonic approaches- more suited to
access upper abdominal structures,
which are often more difficult to work
with if using a transgastric approach.

42. NOTES: ROUTES
 Transvaginal access appears to
be the safest and most
feasible.
 potentially less complications,
but only possible in women.

43. PROCEDURES DESCRIBED
TILL NOW
 Laboratory reports
Cholecystectomy, Splenectomy,
Tubal ligation, Gastrojejunostomy,
Pyloroplasty,
Staging peritoneoscopy, Liver biopsy,
Distal pancreatectomy,
Ventral hernia repair,
Gastric sleeve resection,
Colectomy (right and left)

44. PROCEDURES DESCRIBED
TILL NOW
 Human cases
TG- appendectomy,
TV- cholecystectomy,
TG- cholecystectomy,
TG- gastro-enterostomy,
Cancer staging.

46. FIRST ‘NOTES’
(TRANS-VAGINAL)
CHOLECYSTECTOMY

48. NOTES: The Way Forward
 NOSCAR
 Regulates progress of NOTES
 NOTES necessitates surg skills,endosc skills
& ability to manage complications
 NOTES expertise,,,Dlilgent lab work-
systematized training models-judicious
clinical trials,,,,stepwise approach
 Instituitional training & fellowship in NOTES
 Research engineers focus Comptr assissted
3D image system
 Routine clinical Application-long way-steady

49. NOTES: The Way Forward
 Advance technolog develop in
progress,substantial refinement
 A spate of new instruments
more suitable,flexible
 Time may come when NOTES
may well become the order of the
day.
 FUTURE OF SURGERY???

50. NOTES: The Way Forward
The medical fraternity & Gen public has
captivated the idea of NOTES-scarless
abd surgery,with great enthusiasm &
interest
BUT
For us,the patients
safety & welfare is of paramount
importance,not the advancement of
NOTES,,,,,no ground for over-exitement

51. NOTES:Current Challenge
 Change is part of
surgery but it is
never easy to
accept.
 A lot of
sceptisism,undoubt
ed interest as well

52. NOTES:Current Challenge
 At the dawn of surgery, excellence of
a surgeon was associated with big
incisions:
"Big scar, big surgeon”.

53. NOTES:Current Challenge
 1882- open chole
 1985- first laparoscopic chole-- strongly
criticized.
 1992- lap chole- declared tmt of choice
for GB-stones.
 SILS,,,,,New dimention,,,step towards
NOTES,,,,

54. NOTES:Current Challenge
 But now with NOTES moving one
step further: philosophy of surgery
will be dramatically changed, as
surgical trauma & associated pain -
physical barrier for surgery.

55. NOTES Questions???
 What are the infectious complications?
 How reliable is the organ
Closure?
 How practical is viscerot?
contravenes surg dogma.
 How good are instruments
 Ethics/Acceptability
 Cogent answers needed

56. NOTES:Hurdles-Problems
 Presently NOTES cases being reported
anecdotally
 Inadequate instruments,organ closure
 Ethical/Moral issues
 Lack of instituitional training & supervision
 One of basic tenets of Lap surg is tringulation
of Optics & Instruments,,,,lost in NOTES result
is partial loss of spatial orientation & depth
perception.
 Who is Who?Dilema of speciality?

57. NOTES
 witnessing a true remarkable shift in
their lifetime i.e. Natural Orifice
Transluminal Endoscopic
Surgery (NOTES).