Introduction

Surgical procedures have been performed since Neolithic times with advances in the field marked by key events.¹ In 1809, McDowell completed the first successful abdominal operation without the use of general anesthetic.² The invention and use of inhaled ether as a form of general anesthetic marks the first great advance in surgical therapy (Fig. 55.1), followed by the introduction of antisepsis by Lister.³ In the centuries that followed, large abdominal incisions were required to permit the surgeon’s hands and instruments access to the disease process. More recently, disease processes have been accessed with smaller incisions (as in laparoscopy) or by a different route entirely (endoscopy or endovascular), decreasing the pain and infection risk of the abdominal incision and improving patient outcomes.

Fig. 55.1 Artist’s conception of Dr. Crawford Long demonstrating for the first time the use of ether as an inhaled anesthetic on March 30, 1842.

(From Boland F: The first anesthetic: The story of Crawford Long, Athens, 1950, University of Georgia Press.)

Natural orifice transluminal endoscopic surgery (NOTES) is an experimental surgical technique whereby scarless abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, anus, vagina, or urethra) and then through an internal incision in the stomach, colon, posterior vaginal fornix, or bladder, avoiding any external incisions or scars (Fig. 55.2). Similar to the introduction of laparoscopy, surgical opinions of this new approach vary widely. This chapter briefly reviews NOTES and examines current surgical opinions.

Fig. 55.2 A–C, Renderings of natural orifice access through transgastric (A), transcolonic (B), and transvaginal (C) routes.

(From Bessler M, Stevens P, Milone L, et al: Transvaginal laparoscopically assisted endoscopic cholecystectomy: A hybrid approach to natural orifice surgery. Gastrointest Endosc 66:1243–1245, 2007.)

History of Minimally Invasive Surgery

The advent of minimally invasive surgery brought with it an opportunity to decrease postoperative pain with resultant shorter hospital stays and quicker returns to normal activity and to shrink surgical scars, providing a more pleasing cosmetic outcome.⁴ The minimally invasive surgery concept influenced the next paradigm shift in intervention, NOTES, which may eliminate the anterior abdominal wall approach altogether (Fig. 55.3).

Fig. 55.3 Depiction of the transfer of advances in technology between specialties leading to decreased invasiveness.

History of Natural Orifice Transluminal Endoscopic Surgery

The history of NOTES begins in 1901, when Ott performed the first endoscopic examination of the peritoneal cavity through the vagina.⁵ He termed the procedure ventroscopy and became the pioneer of natural orifice access. The feasibility of a peroral transgastric flexible endoscopic approach to the peritoneal cavity with long-term survival in a porcine model was reported by the Apollo Group in 2004 (Fig. 55.4).⁴