NOTES: The Newest Frontier In Minimally Invasive Surgery

Insights from Chicago on a potentially safer type of surgery

Last month I went to a conference in Chicago that focused on an exciting new type of surgery — one that has the potential to reduce scarring and recovery times, along with other potential benefits. The conference was the 7th International NOTES® Summit, sponsored by the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons.

What is NOTES?

NOTES stands for natural orifice transluminal endoscopic surgery. The word “translumenal” refers to going beyond the margins of a hollow organ (or “lumen”, such as the stomach or vagina). “Endoscopic” is a type of surgery that uses special surgical instruments to go through small incisions or natural body openings in order to diagnose and treat diseases and other medical conditions. Instead of “traditional” surgery involving large incisions, or even laparoscopy, which uses specialized surgical instruments used through small incisions, NOTES involves interior incisions made within the body’s natural openings.
As an ob/gyn, I’ve been particularly interested in NOTES developments as they relate to surgical procedures that can be done via incisions made in the vagina. While at the NOTES conference, I participated in the transvaginal access workgroup and provided guidance to the group in reference to the methods and complications of posterior colpotomy, a procedure that involves an incision made in the back of the vaginal wall.

Why is NOTES important?

Simply stated, NOTES has the potential to make many kinds of surgery safer. In particular, abdominal NOTES procedures can avoid the need for abdominal incisions. This offers the following potential advantages:
  • lower risk of infection
  • less anesthesia required
  • less pain
  • lower risk of disability
  • shorter hospital stays
  • faster recovery time, and
  • no visible scarring

Why isn’t NOTES used more?

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While NOTES techniques have great potential, this is an area that is still in development, especially for more complicated procedures. Surgeons need training and new, flexible medical instruments must be developed. Computer-assisted 3-D imaging systems similar to those used in the da Vinci Surgical System must be created or refined to allow surgeons to see inside the patient’s body during procedures. In addition, research is being conducted to determine the best techniques for closing internal incisions and preventing infections.

Outlook for NOTES acceptance

The last time the medical field was faced with this level of innovation and radical change was the late 1980s, when laparoscopic surgery was introduced. Initially, many surgeons resisted laparoscopy due to a fear of various potential complications. Following extensive research along with development of specialized laparoscopic instruments, today laparoscopy is considered a safe and “mature” technique— and a standard approach for many of the advanced ob/gyn procedures I perform. It’s likely that NOTES will reach the same level of success and acceptance.

Additional information on NOTES

In 2006, a group of surgeons and gastroenterologists was organized to develop standards for this emerging technique. This group is known as the Natural Orifice Surgery Consortium For Assessment And Research, or NOSCAR. More information on NOTES, NOSCAR and NOSCAR’s NOTES Summit can be found at
Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. For more information on Dr. Garofalo and his medical practice, go to Dr. Garofalo can be reached for a personal consultation at 203.803.1098.



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