NOTES Techniques: present and future

Summary BACKGROUND: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a promising approach to decrease surgical morbidity. However, the techniques and instrumentation are still primitive, requiring major modifications for use in NOTES procedures. METHODS: Review of the literature, personal communications and experiences. RESULTS: The operating room environment need to change with a larger sterile field and long sterile tables to accommodate long flexible instruments. Operating systems need to be improved to allow surgeons to have free ergonomic-friendly movements with long instruments. Modified endoscopes or flexible overtubes are required to provide a stable site of dissection at the end of a long flexible tube. Graspers need to be developed that are accurate and robust at a long distance from the operator. Tissue dissection through a flexible channel (ideally ultrasonic) will allow more complex NOTES procedures. Techniques of tissue closure and anastomosis are primitive and need to reach the standard seen with laparoscopic surgery. CONCLUSIONS: It is our judgment that NOTES will play a pivotal role in GI surgery. A general, coordinated effort will probably make NOTES a widespread reality.