A transformational new diagnostic and therapeutic approach that utilizes the mouth, anus and vagina to enter the abdominal, pelvic and thoracic cavities, natural orifice surgery (NOTES) is becoming a viable option for minimally invasive procedures. 

The Boston-based, CIMIT-supported initiative is a multidisciplinary, multi-institutional collaboration of leading surgeons and endoscopists from Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, the Massachusetts Institute of Technology and Dartmouth Medical Center. David Rattner, MD, chief of the Division of General and Gastrointestinal Surgery at MGH, leads the CIMIT strategic initiative and is a founder of NOSCAR, the national coalition of doctors interested in this revolutionary approach to scarless surgery.

» VIDEO: What is the Boston-based NOTES Initiative?

CIMIT has been supporting NOTES research since 2003.  In 2008, it selected the NOTES team as the CIMIT Strategic Initiative and awarded a three-year $2.1 million grant. Its four key focus areas of the NOTES initiative are:

• Refinement of NOTES technology to perform a gastrojejunal anastomosis
• Refinement of the trans-rectal approach to the peritoneal cavity and performance of segmental colon resections using a Transanal Endoscopic Microsurgery (TEM)/NOTES approach
• Development of trans-esophageal mediastinal and intrathoracic NOTES procedures
• Development of platform devices to allow complex tissue manipulation that will facilitate NOTES procedures

A significant milestone of the NOTES Strategic Initiative was achieved in November 2009 when MGH Surgeon Patricia Sylla, MD travelled to Barcelona to perform the first-in-human transanal NOTES rectal cancer resection using TEM. In May of the same year Dr. Rattner led a surgical team at MGH in performing the New England region’s first NOTES procedure, entering the patient’s abdominal cavity through the vagina to remove her gall bladder. In the U.S., five centers have performed NOTES procedures in human patients.

Progress has also been made in each of the initiative’s four target areas. 

• Researchers are currently working to refine their NOTES gastrojejunostomy technique to be able to perform it on patients with duodenal obstruction. 
• The TEM approach is being expanded to perform formal colon resections as well as access upper abdominal organs. 
• In an effort to consider alternative logical entrance points into the thoracic cavity, researchers have developed a method of transversing the esophageal wall to access the mediastinum and pleural cavity. They have demonstrated it to be safe when tested on animals, and work is currently planned to develop this methodology further for both diagnostic and therapeutic applications.
• A small intestinal submucosal (surgiSISÒ) covered stent that could be deployed over the mucosectomy site and tunnel has been developed, and an investigation into the best closure method, stenting or suturing, of the transedophageal exit site created during NOTES procedures is currently underway. 

All of these steps should bring researchers closer to making NOTES procedures through all orifices ready for human trials.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) offers many benefits over traditional abdominal surgery and could offer certain advantages to laparoscopic approaches.  Patients are the primary beneficiaries of NOTES procedures as it is likely to be much less painful, leave no scars and consequently lead to a much more rapid recovery than is seen in current surgical procedures. And with shorter recovery periods, employers will benefit because employees will be able to return to work sooner. 

Significant challenges remain before a NOTES alternative can be realized.  In order to prevent complications, a new stable working platform must be developed to provide a failsafe method to enter these cavities and close the access sites.  Also important will be methods to ensure sterility and enhance dexterity beyond what is currently possible using flexible endoscopes.

The national NOTES initiative is a global collaboration facilitated by leading endoscopists, surgeons and NOSCAR, the organization jointly created and supported by the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).