A review on the status of natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy: techniques and challenges

Michael C Meadows^1,3, Ronald S Chamberlain<sup>1,2,3

1</sup>Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; ²Department of Surgery, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA; ³Saint George’s University, School of Medicine, West Indies, Grenada

Introduction: The evolution of techniques for the performance of a cholecystectomy over the last 25 years has been swift. The laparoscopic approach is now the gold standard for removal of the gall bladder and is the most frequently performed minimally invasive procedure globally. Currently in its infancy stage, natural orifice transluminal endoscopy surgery, or NOTES, is purported to be the next leap forward in minimally invasive approaches. The safety, feasibility, and effectiveness of this procedure, as well as the significance of potential benefits to patients beyond current surgical approaches are yet undetermined.
Methods: A comprehensive literature search was conducted using PubMed, a search engine ­created by the National Library of Medicine. Keywords used in the search included “natural orifice transluminal endoscopic surgery”, “NOTES”, “cholecystectomy”, “transcolonic”, “transvaginal”, and “transgastric”. The accumulated literature was critically analyzed and reviewed.
Results: One-hundred and eighty-six cases of NOTES cholecystectomies have been published to date. Of these, 174 have been performed through a transvaginal approach. The remainder of the procedures were performed transgastrically. There are no published reports of ­transcolonic cholecystectomies performed in humans. Four of 186 cases (2.15%) were converted to traditional laparoscopy due to intraoperative complications. No significant complications or mortalities have been reported.
Conclusion: NOTES cholecystectomy appears to be a feasible procedure. However, technical, safety, and ethical issues remain relatively unresolved. Besides improved cosmesis, whether additional patient benefits are likely to accrue, in comparison to traditional laparoscopic ­cholecystectomy or single incision laparoscopic surgery (SILS), is unclear. Development of instrumentation to facilitate novel NOTES techniques is in its infancy, but is critical if NOTES is to be broadly applicable. Larger human trials, the development of technological and ­educational platforms, and an open discussion regarding the ethical concerns are necessary if this approach is to move forward.

Keywords: natural orifice transluminal endoscopic surgery, NOTES, cholecystectomy, ­transvaginal, transgastric, transrectal, transcolonic