Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors

Diagnosis of gastric subepithelial tumor(SET) has shown a rapid increase worldwide.Although,until now,endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET,the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection.However,endoscopic resection or laparoscopic wedge resection alone also has some limitations.Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large(larger than 25 mm diameter).On the other hand,gastric SET in a difficult location,such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection.The hybrid natural orifice transluminal endoscopic surgery(NOTES) technique is a combined method,including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs.This method may be performed safely with reasonable operation times,less bleeding,and adequate resection margin and regardless of tumor size.In particular,in the case of a difficult location for resection,such as the esophagogastric junction or pyloric ring,hybrid NOTES is currently believed to be an ideal treatment method.

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

Removal of a guide-wire sliding into abdominal cavity via transgastric natural orifice transluminal endoscopic surgery: A case report

BACKGROUND Guidewire slippage into the peritoneal cavity during clinical operations is extremely rare.Therefore,this paper aims to report a successful case of guidewire removal using transgastric natural orifice transluminal endoscopic surgery(NOTES).The goal is to enhance physicians'understanding of the management plan for this unique scenario and provide a valuable reference for clinical practice.CASE SUMMARY A 64-year-old man presented with abdominal distension and was diagnosed with cirrhosis combined with massive ascites.To proceed with treatment,the patient underwent ultrasound-guided peritoneal puncture and underwent catheterization and drainage.Unfortunately,a 0.035-inch guidewire slipped into the abdominal cavity during the procedure.Following a comprehensive evaluation and consultation by a multidisciplinary team,the guidewire was successfully removed using NOTES.CONCLUSION This case highlights the potential consideration of transgastric NOTES removal when encountering a foreign body,such as a guidewire,within the abdominal cavity.

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery

BACKGROUND At present,laparoscopic cholecystectomy(LC)is the main surgical treatment for gallstones.But,after gallbladder removal,there are many complications.Therefore,it is hoped to remove stones while preserving the function of the gallbladder,and with the development of endoscopic technology,natural orifice transluminal endoscopic surgery came into being.AIM To compare the quality of life,perioperative indicators,adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery(EGPS)in patients with gallstones.METHODS Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected.We adopted propen-sity score matching(1:1)to compare EGPS and LC patients.RESULTS A total of 662 cases were collected,of which 589 cases underwent LC,and 73 cases underwent EGPS.Propensity score matching was performed,and 40 patients were included in each of the groups.In the EGPS group,except the gastr-ointestinal defecation(P=0.603),the total score,physical well-being,mental well-being,and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery(P<0.05).In the LC group,except the mental well-being,the total score,physical well-being,gastrointestinal digestion,the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery(P<0.05).When comparing between groups,gastrointestinal defecation had significantly difference(P=0.002)between the two groups,there was no statistically significant difference in the total postoperative score and the other three subscales.In the surgery duration,hospital stay and cost,LC group were lower than EGPS group.The recurrence factors of gallstones after EGPS were analyzed:and recurrence was not correlated with gender,age,body mass index,number of stones,and preoperative score.CONCLUSION Whether EGPS or LC,it can improve the patient’s symptoms,and the EGPS has less impact on the patient’s defecation.It needed to,prospective,multicenter,long-term follow-up,large-sample related studies to prove.

Natural orifice transluminal endoscopic surgery:Where are we going?

The foundation for natural orifice transluminal endoscopic surgery(NOTES) is to access the peritoneal and other body cavities through the wall of the alimentary tract via natural orifices,with the goal of performing procedures within the peritoneum and other cavities,without the need to make incisions in the abdominal wall.We have made great progress in the field of NOTES since the publication of the White Paper in 2006.There are still major fundamental goals as outlined by the Society of American Gastrointestinal and Endoscopic Surgeons/American Society for Gastrointestinal Endoscopy joint committee that need to be evaluated and answered before NOTES is ready for widespread clinical use.These include prevention of infection,instrument development,creation of a multitasking platform,and the ability to recognize and treat intraperitoneal complications such as hemorrhage and other physiological adverse events.In response to this need,recent abstracts and papers have focused on the management of intraoperative complications.The next phase is to focus on controlled prospective multicenter clinical trials that compare defined NOTES procedure to standard laparoscopy.The goal is to produce reliable and convincing data for the United States Food and Drug Administration,insurance companies,the physician community and the general public.At the present time,we still have many important milestones that still need to be met.Most investigators agree that a hybrid technique and not a pure NOTES practice should be advocated until devices can meet the current and new challenges in this f ield.

Current developments in natural orifices transluminal endoscopic surgery:An evidence-based review

Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access,safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in humans has yet to be determined. Reports of human NOTES procedures are emerging, and the possibility of accomplishing human NOTES based on existing technology has been demonstrated. However, dedicated platforms and devices are still lacking to allow for pure NOTES procedures, and whether NOTES can deliver the postulated benef its of earlier recovery and improved cosmesis remains uncertain.

Natural orifice transluminal endoscopic surgery:The transvaginal route moving forward from cholecystectomy

The advent of minimally invasive surgery and the advances in endoluminal flexible endoscopy have converged to generate a new concept in digestive surgery,whose acronym natural orifice transluminal endoscopic surgery(NOTES),has become a familiar term in the surgical community.NOTES has been performed through the mouth,the bladder,the rectum and the vagina.Of these four approaches,the vagina has gained most popularity for several reasons.It is not only readily accessible and easy to decontaminate but it also provides safe entry and simple closure.The transvaginal approach has been described in the experimental and the clinical setting as an option for cholecystectomy,nephrectomy,splenectomy,segmental gastrectomy,retroperitoneal exploration and bariatric surgery.However,larger series are needed to delineate the exact risks of this approach,and to transcend cultural barriers that impede its wider introduction.Prospective randomized trials will shed light on the definitive role of the vaginal approach in minimal invasive surgery of the future.

Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model

AIM: To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model. METHODS: The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy. RESULTS: Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels. CONCLUSION: The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.

Natural orifice transluminal endoscopic surgery in urology: The Chinese experience

Objective:To describe the Chinese experience of natural orifice transluminal endoscopic surgery(NOTES)in urology.Methods:From December 2008 to May 2017,35 animal experiments and 305 clinical surgeries of NOTES or natural orifices specimen extractions(NOSE)were performed in China.The animal experiments included five kidney biopsies,24 nephrectomies and six partial nephrectomies.The clinical surgeries included 12 transvaginal NOSE(TV-NOSE),266 hybrid transvaginal NOTES(TV-NOTES)and 27 pure TV-NOTES.The TV-NOSE procedure was performed in five transumbilical laparoendoscopic single-site(U-LESS)nephrectomies,four suprapubic-assisted laparoendoscopic single-site surgery(SA-LESS)nephroureterectomies,and three laparoscopic radical cystectomies.The hybrid TV-NOTES procedure included 210 nephrectomies,31 adrenalectomies,eight nephroureterectomies,13 partial nephrectomies,and four heminephrectomies.The pure TV-NOTES procedure included five renal cyst decortications and 22 nephrectomies.Results:A total of 29 animal experiments were successfully performed.One partial nephrectomy was converted to standard laparoscopic surgery.Two kidney biopsies and two nephrectomies were unsuccessful.A total of 297 clinical surgeries were successfully performed.Six patients who underwent hybrid TV-NOTES were converted to open surgery.Two patients who underwent pure TV-NOTES were converted to SA-LESS.There were 22 major complications,16 occurred intraoperatively and six postoperatively.The mean visual analog score(VAS)of 48 h after the operation was 2.5 points in TV-NOSE,2.3 points in hybrid TV-NOTES and 1.7 points in pure TV-NOTES.The mean follow-up of 50.6(3.0-87.0)months showed that all patients were in good condition.The umbilicus scars were nearly invisible in TV-NOSE and hybrid TV-NOTES.The vaginal incision healed well.Conclusions:TV-NOSE and TV-NOTES are feasible,safe,and effective with little injury,low pain,fast recovery,and good cosmetic outcomes in properly selected patients.They are worth consideration for urological clinical practice.

Natural orifice transluminal endoscopic surgery:Educational challenge

Natural orifice translumenal endoscopic surgery(NOTES) training is unique in that it crosses specialty lines and most practitioners do not possess both the knowledge and skill to perform the procedures in their current form.The learning process becomes even more complex because the field is in constant evolution with advances in technology and technique being introduced almost daily! The challenges of learning NOTES illustrates a larger problem in all procedurally based medical specialties today-the pace of change has become so rapid that a practicing physician's technical skills become out of date within five to ten years of completing residency or fellowship training.As a result,practicing physicians must develop a strategy to rapidly learn about a new technique or technology and introduce it safely into their practice while satisfying the concerns of their hospital's credentialing committee.This chapter will explore the options for learning new procedures and discuss the rapidly expanding armamentarium of education institutes and the developing technology to measure procedural competence.

Embryonic natural orifice transluminal endoscopic surgery in the treatment of severe acute pancreatitis complicated by abdominal compartment syndrome

BACKGROUND: The study aimed to estimate the value of embryonal natural orifice transluminal endoscopic surgery(ENOTES) in treating severe acute pancreatitis(SAP) complicated with abdominal compartment syndrome(ACS).METHODS: The patients, who were randomized into an ENOTES group and an operative group, underwent ENOTES and laparotomy, respectively. The results and complications of the two groups were compared.RESULTS: Enterocinesia was observed earlier in the ENOTES group than in the operative group. Acute Physiology and Chronic Health Evaluation II(APACHE II) score of patients in the ENOTES group was lower than that of the operative group on the 1st, 3rd and 5th post-operative day(P<0.05). The cure rate was 96.87% in the ENOTES group, which was statistically different from 78.12% in the operative group(P<0.05). There were significant differences in complications and mortality between the two groups(P<0.01).CONCLUSION: Compared with surgical decompression, ENOTES associated with flexible endoscope therapy is an effective and minimal invasive procedure with less complications.

Natural orifice transluminal endoscopic surgeryvs laparoscopic ovariectomy:Complications and inflammatory response

AIM:To compare natural orifice transluminal endoscopic surgery (NOTES) vs standard laparoscopic ovariectomy in mini pigs with respect to technical aspects,complications and parameters of systemic inflammatory response.METHODS:This was a randomized,experimental,survival study.Ten female mini pigs underwent NOTES transgastric ovariectomy (NOTES group) and ten female mini pigs underwent laparoscopic ovariectomy (LAP group).A "percutaneous endoscopic gastrostomy" approach with guidewire and sphincterotome was used for gastrotomy creation.The ovary was resected using standard biopsy forceps and a snare.The access site was closed using a "KING" closure with a single endoloop and several clips.In the laparoscopic group,a three-port laparoscopy and an ovariectomy were performed with the use of standard laparoscopic devices.C-reactive protein (CRP),white blood count and interleukin (IL)-6 plasma levels were used as indicators of systemic inflammatory response.All animals were euthanized 28 d after surgery.RESULTS:All animals survived without complications.The mean procedure time was 41.3 min ± 17.6 min (NOTES group) and 25.7 min ± 5.25 min (LAP group,P < 0.02).Postmortem examinations demonstrated that 50% and 70% of animals were free of any complications in the NOTES and LAP groups,respectively.The remaining animals developed minor complications (adhesions) in a comparable frequency between the two groups.In the NOTES group,one animal developed a small intramural gastric abscess close to the gastrotomy site.A minor serous exudate that was present in 50% and 40% of the animals in the NOTES and laparoscopy groups,respectively,was not considered a complication.In both groups CRP levels increased significantly on the 2nd and 7th postoperative days (POD) and returned to normal after 28 d.On POD 2,an increase of CRP level was significantly higher in the NOTES group compared to the LAP group.Values of IL-6 did not differ from baseline values in either of the groups postoperatively.Interestingly,the platelet count decreased significantly on POD 2,but returned close to baseline values on POD 7 and PODs 28-30.CONCLUSION:Both NOTES and laparoscopic ovariectomies had a similar frequency of minor complications.However,the NOTES technique produced an increased systemic inflammatory response on POD 2.

Natural orifice transluminal endoscopic surgery:New minimally invasive surgery come of age

Although in the past two decades,laparoscopic surgery,considered as a great revolution in the minimally inva-sive surgery field,has undergone major development worldwide,another dramatic surgical revolution has quietly appeared in recent years.Ever since Kalloo's first report on transgastric peritoneoscopy in a porcine model in 2004,interest in a new surgical procedure named natural orifice transluminal endoscopic surgery(NOTES)has blossomed worldwide.Considering that a NOTES procedure could theoretically avoid any abdomi-nal incision,operation-related pain and scarring,many surgeons and endoscopists have been enthusiastic in their study of this new technique.In recent years,sev-eral NOTES studies have been carried out on porcine models and even on humans,including transvaginal cholecystectomy,transgastric appendectomy,transvagi-nal appendectomy,and transvesical peritoneoscopy.So what is the current situation of NOTES and how many challenges do we still face?This review discusses the current research progress in NOTES.

Are laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery gallbladder preserving cholecystolithotomy truly comparable?A propensity matched study

BACKGROUND Cholecystectomy is the preferred treatment option for symptomatic gallstones.However,another option is gallbladder-preserving cholecystolithotomy which preserves the normal physiological functions of the gallbladder in patients desiring to avoid surgical resection.AIM To compare the feasibility,safety and effectiveness of pure natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving cholecystolithotomy vs laparoscopic cholecystectomy(LC)for symptomatic gallstones.METHODS We adopted propensity score matching(1:1)to compare trans-rectal NOTES cholecystolithotomy and LC patients with symptomatic gallstones.We reviewed 2511 patients with symptomatic gallstones from December 2017 to December 2020;517 patients met the matching criteria(NOTES,110;LC,407),yielding 86 pairs.RESULTS The technical success rate for the NOTES group was 98.9%vs 100%for the LC group.The median procedure time was 119 min[interquartile ranges(IQRs),95-175]with NOTES vs 60 min(IQRs,48-90)with LC(P<0.001).The frequency of post-operative pain was similar between NOTES and LC:4.7%(4/85)vs 5.8%(5/95)(P=0.740).The median duration of post-procedure fasting with NOTES was 1 d(IQRs,1-2)vs 2 d with LC(IQRs,1-3)(P<0.001).The median post-operative hospital stay for NOTES was 4 d(IQRs,3-6)vs 4 d for LC(IQRs,3-5),(P=0.092).During follow-up,diarrhea was significantly less with NOTES(5.8%)compared to LC(18.6%)(P=0.011).Gallstones and cholecystitis recurrence within a median of 12 mo(range:6-40 mo)following NOTES was 10.5%and 3.5%,respectively.Concerns regarding the presence of abdominal wall scars were present in 17.4%(n=15/86)of patients following LC(mainly women).CONCLUSION NOTES provides a feasible new alternative scar-free treatment for patients who are unwilling or unable to undergo cholecystectomy.This minimally invasive organ-sparing procedure both removes the gallstones and preserves the physiological function of the gallbladder.Reducing gallstone recurrence is essential to achieving widespread clinical adoption of NOTES.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model. METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope. RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to sixstitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer:A case report

BACKGROUND Pure natural orifice transluminal endoscopic surgery(NOTES)for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges,including loss of triangulation,in-line orientation,and instrument collision.Transvaginal(v)NOTES,however,can overcome these technical challenges.We report a case of pure vNOTES right hemicolectomy for colon cancer,attached with surgical video.CASE SUMMARY A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy.Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons.The operative time was 200 min and the estimated blood loss was 30 mL.No intraoperative or postoperative complications occurred within 30 d after the surgery.The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3.The patient was discharged at postoperative day 6.The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.CONCLUSION vNOTES right hemicolectomy,performed by well-experienced surgeons,overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diag- nostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.

Natural orifice transluminal endoscopic surgery and localized resection for colorectal neoplasia

Modern methods of surgical intervention have the potential to provide effective,definitive management of early stage colorectal neoplasia by truly minimally invasive means.Margin-free clearance of early colonic neoplasia from within the intestinal lumen can already now be effected by endoscopic submucosal dissection in the colon and transluminal endoscopic microsurgery(TEM) in the rectum.Natural orifice transluminal endoscopic surgery(NOTES) offers the potential for providing transmural,full thickness excision as TEM does but at sites in the colon proximal to the rectum.The next conceptual advance required to make this practice an effective reality lies in evolving surgical regional staging strategies to effectively partner localized resective approaches and allow their deployment as definitive curative therapy.As the most compelling modality for nodal status ascertainment in the absence of lymphatic basin excision for other malignant disease processes,it seems timely to reconsider sentinel node biopsy in cancer of the colon and rectum.Whether by this means or indeed any other,such an ability to confidently identify patients with node negative disease would allow nascent innovative techniques flourish as definitive management for confined(N0) T1 and T2 cancers and so allow the application of available advanced technology for clinical benefit.Conversely,the development of a specific clinical niche for NOTES(whether,as here,for full thickness localized colonic excision or nodal staging alone) would greatly benefit the evolution and incorporation of this surgical strategy into clinical care paradigms.

Gastrointestinal tract access for urological natural orifice transluminal endoscopic surgery

We conducted a literature review of natural orifice transluminal endoscopic surgery(NOTES),focusing on urologic procedures with gastrointestinal tract access,to update on the development of this novel surgical approach.As part of the methods,a comprehensive electronic literature search for NOTES was conducted using Pub Med and Cochrane Library from March 2002 to February 2016 for papers reporting urologic procedures performed utilizing gastrointestinal tract access.A total of 11 peer-reviewed studies examining utility of gastrointestinal access for NOTES urologic procedures were noted,with the first report in 2007.The procedures reported in the studies were total/radical nephrectomy,partial nephrectomy,adrenalectomy,and prostatectomy.The transgastric approach was identified in five studies examining total/radical nephrectomy(n = 2),partial nephrectomy(n = 1),partial cystectomy(n = 1),and adrenalectomy(n = 1).Six studies evaluated transrectal approach for NOTES,describing total/radical nephrectomy(n = 3),partial nephrectomy(n = 1),robotic nephrectomy with adrenalectomy(n = 1) and prostatectomy(n = 1).Feasibility was reported in all studies.Most studies were preclinical and acute,and limited by concerns regarding restricted instrumentation and infection risk.We concluded that gastrointestinal access for urologic NOTES demonstrates promise as described by outlined feasibility studies in preclinical models.Nonetheless,clinical application awaits further advancements in surgical technology and concerns regarding infectious potential.

NOTES-Natural orifice transluminal endoscopic surgery:Why not?

Since natural orifice transluminal endoscopic surgery(NOTES) was first described by Anthony Kalloo,it has attracted tremendous interest from surgeons and gastroenterologist all around the world.This special issue of the World Journal of Gastrointestinal Surgery explores the current possibilities and future potential of the most disruptive revolution in the field of surgery represented by the NOTES approach.In the future,new technologies developed for this approach and deeper insight into several gastrointestinal diseases will lead to the design of completely new interven tional procedures and change the way we will operate,bringing us to the previously unimaginable goal of "no scar surgery".