Dr. Parveen Bhatia
Consultant Laparoscopic Surgeon & Medical Director,
Bhatia Global Hospital & Endosurgery Institute
www.bhatiaglobalhospital.com
Email: bhatiaglobal@yahoo.co.in

 

It is unique in one’s career in medicine to see a true paradigm shift that significantly changes patient management. This generation experienced such a paradigm shift with the introduction and development of laparoscopic surgery. It is possible that we are on the verge of another paradigm shift—Natural Orifice Translumenal Endoscopic surgery (NOTES).

Digestive medicine has changed progressively and dramatically over the last few decades. The major players on the digestive stage were easy to distinguish: Gastroenterologists wore suits and offered advice, Surgeons wore scrubs and made large incisions, and Radiologists wore lead aprons and looked at shadows. Gastroenterologists are becoming progressively more invasive, whilst much of surgery has become less so. The actors on the digestive stage now look very similar: minimally invasive surgeons, interventional gastroenterologists and radiologists all wear scrubs, gowns and gloves, and work with complex instruments passed through small holes in their patients, guided by images on endoscopic and radiologic monitors.

Endoscopists have begun to perform peroral fundoplication, and there is much interest in developing endoscopic approaches to obesity. Widespread mucosal resection is used increasingly for treatment of neoplasia in the esophagus, stomach and colon. The most
dramatic change is that a few pioneers have literally jumped “out of the box,” escaping the constraints of the lumen by driving their endoscopes through the gastric wall into a whole new world—the abdominal cavity— so called Natural Orifice Trans-lumenal Endoscopic Surgery (NOTES). The mouth is not the only route; other endoscopists have approached the peritoneum through the colon and the vagina.

As knowledge and technology race headlong in pursuit of disease processes, the distinction between physicians who treat similar conditions as different specialists becomes increasingly blurred. The natural evolution is collaboration as we decipher the best way to attack a common enemy with our ever expanding arsenal of molecular and mechanical tools. Time is just ripe for the mergence of minimally invasive surgery and gastro-intestinal endoscopy. SAGES (Society of American Gastrointestinal and Endosurgeons) and the ASGE (American Society for Gastrointestinal Endoscopy) came together for a meeting in New York City in July, 2005 and again in Scottsdale, Arizona in March, 2006. They jointly held the first International conference on Natural Orifice Trans-Lumenal Endoscopic Surgery (NOTES). The meeting brought together gastroenterologists and surgeons, teams of experts in flexible endoscopy and laparoscopic surgery from around the world to explore the challenges in bringing translumenal endotherapy to the clinical realm.

NOSCAR
Natural Orifice surgery consortium for Assessment and Research.
www.noscar.org

A NOTES white paper was written and published by SAGES and ASGE in February, 2006 to represent a cooperative effort to ensure that this cutting edge technology is developed with the safety of the patient in mind. White paper is published in Gastrointestinal Endoscopy: (volume 63, No. 2, 2006) and Surgical Endoscopy (2006, 20: 329–333). Both Dr. G. V. Rao and Dr. Nageshwar Reddy from Asian Institute of
Gastroenterology, Hyderabad were on the List of Conference Faculty.

In SAGES Annual meeting, held in April, 2006 at Dallas, Texas Transgastric Surgery Panel discussed the latest developments in the emerging field of Natural Orifice Surgery. The objectives were to understand the current techniques of accessing the peritoneal cavity via a trans-grastric route, device development needs, and the status of human trials in natural orifice surgery. The panel included Drs. David Rattner, Robert Howes, Lee Swanstorm, Jeffrey Ponsky, Chris Thompson and G. V. Rao. Dr. G. V. Rao from Asian Institute of Gastroenterology, Hyderabad made the country proud by showing seven cases of Transgastric Appendicectomy. He demonstrated his graduation from animal studies to human appendicectomies using flexible gastroscope, balloon dilators, snares, electrocautery, endocinch and endosuturing devices.

A recent membership survey indicated that over 60 percent of SAGES members currently practice endoscopy and feel that it will play an important role in their future practice.

It is anticipated that the skill sets needed will be hybrid that includes Laparoscopic skills as well as advanced flexible endoscopic skills.

‘T’ in NOTES stands for Trans-enteric, Trans Lumenal or Trans visceral. NOTES provides access to the peritoneal cavity to perform abdominal surgical procedures without skin incisions. Flexible endoscopes and current endoscopic devices have multiple limitations which include the lack of a stable platform, restrictions on retraction and spatial incongruity. These limitations inside the peritoneal cavity can potentially be overcome by blending the use of both a Laparoscope and a flexible upper endoscope-a hybrid approach. This surgery is also hybrid minimally invasive surgery—a bridge between laparoscopic and translumenal surgery.

FUTURE

Robotic NOTES

In vivo, robotics has evolved to provide wireless endolumenal mobile robotic capability. A miniature robot is inserted through the mouth via gastroscope. Gastrotomy is made and mini-robot traverses into abdominal cavity obviating the need for any skin incisions. The robot has a built in camera, wheels and biopsy capability. The robot measures 15mm by 75mm and is cylindrical. The miniature robot is able to provide an enhanced field of view of the abdominal cavity from multiple angles. The built in grasper is capable of obtaining a biopsy from a variety of abdominal organs. Such technology will reduce patient trauma while providing surgical flexibility.

“Be not the first when the new is tried. Nor yet the last to lay the old aside” - Alexnder Pope.