NOTES Surgery

NOTES Surgical Procedures Explained

NOTES Surgery, NOTES surgeons, NOTES procedures
Surgeons in the OR. Image: Getty

What is NOTES Surgery?

NOTES Surgery, or Natural Orifice Translumenal Endoscopic Surgery, is not a single procedure, it is a type of surgical approach that minimizes incisions on the body and scarring.  How is this possible? NOTES is a surgical technique that requires no external incision. The lack of an incision made in the skin is why this type of procedure is also referred to as "scarless surgery."

NOTES is still considered an experimental surgical technique, but is expected, by some, to become the next evolution in minimally invasive surgery.

Instead of making an incision on the skin, the incision is made inside the body, using an orifice -- a way into the body that already exists. Most procedures are performed through the mouth or via the vagina, but can be done through the anus or urethra.

In some cases, additional instruments may be inserted through a tiny incision made in the belly button, as a way to guide the surgeon. The location of this incision means that no scar will be apparent, as it will be hidden in the folds of the skin.

One example of a NOTES procedure is a surgery performed upon the stomach, where the instruments are inserted into the mouth, down the esophagus, and the surgeon works on the stomach from the inside, or makes an incision in the stomach to operate outside of the stomach.

NOTES procedures are often referred to as scarless, because any incision that is made is internal and cannot be seen. While laparoscopic surgery is commonly referred to as minimally invasive, NOTES is the next generation of surgical approaches, an even less invasive procedure.

How Notes Surgery is Different

NOTES is a unique approach to surgery, using a natural opening in the body for better surgical access.

It avoids techniques that cause pain during the healing process, such as cutting through the skin and abdominal tissues, and avoids cutting the abdominal muscles, which also contributes to pain and can lead to complications like hernias.

In this example we will look at the cholecystectomy, the surgery to remove the gallbladder, which can be performed multiple ways.

The original "open" procedure requires an abdominal incision that is about 4 inches long, through which the surgeon visualizes the gallbladder, performs surgery and removes the diseased organ.

The next evolution of the cholecystectomy surgery was laparoscopic surgery, also known as minimally invasive surgery, to remove the gallbladder. This technique required four half-inch long incisions, one of which was usually hidden in the belly button, through which instruments including a tiny camera were inserted. The surgeon sees the procedure on a monitor, which shows the live video shot by the camera.

The NOTES procedure to remove the gallbladder starts in the vagina, where the incision is made to allow access to the gallbladder. The instruments, including an endoscope with a tiny camera, are then inserted through the vaginal incision until the gallbladder can be visualized using the camera.

The surgeon performs the surgery by watching the video on a monitor, just as they do with laparoscopic procedures.

With each progression in the technique used to perform the surgery, the risks of the procedure are reduced and recovery time is improved upon.

For men, there is obviously no transvaginal procedure for gallbladder surgery, but there is a similar NOTES procedure that is performed via the rectum. If that approach is not appropriate, then the more traditional laparoscopic surgery can be used.

Types of Surgery Performed With NOTES 

There are multiple surgical procedures that are possible using the NOTES scarless approach.

Additional procedures will certainly be added to this list as the technique becomes more widespread over time as the technique is still considered experimental (but viewed as having great promise).

Procedures Possible With NOTES Techniques:


Natural Orifice Surgery: Initial Clinical Experience. Santiago Horgan, et al, Accessed March 2011.>

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