NOTES (Natural Orifice transluminal endoscopic surgery) – Incisionless procedures
Scarless surgery performed on internal organs, also known as Natural Orifice Transluminal Endoscopic Surgery (NOTES), is a form of minimally invasive surgery combining endoscopic and laparoscopic approaches with entry through a natural orifice, such as the mouth, anus, vagina, etc. NOTES has gained a great interests of surgeons and public after a revolutionary success of laparoscopic surgery a decade ago. Although, this novel and promising approach has been trialed for many abdominal operations, only few procedures emerged to today’s practice. Below is a table comparing surgical approaches.
|Single-Port laparoscopic Surgery
|Length of Incision (cm)
|2-3one site in the umbilicus
|Least or none
|Scar tissue risk (adhesions)
|Extremely Low to none
|Risk of incision infection
|Risk of hernia
Some of the NOTES procedures are used in combination with traditional laparoscopic approach, the others are true incisionless operations. Because of inherent technical complexity, they are mainly performed in large specialty centers. As a community hospital ,Hilo Medical Center stands out in this regard as we are capable of performing all existing type of NOTES accepted in surgical practice to date. For over eight years we have been offering peroral surgical treatment of esophageal diverticulum, known as Zenker’s diverticulum, and TAMIS (transanal minimally invasive surgery). The later procedure allows for removal of large and precancerous intestinal polyps that could not be removed via traditional endoscopy without incisons or removal of part of intestine. The first transanal mesorectal excision operation (or TaTME – a form of NOTES) ever performed at a community hospital was first successfully conducted at HMC in 2017. A series of first successful peroral endoscopic myotomy (POEM) in the state of Hawaii was also performed at HMC. Below is a table with NOTES and advanced endoscopic procedures we offer at HMC today:
|Peroral endoscopic myotomy (POEM)
|Performed with flexible scope, just like upper endoscopy. It used for esophageal motility disorders and esophageal diverticula.
|G-POEM (endoscopic pyloromyotomy)
|Used for treatment of gastroparesis (“lazy stomach”) and alleviates food passage into intestine.
|Endoscopic submucosal dissecation (ESD)
|Pure endoscopic procedure allowing for removal of large or precancerous gastric and intestinal lesions.
|Using a suturing device attached to the end of conventional flexible endoscope allows for full thickness intestinal defects or fistula closure without operation or fixation of stents to prevent their migration.
|Peroral endoscopic stapling esophago-diverticulostomy
|Incisionless surgery for Zenker’s diverticulum in upper esophagus
|Transanal minimally invasive surgery (TAMIS)
|Surgical excision of larger intestinal polyps and lesions, which could not be removed endoscopically
|Transanal mesorectal excision (TaTME)
|A spincter preserving removal of rectum for rectal cancer; combined with laparoscopic approach.
|Stretta (radiofrequency treatment of acid reflux)
|Endoscopic procedure to augment lower esophageal sphincter to improve it’s function against gastro-esophageal reflux.
Despite the obvious benefits of minimally invasive approach, not all patients could be candidates for some of these complex procedures. For best results we consider patient’s individual patterns, anatomy and physiology with the help of intensive work up and detailed discussion. The role of pioneers of endoscopic surgery in the state of Hawaii obligates us to maintain up to date knowledge and skills via CME (continued medical education) courses with world experts in the area. We dedicated to provide the best possible surgical care available to our community.