NOTES: Current Status and Recent Developments

Background: The beneficial clinical results of laparoscopic surgery have prompted modern investigations to further minimize surgical trauma and to optimize cosmetic results. Natural orifice transluminal endoscopic surgery (NOTES®) refers to the surgical concept of entering the surgical field through a body lumen for diagnostic and therapeutic purposes without producing visible scars. Method: A review of the current literature was undertaken by means of the electronic databases Excerpta Medica and EMBASE. Results: Although the level of clinical evidence is low, the concept of NOTES has found clinical application in a variety of abdominal procedures, such as cholecystectomy, appendectomy, and sigmoidectomy. The vagina represents the most frequent access route for NOTES while the stomach, the rectum, and the transoral approach are further options. Several clinical studies have demonstrated the feasibility of a wide variety of NOTES procedures; however, there are currently no hard data supporting the superiority of this approach over conventional laparoscopic techniques. Furthermore, inherent limitations of the NOTES concept, such as the loss of triangulation, difficult tissue manipulation, and the potential contamination of the surgical field, warrant technological advances in medical endoscopy, instrumentation, and endoscopic tissue closure. Conclusions: In its current status, NOTES has to be considered as a stage towards minimization of surgical access trauma rather than as an established surgical concept.