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No need for general anesthesia // Virtually pain-free // Speedy discharge from the hospital // No unsightly scars to show you were ever there.

Down the Hatch

By Charles Slack // Spring 2006
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natural orifice translumenal endoscopic surgery (NOTES)

Leland Bobbe/Getty Images

Generations of American children have drawn their first impressions of surgery trying to save the life of Sam, a patient in the iconic board game Operation. Using metal tweezers, players try to remove body parts (wishbone, butterflies in the stomach) without touching the metal sides of body cavities. Slip up, and Sam’s red nose flashes. The game bears little resemblance to real surgery except in one crucial regard—it recognizes that there are serious penalties for setting off the body’s alarms.

In an actual patient, of course, the alarm systems are infinitely more sensitive and complex. And now the analogy shifts from a children’s board game to a museum guarded by lasers and sophisticated motion detectors. Surgeons targeting organs in the abdominal cavity traverse a delicate, complicated network of nerves, antibodies and chemical messengers designed to recognize and attack all invaders—bacteria, a surgeon’s scalpel—with lightning speed. To get past these defenses, surgeons rely on stealth and subterfuge. They make ever-smaller incisions and employ less invasive equipment. In that sense, the entire history of surgery is a quest for the perfect crime.

While the internal organs themselves are relatively free from nerves, getting at them, even with minimally invasive techniques such as laparoscopy, requires cutting through the nerve-laden abdominal wall and parietal peritoneum. That’s where most of the pain from abdominal surgery comes from. But what if a surgeon could find another way into the body, and thus avoid cutting through the abdominal wall at all? Advances in endoscopy already provide close-up views of the entire digestive tract, utilizing probes and cameras not just to diagnose but also to treat a variety of gastrointestinal disorders. What if the next logical step were to approach the heavily guarded bodily museum through the mouth or anus and then sneak into the abdominal cavity, gaining access to internal organs, through an incision in the stomach wall?

To a growing group of proponents, this has become much more than a pipe dream. Already the new procedure has a name—NOTES, for natural orifice translumenal endoscopic surgery—and several American surgeons have been honing their techniques on test animals. Meanwhile, two surgeons in India have reportedly done limited experiments on humans, using a combination of laparoscopic and natural orifice surgery. (A few U.S. researchers have seen a short video of the procedures, but the results haven’t been published and few details are known.) Estimates for when human trials will begin in the United States range from two years to five or more.

For natural orifice surgery to succeed, surgeons will have to win over critics, who contend that the new approach offers scant improvement over laparoscopic technology and may not be worth the risks, which include fatal infection. But supporters say the procedure, if perfected, could offer a revolutionary prospect to patients suffering from problems of the gallbladder, appendix, spleen or other organs: abdominal surgery with no pain, no scars and almost no recovery time.

previous // next
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Quest for the Perfect Crime

The tools of minimally invasive surgery are becoming smaller and stealthier.

A New Step in Scarless Surgery

Years ahead of schedule, doctors perform on humans a surgery that involves reaching internal organs via the mouth or other natural orifices.


1. “ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery,Surgical Endoscopy, February 2006. This white paper by 14 gastroenterologists and surgeons offers a detailed description of the challenges facing NOTES.

2. “Flexible Transgastric Peritoneoscopy: A Novel Approach to Diagnostic and Therapeutic Interventions,” by Anthony N. Kalloo et al., Gastrointestinal Endoscopy, July 2004. Groundbreaking study by a NOTES pioneer and his Johns Hopkins team.

3. “Transgastric Surgery Panel.” Panel discussion held at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Dallas, April 28, 2006, moderated by David W. Rattner.

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