Natural orifice transluminal endoscopic surgery (NOTES): when a step forward may be a step too soon or too far.

To the editor, In the 1980s and 1990s, the advent of laparoscopy revolutionized abdominal surgery. Despite the absence of a randomized, controlled, large-scale evaluation, laparoscopic cholecystectomy has become the gold standard for the management of symptomatic cholelithiasis. Laparoscopy has allowed cholecystectomy to be performed with very low rates of complications and mortality, a very short hospital stay (\12–24 h), and less postoperative pain. Moreover, the cosmetic results for laparoscopic cholecystectomy performed using a 10-mm trocar in the ombilicus and two other 2or 5-mm abdominal trocars are excellent. Recently, natural orifice transluminal endoscopic surgery (NOTES) was proposed as a new surgical technique, with the aim of performing abdominal surgical procedures through natural orifices such as the mouth, the vagina, or the rectum to avoid visible incisions, allowing for perfect cosmetic results. The NOTES approach has been sponsored largely by the surgical industry looking for a new potential market. Moreover, we, the surgical community, were the victims of our own pride, with many surgeons trying to be the ‘‘first to use NOTES’’ and to report it. In the past 5 years, experimental and clinical NOTES procedures have become a hot topic at nearly all abdominal surgical meetings, with very few cautionary tales. In the August 2009 issue of Surgical Endoscopy, Bachman et al. [1] compared two methods of colonic decontamination in their experimental study using a swine model. Both of their study groups showed a very significant decrease in live colonic bacteria, but NOTES performed in these animals resulted in peritoneal bacterial contamination. Someone may eventually publish a method for efficient decontamination of the colon after sterile NOTES procedures through the colon. But anyone who has experienced bowel preparation for colonoscopy (and I did) may testify that this is not great fun. To me, a total colonic decontamination to allow transcolonic cholecystectomy seems thoughtless. Moreover, inducing an iatrogenic perforation of the colon for a rather simple and safe abdominal procedure such as cholecystectomy will certainly induce postoperative colonic fistulas, a new complication that will be dramatic even if rare. The same problem of postoperative fistulas may be argued for transgastric NOTES. Another article in the August issue of Surgical Endoscopy reports that Peterson et al. [2] asked women whether they would undergo transvaginal NOTES cholecystectomy on the basis of better cosmesis and a lower rate of postoperative incisional hernia. Of course they were! However, nowhere in the article were the potential hazards of this new procedure mentioned, nor the possibility of severe complications including bladder or rectal perforation, Douglas abscess, or postoperative vaginal bleeding. These potential risks were not mentioned in the case of transvaginal hybrid NOTES reported in the same issue by Horgan et al. [3], who stated that the patient signed an informed consent. What is a truly informed consent for a surgical procedure that we, the surgeons, do not even know is safe? In addition, the procedure described by Horgan et al. [3] illustrates the recent NOTES trends. First the access was transvaginal, as in most reported cases to date due to the unsolved problems of transluminal access. Does another solution exist that may fit the male population? Moreover, they used a 5-mm transabdominal trocar, resulting in a O. Detry (&) B. Nsadi L. Kohnen Department of Abdominal Surgery and Transplantation, University of Liege, Sart Tilman B35, 4000 Liege, Belgium e-mail: oli.detry@chu.ulg.ac.be