Natural orifice surgery: applications in colonic surgery

Natural orifice transluminal endoscopic abdominal surgery, or NOTES, allows invasive operations to be performed through a single or multiple natural-orifice approach either in isolation (“pure”) or in combination with a transparietal (”hybrid”) access format. Therefore, to facilitate a colonic or rectal resection, the transgastric, transrectal or transcolonic routes, as well as the transvaginal route in women, can all be used either alone or in combination. We are now performing resectional colonic techniques on our patients that have been inspired by this revolutionary concept, carefully planned with storyboarding and validated in porcine models with survival analysis. Adaptation of existing equipment along with the use of new instruments and some simple ideas, such as magnetic fields to retract and mobilize the colon, have allowed us to simplify and standardize the operative technique (the first steps to ensuring procedural reproducibility). Initial potential applications can easily be imagined for partial colonic resections for voluminous benign polyps and for small early cancers, but these applications may extend to incorporate inflammatory bowel diseases such as diverticular disease of the sigmoid colon. For these techniques to further improve and the concept to become a concrete reality, a change in current surgical practice is required, and conventional laparoscopic techniques must be understood to represent a point along the evolutional development of surgery and not considered the final destination. However, as important as technical capacity is, due consideration and assurance of oncological and immunological propriety is essential, as is the issue of clarifying precise patient harm:benefit risk ratios.