First time in the history of surgery antony kalloo presented transgastric surgery in 2004, he could not imagine that he and notes would be a revolution in laparoscopic surgery. When asge and sages created a working group to develop transluminal surgery, while some did think that notes would improve conventional flexible endoscopy, none of the leaders sensed that this idea would have some repercussion on laparoscopic surgery.
The initial idea behind notes was that of an incisionless surgery, which would de facto eliminate scars accessing the peritoneal cavity via natural orifices. This implies the use of controlled procedures that breech the lumen of a healthy hollow viscus such as the stomach, the colon, the vagina or the urinary bladder. Research has to focus on finding the best way of accessing the peritoneal cavity, on the development of leak-proof closure methods and on minimizing the potential risks related to contamination. Several options are available: decrease the number of instruments, gather ports in the same incision, use multiple instruments through the same port or use an operative scope through a single port. In the nineties, the first descriptions of cholecystectomy techniques performed through an approach that allowed reducing the number of ports or gathering them at the umbilicus. Single-port laparoscopic appendectomies were reported. These experiments were not known to all. It was brought to the general attention with the advent of notes. What is clear however is that all this testifies renewed interest in finding a way to minimize bodily trauma. Improved cosmesis is an obvious additional psychological advantage for patients. These techniques build a bridge between laparoscopic and transluminal surgery and the newly achieved developments. Most likely the technological developments that tues and notes require will confer reciprocal benefits. While secure closures of gastric or colonic incisions are critical and difficult, the experience of gynecologists performing transvaginal procedures has demonstrated the safety of this route: infection rate is 0.001%, rectal injury is 0.002% and localized bleeding is 0.2%. This compares favourably with the risks related to the use of trocars in laparoscopic surgery: 0.03-0.3% of visceral and vascular injuries, 0.7-1.8% of incisional hernia. This is the reason why the first clinical application of notes, cholecystectomy, was performed through the transvaginal route. The idea behind this was to create a model for notes, avoiding the drawbacks of new entry sites, thus allowing for an objective evaluation of the potentials of this concept. But this approach, per se, has limitations. In addition, time is needed to develop technologies that would facilitate the procedure and to study the consequences of the breach of a hollow viscus of the gi tract. This matter has forced us, laparoscopic surgeons, to think. Studies have shown that postoperative pain is decreased when fewer and smaller trocars are used. Laparoscopic cholecystectomy with micro-instruments confirmed these findings. Nevertheless, this technique did not become as popular and as widespread as one would have imagined. This is mainly due to the technical challenge related to the size and lack of stability of micro-instrumentation. Therefore, surgeons needed to rethink this and look for other solutions. How can we possibly reduce the number of trocars, how can we improve the cosmesis in laparoscopic surgery? How can we perform a procedure that needs several instruments and therefore multiple ports, when aiming at reducing the number of ports?
Dr. Sadhana Mishra is a General Surgeon
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