First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Agiou Thoma 17 St., Athens, Greece.
Am J Surg. 2012 Jul;204(1):93-102. doi: 10.1016/j.amjsurg.2011.05.019. Epub 2011 Dec 28.
We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated.
Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated.
The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable.
NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.
我们评估了模型、技术以及将其应用于自然腔道手术（主要是经自然腔道内镜外科手术[NOTES]）临床环境的适用性，这些手术主要是普外科手术。由于NOTES 有可能开创一种完全替代传统经自然腔道手术的方法，因此其受到了广泛关注。除了潜在的无疤痕手术和消除与皮切开相关的并发症之外，还必须评估这种新手术技术的安全性和有效性。
通过检索 MEDLINE、EMBASE、Cochrane 图书馆和 Entrez PubMed 从 2007 年到 2011 年 2 月进行了研究。大多数参考文献是在 2009 年至 2010 年确定的。评估的研究仅涉及人类，不包括尸体或动物，因此在评估的人群方面没有任何限制，但在评估的研究证据水平方面存在限制。
符合我们综述要求的研究主要发表于 2007 年至 2010 年（见方法部分）。所有评估的研究均仅在人类中进行。我们研究了文献中最常见的入路，如阴道、口腔、胃、食管、肛门或尿道。由于每个手术的性质不同，因此无法确定最佳的进入途径和方法。我们主要研究普外科手术，如胆囊切除术、肠道癌症、肾脏癌症、阑尾切除术、纵隔镜检查和腹膜镜检查。所有手术均可行，大多数术后均无并发症。尽管已经遇到了一些技术问题，特别是对于纯 NOTES 手术而言，但为了促进每个入路，开发新的内镜器械的需求是不可否认的。
NOTES 仍处于发展的早期阶段，需要更强大的技术来实现可靠的闭合并克服技术挑战。需要在人类中进行精心设计的研究，以确定 NOTES 在临床环境中的安全性和有效性。在这些 NOTES 入路中，经阴道入路似乎不太复杂，因为它实际上消除了对泄漏和瘘管的担忧。经阴道入路进一步有利于上腹部手术，因为它为上腹部器官（如肝、胆囊、脾、腹部食管和胃）提供了更好的操作能力。胃被认为是最有前途的目标之一，因为这种大器官一旦充分游离，就可以用吻合器轻松切断。大多数入路似乎即使使用目前的设备也可行，但是为了获得更好的结果并将其更广泛地应用于人类，需要开发新的内镜器械来促进每个入路。
