A new technique promises to avoid the scars and complications caused by traditional laparoscopic surgery. It particularly could help patients for whom traditional surgery is especially risky, including the morbidly obese. The technique is called natural orifice transluminal endoscopic surgery, or NOTES.

In the procedure, the endoscope is routed to the abdominal cavity through the colon, where surgical endoscopic accessories can be employed to perform procedures in the abdominal cavity from inside the patient outward, rather than from outside inward, as in traditional laparoscopic surgery. To minimize infection, the colon and stomach typically are washed using various methods prior to insertion of the endoscope. For the same reason, an overtube typically is guided through the colon before inserting the endoscope.

Dr. Mihir S. Wagh and Dr. Christopher C. Thompson of Brigham and Women’s Hospital in Boston have reviewed this procedure. They caution that enthusiasm based on its assumed advantages is outpacing research, and they call for more clinical and scientific evaluation of the technique. So far, no human trials have been reported, aside from one anecdotal report.

The reviewers also call for development of endoscopic accessories for this particular type of surgery. They compare the use of traditional surgical accessories in transluminal surgery with driving a nail with a screwdriver. They said that closing the surgical access site is the most important step, and several devices are being developed for that purpose.

They also state that training programs will need restructuring to integrate this technique because it is a surgical technique — yet one that is designed for gastroenterology — and gastroenterologists are not surgeons. Further considerations include determining the effect of the surgery on the immune system and identifying the patient population that will receive the most benefit from the procedure. (Nature Clinical Practice Gastroenterology & Hepatology, July 2007, pp. 386-392.)