Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR)

Natural Orifice Translumenal Endoscopic Surgery (NOTES) might represent the next major advancement in minimally invasive therapy. To address this emerging technology, a working group consisting of expert laparoscopic surgeons from SAGES and a group of expert interventional endoscopists representing ASGE have joined together as the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) Working Group on (NOTES).

The growing capabilities of therapeutic flexible endoscopy have ushered in a new era in treatment of gastrointestinal conditions. Refinements in laparoscopic surgery have progressed to the point that complex surgical procedures, such as gastric bypass, can now be performed in a minimally invasive fashion. These trends have set the stage for the development of even less invasive methods to treat conditions in both the gut lumen and in the peritoneal cavity. It seems feasible that major intraperitoneal surgery may one day be performed without skin incisions. The natural orifices may provide the entry point for surgical interventions in the peritoneal cavity thereby avoiding abdominal wall incisions.

The NOSCAR group identified a number of baseline issues. For NOTES® to mature into a viable technology, both procedure and device development must continue. At this stage, NOTES® must be performed by a team that has the skills of an advanced therapeutic endoscopist and a laparoscopic surgeon who in many instances will bring unique but complementary skills. There are a number of other fundamental issues, many of which are identified in the white papers which may be accessed via www.NOSCAR.org – the group’s official web site. These issues must be understood prior to the safe introduction of NOTES®. These are best addressed in laboratory settings. Having supportive laboratory data is an essential step prior to approval from regulatory agencies like the FDA or Institutional Review Board for performing initial NOTES. The most important areas for initial study are: safe peritoneal access and secure gastric closure, intraperitoneal contamination, image display and maintenance of spatial orientation, development of stable working platforms, physiologic perturbations, and tissue approximation methods (suturing and others).