Adrenal natural orifice transluminal endoscopic surgery (NOTES): a step too far?

Abstract

Surgical approach to adrenal gland has evolved from open to minimally invasive surgery. With the advent of technology, multiple techniques and approaches are available in a surgeon's armamentarium today to deal with adrenal nodules that require surgical intervention. Each approach has its own advantages and disadvantages. The era of minimal invasive surgery has fuelled our quest for better cosmesis, faster recovery, early return to work and reduced hospital stay. While minimal invasive method is the preferred approach for most benign adrenal masses less than 6 cm, its application for large adrenal lesions as well as adrenocortical carcinoma is still debatable. Single incision minimal invasive procedures further try to reduce the incisions and wound morbidity. With the aim to completely remove visible scars and possibly reduced morbidity, the concept of natural orifice transluminal endoscopic surgery (NOTES) has been proposed by some surgeons as well as interventional gastroenterologist. In NOTES, the peritoneal cavity is accessed through a hollow viscus to perform therapeutic as well as diagnostic procedures. While the theoretical advantages of scar less surgery and its advantages sound encouraging, the precise indications and its potential advantages for adrenal pathologies is yet to be defined. It should in no way, compromise our goal of safe patient surgery and outcomes.

Mini-laparoscopic adrenalectomy with transgastric specimen extraction

“…Transgastric route can also be used both in females and males as an advantage over the transvaginal route. Previous abdominal surgery can be considered as an obstacle to transgastric access [3]. Fifty percent of our patients had a history of previous abdominal surgery, but we did not have a problem related to this.…”

“…After a widespread acceptance of laparoscopic approaches in adrenal surgery, a trend to quest and perform less and less invasive methods, such as laparo-endoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES), came up [3]. Natural orifice specimen extraction (NOSE) that allows the specimens to be removed via natural orifices (i.e., vagina, mouth,anus) without any additional incision or enlarging trocar incisions, has become a reality particularly for colorectal resections.…”

The Advantages and Disadvantages of Transgastric Natural Orifice Transluminal Endoscopic Gallbladder-Preserving Surgery Compared with Traditional Operation and its Clinical Application

“…It refers to the operation mode of various diagnosis and surgical operation through hollow viscera or natural opening (such as vaginal vault, stomach, etc.) into peritoneal cavity [11]. As there is no abdominal incision in notes, there are no abdominal wall complications, which can achieve good cosmetic effect and reduce anesthesia requirements [12].…”

“…For long-term notes, many departments have already used them. A series of experiments have proved the feasibility of adrenalectomy, uterus surgery and gallbladder surgery through natural orifice surgery in general surgery, urology and Gynecology, but the clinical application is very limited [11,21]. For patients with intra-abdominal emergency, when a series of diseases such as ulcer perforation and infectious pancreatic necrosis caused by interruption of blood supply (bleeding, ischemia) or normal gastrointestinal tract (obstruction, perforation or leakage) need emergency intervention, the application value of notes is more important.…”