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Media Backgrounder

NOTES® (Natural Orifice Translumenal Endoscopic Surgery®) ASGE Logo

Natural Orifice Translumenal Endoscopic Surgery® (NOTES®) is a new type of hybrid endoscopic/surgical procedure currently being studied at hospitals and research facilities around the world. NOTES® represents the next frontier of surgical principles and endoscopic techniques. The standard approach to reaching the peritoneal cavity (that portion of the abdomen where organs such as the gallbladder and liver are found) is via a surgical incision of the skin or puncturing the skin, allowing the introduction of small cameras deep into the abdomen. The latter technique is known as laparoscopic surgery.

Portions of the gastrointestinal tract such as the stomach and colon commonly examined with endoscopy (such as for colon cancer screening) also reside in the peritoneal cavity. Perforation (inadvertent puncture creating a hole) of the gastrointestinal tract has been traditionally considered an undesirable event. Interventions using NOTES®, however, intentionally perforate the stomach, bowel or vagina, thereby allowing the operator to access the peritoneal cavity using a normal body orifice as a conduit. Here, any peritoneal structure is theoretically approachable.

As an example, in natural orifice surgery the gallbladder might be removed through the mouth. The doctor would insert a tube down the esophagus, make a small incision in the stomach wall to gain access to the abdominal peritoneal cavity and take the gallbladder out by the same route. Potential advantages of the NOTES® technique include reduced post-operative pain, shortened recovery times, and improved cosmesis (lack of surgical incision scars).

A range of procedures might be performed this way, such as gastric bypass, fallopian tube ligation, removal of the ovaries and diagnostic work. Some operations might be done via the rectum, vagina, urethra or bladder as well. Because NOTES® is so new, research generally has been confined to animals, mainly pigs. Recently, however, human studies have emerged that report the procedures to be feasible. Further studies involving a variety of NOTES® procedures, under close supervision by medical experts and Institutional Review Boards, are being performed. The first multicenter human clinical trial in the U.S. is currently underway. For more information visit

The NOTES® initiative is a joint effort of the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES). Together, these societies have formed the Natural Orifice Surgery Consortium for Assessment and Research® (NOSCAR®), a group that provides guidance and oversight and evaluation NOTES® of techniques and the related research required.

Reviewed November 2010