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NOTES — Natural Orifice Transluminal Endoscopic Surgery

Scarless surgical approach using flexible endoscopes through natural orifices (mouth, anus, vagina, urethra) to access peritoneal, thoracic, or retroperitoneal cavities, eliminating abdominal wall incisions and improving cosmetic outcome.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Genel Cerrahi department. Book Appointment →

What is NOTES — Natural Orifice Transluminal Endoscopic Surgery?

NOTES (Natural Orifice Transluminal Endoscopic Surgery) refers to surgery conducted through naturally occurring orifices using a flexible endoscope to traverse a hollow viscus wall and access a target cavity (peritoneal, mediastinal, retroperitoneal).

Routes include transgastric (oral approach through stomach wall), transvaginal, transrectal, transcolonic, transvesical (urethra-bladder), and transesophageal; transvaginal cholecystectomy and transanal total mesorectal excision (taTME) are most clinically established.

Pure NOTES uses only the natural orifice while hybrid NOTES combines a single transabdominal port for retraction and safety; technological barriers include flexible instruments, secure viscerotomy closure, sterilization concerns, and absence of dedicated platforms.

Symptoms

Indications mirror those of laparoscopic surgery — cholecystectomy, appendectomy, hernia repair, gynecologic resection, and total mesorectal excision (TME) for rectal cancer
Preferred for patients prioritizing cosmesis, those with abdominal wall pathology, or specific subgroups (obese, prior multiple abdominal operations) where transvaginal route is feasible
Transanal TME is particularly useful in low rectal cancer with narrow male pelvis or distal mesorectal exposure challenges
Symptoms or pathology requiring surgical access — gallstones, appendicitis, ovarian cyst, rectal cancer, GERD, or staging biopsy
Patient preference for scarless cosmesis when alternative is multi-port laparoscopy
Female reproductive-age patients (transvaginal) or post-hysterectomy without contraindication

Risk Factors

Specific NOTES complications: viscerotomy leak, peritoneal contamination, internal organ injury during transluminal passage
Transvaginal route limited to females, and ideally not pregnant or planning pregnancy soon; pelvic adhesions are relative contraindication
Transgastric route has higher concerns about gastrotomy closure leak; carries risk of mediastinitis if esophageal access is used
Transrectal access has potential for fecal contamination of peritoneum despite bowel preparation
Operator learning curve, longer operating times in early adopters, scarcity of dedicated instruments
Limited high-quality evidence for long-term oncologic outcomes (taTME debate following Norwegian moratorium)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Symptoms or imaging findings suggesting need for elective abdominal surgery — discuss minimally invasive options including NOTES if available
  • Postoperative high-grade fever, severe abdominal pain, signs of peritonitis after NOTES — emergency evaluation for visceral leak
  • Vaginal bleeding or discharge after transvaginal NOTES — gynecology evaluation
  • Persistent vomiting or hematemesis after transgastric NOTES — endoscopic assessment
  • Specialist NOTES centers for selected patients seeking scarless options — surgical referral with pros/cons discussion

Treatment Methods

01
Patient selection — body habitus, prior surgeries, sex (transvaginal), reproductive plans, comorbidities, and informed consent including investigational nature
02
Hybrid NOTES technique with one assisting transabdominal port often used to enhance safety, retraction, and surgical control
03
Secure viscerotomy closure using endoscopic clips, T-tags, suturing devices, or staplers; testing for leak before completion
04
Specific procedures: transvaginal cholecystectomy, transanal TME (with caveats), transgastric appendectomy, transvesical pelvic procedures, transgastric peritoneoscopy for staging
05
Postoperative monitoring for visceral leak, infection, late stricture; appropriate antibiotic prophylaxis; follow-up endoscopy when indicated

Which Department to Visit?

You can visit our Genel Cerrahi department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.