What is the status and approach for intra-abdominal surgery performed through the mouth with no incision, particularly in high-risk patients such as older adults or those with multiple comorbid conditions?

Natural Orifice Transluminal Endoscopic Surgery (NOTES): Current Status and Clinical Application

Natural Orifice Transluminal Endoscopic Surgery (NOTES)—intra-abdominal surgery performed through the mouth without external incisions—remains largely investigational and is not routinely recommended for standard clinical practice, particularly in high-risk older adults with multiple comorbidities. 1

What is NOTES?

NOTES represents an evolving surgical approach that uses natural orifices (primarily the mouth via transgastric access) to perform intra-abdominal procedures without abdominal wall incisions. 1 The technique involves intentional perforation of the gastrointestinal tract to access the peritoneal cavity—a concept that fundamentally contradicts traditional surgical principles where perforation is a dreaded complication. 1

Theoretical Advantages

The approach offers several potential benefits:

• No abdominal wall incision or scarring 1
• Decreased physiologic stress compared to traditional laparotomy 1
• Potentially less postoperative pain due to intact abdominal musculature 1
• Fewer adhesions and faster recovery times 1
• Particularly appealing for obese patients where transabdominal approaches are technically challenging 1

Procedures Demonstrated in Research

Animal and early human studies have shown feasibility for:

• Peritoneoscopy and liver biopsy 1
• Gastrojejunostomy 1
• Fallopian tubal ligation 1
• Splenectomy 1
• Gastric reduction surgery (bariatric procedures) 1
• Herniorrhaphy 1

Critical Limitations and Barriers

Technical Challenges

Major unresolved issues include: 1

• How and where to safely make intestinal incisions
• Management of infectious complications from intentional GI perforation
• Lack of adequate endoscopic surgical instruments
• Difficulty with surgical anatomy visualization from an endoscopic perspective

Clinical Concerns for High-Risk Patients

For older adults and patients with multiple comorbidities, NOTES poses significant concerns:

• Older adults undergoing abdominal surgery already face mortality rates of 17.3% with conventional approaches, increasing to 22.7% in those ≥90 years 2, 3
• Advancing age correlates with escalating complication rates (14.6% at ages 65-69 to 22.7% at ≥90 years) 2
• ASA score and premorbid residential status are stronger predictors of mortality than age alone in patients ≥85 years 3
• High-risk abdominal surgery patients experience protracted critical periods with 34% one-year mortality 4

Psychological and Professional Barriers

Adoption faces substantial resistance: 1

• Intentional GI perforation contradicts decades of surgical training
• Concerns about "nonsurgeons" performing surgical procedures
• Requires mastery of endoscopic surgical views that differ substantially from laparoscopic perspectives
• Gastroenterologists must learn surgical anatomy—a surmountable but significant barrier

Current Clinical Status

NOTES remains in the research and development phase. 1 The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons created the Natural Orifice Surgery Consortium to address impediments to adoption, but this was as of 2006. 1

Recommendations for High-Risk Patients

For older adults and patients with multiple comorbidities requiring intra-abdominal surgery:

Preferred Approaches

• Laparoscopic surgery remains the gold standard when expertise is available, offering proven benefits of less pain, lower infection rates, and shorter hospital stays 5, 6
• Minimally invasive techniques (laparoscopy) may provide decreased morbidity and shorter recovery times, particularly beneficial for older patients 7
• Specialized anesthetic techniques such as thoracic continuous spinal anesthesia may be considered as alternatives to general anesthesia in very high-risk older patients 8

Risk Stratification Factors

Key predictors of poor outcomes in older adults undergoing abdominal surgery include: 2, 3

• ASA score (more important than chronological age)
• Premorbid residential status
• Emergency vs. elective surgery status
• Charlson comorbidity index
• Goldman cardiac risk index
• Abnormal chest radiograph and lung examination findings 9

Common Pitfalls to Avoid

• Do not consider NOTES for routine clinical practice—it remains investigational 1
• Do not assume age alone determines surgical risk—functional status and comorbidity burden are more predictive 3
• Do not overlook that pulmonary complications may be more common than cardiac complications after abdominal surgery, with 33% of patients experiencing both 9
• Do not underestimate the protracted recovery period—high-risk patients experience prolonged critical periods with high complication rates 4