NOTES & SILS in Colorectal Surgery: On the Horizon

Laparoscopic colorectal surgery (LCS) using multiple ports has become commonplace in colorectal surgery, offering a safe alternative to open surgery with similar surgical results supported by evidence. In addition, LCS is associated with less postoperative pain and ileus, better respiratory function, faster postoperative recovery, shorter hospital stays and aesthetically more appealing results. In other types of surgery, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) are growing in popularity. A review article in the recent online issue of World Journal of Gastroenterology explores the potential to use SILS and NOTES instead of conventional laparoscopic surgery (CLS).

The authors review a large number of studies that look at SILS and NOTES, including history, outcomes data (where possible) and technical skill publications. Studies have already been completed validating that SILS has cosmetic advantages over CLS due to the significantly shorter incision. Studies designed to determine differences between CLS and SILS outcomes—operative time, postoperative morbidity profiles, portsite complications rates, oncological appropriateness, duration of hospitalization and cost—are still needed. Some of these studies are underway.

The researchers note that some studies document longer operative time with SILS, a discrepancy that should diminish over time and with increasing experience.

With regard to NOTES, the authors could find case reports describing unresolved issues concerning ideal access site, distant organ reach, spatial orientation, and viscera closure. They report that minilaparoscopy-assisted natural orifice surgery techniques are being developed, with the transanal “down-to-up” total mesorectum excision most advanced. It is used for transanal endoscopic microsurgery. Here, too, large scale randomized controlled trials are needed. The stumbling block to widespread use of NOTES in humans is the need to be certain the endoluminal closure is safe.

The authors are surprised that SILS emerged as a novel colorectal surgery technique before well-designed studies validated advantages. They also indicate that surgeons will need lengthy training before employing NOTES for colorectal surgery, and they again stress the need for safely.