Pregledni članek 

Review article 

Endoscopic surgery in the 21st century 

Endoskopska kirurgija v 21. stoletju 
Michael Stark, Tahar Benhidjeb 

The New European Surgical Academy (NESA) 
Avtor za dopisovanje (correspondence to): 

M. Stark, MD, The New European Surgical Academy, Berlin, Germany; 
e-mail: mstark@nesacademy.org 
Prispelo/Received: 16.1.2007 

To paraphrase Bernard of Chartres: 
“Only by standing on the shoulders of giants will you see beyond the horizon” – 
“Pigmaei gigantum humeris impositi plusquam ipsi gigantes vident” 


Abstract 
In the last quarter of the 20th century, endoscopic procedures replaced most of the traditional 
abdominal operations. They shortened hospital stay and reduced morbidity. At the beginning of the 
21st 

century, the progress in technology enhanced the development of translumenal endoscopic 
surgery in the field of gastroenterology. Parallel, the New European Surgical Academy founded the 
first European based Working Group on Natural Orifice Surgery (NOS). This group concentrates on 
the development of transdouglas procedures in women by using the transdouglas endoscopic device 
(TED). This is a wide multi-channel instrument, which will enable surgeons to perform most of the 
surgical, urological and gynaecological operations through a single entry. This article describes the 
logic behind this approach and the expected challenges. 

Key words. Natural orifice surgery, transdouglas procedures. 
Endoscopic Rev, Vol. 12, No. 27, May 2007 


Izvleček 
Zadnjih 25 let 20. stoletja je endoskopska kirurgija nadomestila večino klasičnih abdominalnih 
operacij. Omogočila je krajšo ležalno dobo in zmanjšala pooperativne zaplete. Na začetku 21. stoletja 
pa so zaradi tehnološkega napredka gastroenterologi razvili transluminalno endoskopsko kirurgijo. 
Sočasno je New European Surgical Academy (NESA) ustanovila prvo Evropsko delovno skupino za 
kirurgijo skozi naravne telesne odprtine (European based Working Group on Natural Orifice Surgery 
(NOS)). Ta skupina razvija operativne postopke skozi Douglasov prostor pri bolnicah z uporabo 
endoskopskih inštrumentov za tak postopek (Transdouglas Endoscopical Device, TED). To je 
inštrument z večdelovnimi kanali, ki omogočajo izvedbo večine kirurških, uroloških in ginekoloških 
operacij skozi eno odprtino. V članku je opisana logičnost takšnega pristopa in pričakovani rezultati. 
Ključne besede. Kirurgija skozi naravne telesne odprtine, postopki skozi Douglasov prostor 
Introduction 

A new surgical discipline is being evolved these 
days. The existing natural openings of the body 
are used for introducing surgical instruments and 
performing surgical procedures, without penetrating 
the abdominal wall. 
This idea is not entirely new. Different operations 
like trans-sphenoidal hypophysectomy or 
vaginal hysterectomy were already performed in 
the past, but the continuation of this trend seems 
to constitute a natural step towards future 
surgical progress. 
It is now 200 years since the first successful laparotomy 
was performed: in 1809, Mrs. Crawford 
in Kentucky survived a cystectomy performed by 
Ephraim McDowell without anaesthesia (1). 
At the beginning, laparotomies were performed 
longitudinally, first sporadically, but became 
routine when general anaesthesia was introduced 
(William Morton, Boston, 1846) (2). Gynaecological 
laparotomies were optimized in 1897, when 
Johannes Pfannenstiel (3) introduced his lower 
abdominal transverse incision. 
Surgeons tend to be conservative. For many years, 
both, the longitudinal and the transverse incisions, 
were used as traditional incisions in different 
institutions. However, the first comparison between 
both incisions (by caesarean section) was 
done only 75 years after the introduction of the 
transverse incision (4). 
In the 20th century, a wave of innovations 
emerged in numerous fields, including general 
surgery. In 1901, Georg Kelling in Germany 

performed the first experimental laparoscopy 
(5,6). This surgical approach could have never 
developed further if the endotracheal intubation 
had not been introduced (7). The intraabdominal 
pressure needed for endoscopical operations requires 
active respiration, which would have been 
impossible without endotracheal respiration. 
When the right conditions were provided, a variety 
of endoscopical procedures emerged, which 
gradually replaced the majority of laparotomies. 
The first laparoscopic cholecystectomy was 
performed by Erich Mühe in 1985 (8), and was 
followed by the first laparoscopic assisted 
vaginal hysterectomy carried out by Harry Reich 
in 1989 (9). This trend has continued until today, 
and most abdominal operations have laparoscopic 
alternatives. Today cholecystectomies are 
mostly performed laparoscopically (10). We believe 
that in the future the caesarean section will 
remain as the only elective laparotomy. 
Laparoscopic operations are expected to yield the 
same results as laparotomies, yet without the 
extended abdominal scars and the associated 
pain, febrile morbidity, limitation of movement 
and prolonged hospital stay (11,12). 

The Natural Orifice Surgery (NOS) 
concept 

In order to optimise the existing surgical procedures, 
the New European Surgical Academy 
(NESA) was founded in 2004. NESA promotes 
the excellency, minimalism and adjustment of 
procedures to their correct indications. NESA's 

Endoscopic Rev, Vol. 12, No. 27, May 2007 


main principle is: "Nothing lacking, nothing 
superfluous". With this principle in mind, NESA 
promotes and develops some evaluated and 
analysed operations, such as the Misgav Ladach 
caesarean section (13) or the ten-step vaginal 
hysterectomy (14). 
Laparoscopic procedures, despite their advantages, 
have not proved to be free of risk: in a series 
of 3,572 patients undergoing laparoscopic assisted 
vaginal hysterectomy, a total of 67 complications 
occurred. One patient died because of injury to 
the aorta caused by insertion of the trocar. Other 
complications related to insertion of the Verres 
needle, principal and accessory trocars, were 
noted in 25 cases (38.2%). Intraoperative complications 
were seen in 32 patients (47.8%) and 
postoperative complications in 10 (14.9%) (15) 
Typical laparoscopical complications result from 
anaesthesia (gas embolism, cardiovascular failure 
due to he hyperinsufflation of the abdomen, blind 
insertion of the Verres needle, insertion of the 
trocar, bleeding from major blood vessels and 
damage to the intraabdominal organs) (15,16). 
The tremendous development of new technologies 
coupled with the current possibilities to 
simulate procedures prior to their clinical 
application enables us to plan operations which 
were previously designed on a trial-and-error 
basis. The simulation is needed to create future 
high-quality and safe operations, associated with 
lower morbidity. 
The natural orifice approach in general surgery, 
though it is still in an experimental phase, is an 
important step taken in this direction. Peritoneoscopy, 
appendicectomy, liver biopsy, splenectomy 
and partial hysterectomy have already been 
performed transgastrically using an endoscope 
(17). 
The transgastric approach is feasible, but may be 
associated with potential problems: the stomach 
acidity, iatrogenic perforation of the stomach, 
bacteriological contamination of the instruments 
introduced through the mouth, oesophagus and 
stomach and the limitations involved with the 
diameter of the instruments used. The American 
term for this surgical approach is NOTES (Natural 
Orifice Translumenal Endoscopic Surgery). Parallel, 
the NESA founded last year the first European 
based Working Group on Natural Orifice Surgery 
(NOS), It was decided to concentrate on the 
transdouglas endoscopic procedures. 

The terminological difference is not coincidental. 
The "T" in NOTES stands for Transluminal. NOS 
is a generic term, which includes the NOTES. 
NOS stands for all surgical procedures performed 
through natural openings in neurosurgery, otorhinolaryngology, 
gastroenterology, general surgery, 
urology and gynaecology (18). 


Figure 1 

Wide multi-channel instrument 

In the past, some procedures were performed 
through the pouch of Douglas: removal of the 
gallbladder at the end of endoscopical cholecystectomy 
(19), appendicectomies following vaginal 
hysterectomy (20,21) and various gynaecological 
procedures, such as myomectomy (22). However, 
routine transdouglas approach for abdominal operations, 
such as cholecystectomies, colectomies 
and splenectomies, is now planned for the first 
time. 
The use of the vaginal route for abdominal 
operations in women is expected to involve more 
benefits and to entail less risk because of the 
following considerations: 

1. 
The need for traditional 15 mm Hg pressure 
for creating space between the abdominal 
wall and the great blood vessels has been 
obviated; only the necessary optimal pressure 
will be used. 
2. 
Surgical instruments are introduced under 
direct vision, avoiding the risk of injury to 
the abdominal organs or blood vessels, which 
may occur with the blind introduction of the 
Verres needle. 
Endoscopic Rev, Vol. 12, No. 27, May 2007 


3. 
Many procedures can be performed with 
epidural anaesthesia because of the lower 
intraabdominal pressure needed. 
4. 
The instruments are introduced parallel to 
and not perpendicular to the major blood 
vessels, thus minimizing the risk of injury. 
5. 
The pouch of Douglas allows for the 
introduction of wide-bodied, multi-channel 
device, affording a single entry surgical 
procedure. 
6. 
The vagina, unlike the mouth or oesophagus, 
can be cleaned and disinfected, which 
minimizes the risk of infections. 
7. 
The vaginal wall repairs itself rapidly ad 
integrum without leaving any visible scars. 
8. 
The transdouglas approach provides optimal 
ergonomic working conditions for the 
surgeon who performs the operation while 
sitting. 
9. 
There is no risk of herniation or eventration. 
Challenges confronting the 
development of the transdouglas 
approach. 

The main challenge is the development of special 
transdouglas endoscopic instrumentation, which 
should take into account the special anatomy of 
the pelvis. 
In order to reach the upper abdomen, an S-shaped 
device was designed, bending first anteriorly, and 
then posteriorly. A relatively wide diameter of 
the device and its multi-channel shape enable the 
operating surgeon to use simultaneously different 
instruments, thereby obviating the need for the 
second puncture. 
This method will be used in a wide variety of 
intraabdominal operations in women, covering 
various surgical disciplines: cholecystectomy, 
splenectomy, different biopsies, colectomies, 
nephrectomies, adrenalectomies, lithotomies etc. 
A U-shaped variant of the instrument has been 
designed for the lower abdomen, respecting the 
anatomy of the pelvis. Various operations of the 
lower abdomen, such as appendicectomy, cystectomy 
and hysterectomy will thus become 
possible. 
Parallel to the technical development of the 
instrument, a multidisciplinary team should be 
created. Surgeons and urologists will need the 

assistance of gynaecologists to enter the peritoneal 
cavity. NESA is planning a surgical subspeciality, 
which will emerge from this interdisciplinary 
cooperation. 

The first European based NOS 
Working Group 

The NESA founded the first European based 
NOS Working Group comprising different disciplines 
and representatives of the industry, coming 
from Canada, France, Germany, Israel, Italy, 
Japan, Switzerland, and the United States. 
The first meeting of the Working Group took 
place in Berlin on 23 June 2006. The concept of 
NOS was presented and discussed, the pharmacological 
and physiological challenges concerning 
the transgastric approach were defined and 
considered, and the published experimental 
achievements discussed. The European NOS 
Working Group comprising scientists and surgeons 
fng Group decided to focus on the use of 
the transdouglas approach in women, and to 
examine the possibility to use the transdouglas 
endoscopic device in men transrectally. 
The reasons for this decision are the following: 

1. 
Transdouglas operations carry less risk of 
bacterial contamination than the transgastric 
approach. 
2. 
The opening and the closure of the vaginal 
wall are done under direct vision; the 
procedure is safe, and the suturing does not 
leave any scars or long-term dysfunction. 
3. 
The potential diameter of the adapted surgical 
instruments enables the surgeon to work in a 
safe and comfortable manner. 
4. 
It is assumed that it will be possible to 
perform most of the transdouglas operations 
using epidural anaesthesia. 
5. 
The operating surgeon will perform the 
procedure under optimal ergonomic 
conditions. 
In order to realize this project, the following 
expert working groups were created: 

1. 
A basic science group 
2. 
A surgical-urological-gynaecological group 
3. 
An interdisciplinary group 
4. 
An instrumentation group and 
Endoscopic Rev, Vol. 12, No. 27, May 2007 


5. 
A scarless surgery group, the NSO Working 
Group, which addresses the issue of scarless 
operations. A new evolving approach 
promotes methods, such as the axillobilateral-
breast (ABBA) operation on the 
thyroid (23). 
The working groups meet twice a year, and maintain 
constant contacts through the NESA web site 
(www.nesacaemy.org). Simulation of various 
intraabdominal operations using TED has been 
done, and the construction of the device is in 
progress. 

Conclusions 

In the past, surgical methods were mostly a result 
of experience gathered in daily clinical practice. 
Only few operations resulted from pre-planned 
thinking and designing, based on theoretical 
considerations and experience, one of these being 
the ten-step vaginal hysterectomy (14). Today, 
surgical techniques, based on surgical skills and 
knowledge, are designed systematically, and the 
required equipment is designed parallel to the 
planned operation. New procedures should be 
based on sound anatomical and physiological 
knowledge, and should be bio-simulated prior to 
implementation. 
New techniques can be introduced only if they 
meet high quality and safety standards, and never 
just for the sake of novelty. 
NESA believes that the transdouglas surgery will 
replace many endoscopic operations, and will 
create a spectrum of innovative, high-quality and 
safe operations, performed by an interdisciplinary 
team. 

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