Introduction: Although not yet clinically applied in North America, a number of laboratories are investigating Natural Orifice Translumenal Endoscopic Surgery (NOTES) as an alternative to conventional minimally invasive surgery (MIS). Even if NOTES proves to be feasible and safe, surgeons will need to adopt the concept and become trained if it is ever to become a mainstream approach. Our group recently demonstrated patient enthusiasm for NOTES and we now aim to assess surgeons’ opinions of NOTES.
Methods: A 75 item survey was administered via email to members of the SSAT, SAGES, and ACS. After describing the basic concepts of NOTES, surgeons were asked to rate the importance of various aspects of surgical procedures. With the assumption of availability and safety, they were then asked if they would choose to undergo and/or to perform cholecystectomies by NOTES or laparoscopic surgery and what factors would affect this decision.
Results: Of the 357 surgeons who responded to the survey, median age was 44 yrs, 60% reported using flexible endoscopy (FE) in less than 10% of cases, and 65% listed their specialty as either gastrointestinal, MIS (23%) or general surgery. In deciding upon a surgical approach, the risk of having a complication was the most important consideration (p<0.01). Surgeons believe NOTES takes greater skill to perform and carries a greater risk of complications than laparoscopic surgery, but they also feel it would be associated with less pain and faster recovery (p<0.01) and 72% were interested in becoming trained in NOTES. Age < 60 yrs and MIS specialty increased interest in NOTES training, while the performance of FE in less than 10% of cases decreased this interest (p<0.01). Forty-seven percent felt NOTES would eventually become mainstream therapy and 44% would prefer to perform cholecystectomy by NOTES if it was feasible and available. Of the 56% who would not prefer NOTES, 88% indicated that they would change to the NOTES approach if data showed improved outcomes over laparoscopy. Finally, 26% would choose to undergo cholecystectomy by NOTES with surgeons declining NOTES citing that they felt it was too new (70%) and more risky than laparoscopic cholecystectomy (79%).
Conclusion: Although only 1/4 of surgeons would currently choose to undergo NOTES, a majority would be interested in becoming trained in NOTES if it were clinically available. Interest in NOTES is affected by a surgeon's age, MIS specialization, and flexible endoscopic volume. The risk of a procedure-related complication is a significant concern for surgeons and the acceptance of NOTES will be contingent upon evidence of its safety.