AIM: To investigate perception of natural orifice transluminal endoscopic surgery (NOTES) as a potential technique for appendectomy. METHODS: One hundred patients undergoing endoscopy and 100 physicians were given a questionnaire describing in detail the techniques of NOTES and laparoscopic appendectomy. They were asked about the reasons for their preference, choice of orifice, and extent of complication risk they were willing to accept. RESULTS: Fifty patients (50%) and only 21 physicians (21%) preferred NOTES (P < 0.001). Patients had previously heard of NOTES less frequently (7% vs 73%, P < 0.001) and had undergone endoscopy more frequently (88% vs 36%, P < 0.001) than physicians. Absence of hernia was the most common reason for NOTES preference in physicians (80% vs 44%, P = 0.003), whereas reduced pain was the most common reason in patients (66% vs 52%). Physicians were more likely to refuse NOTES as a novel and unsure technique (P < 0.001) and having an increased risk of infection (P < 0.001). The preferred access site in both groups was colon followed by stomach, with vagina being rarely preferred. In multivariable modeling, those with high-school education [odds ratio (OR): 2.68, 95% confidence interval (CI): 1.23-5.83] and prior colonoscopy (OR: 2.10, 95% CI: 1.05-4.19) were more likely to prefer NOTES over laparoscopic appendectomy. There was a steep decline in NOTES preference with increased rate of procedural complications. Male patients were more likely to consent to their wives vaginal NOTES appendectomy than male physicians (P = 0.02). CONCLUSION: The preference of NOTES for appendectomy was greater in patients than physicians and was related to reduced pain and absence of hernia rather than lack of scarring.

Department of Gastroenterology and Hepatology Institute for Clinical and Experimental Medicine 14021 Prague Czech Republic

See more in PubMed

Zacks SL, Sandler RS, Rutledge R, Brown RS. A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol. 2002;97:334–340. PubMed

Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004;60:114–117. PubMed

Hucl T, Benes M, Kocik M, Krak M, Maluskova J, Kieslichova E, Oliverius M, Spicak J. A novel double-endoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure. Gastrointest Endosc. 2010;71:806–811. PubMed

Meining A, Feussner H, Swain P, Yang GZ, Lehmann K, Zorron R, Meisner S, Ponsky J, Martiny H, Reddy N, et al. Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: summary of the working group reports of the Euro-NOTES meeting 2010. Endoscopy. 2011;43:140–143. PubMed

Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc. 2008;22:542–547. PubMed

Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg. 2007;142:823–826; discussion 823-826. PubMed

Zornig C, Siemssen L, Emmermann A, Alm M, von Waldenfels HA, Felixmüller C, Mofid H. NOTES cholecystectomy: matched-pair analysis comparing the transvaginal hybrid and conventional laparoscopic techniques in a series of 216 patients. Surg Endosc. 2011;25:1822–1826. PubMed

Varadarajulu S, Tamhane A, Drelichman ER. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy. Gastrointest Endosc. 2008;67:854–860. PubMed

Volckmann ET, Hungness ES, Soper NJ, Swanstrom LL. Surgeon perceptions of Natural Orifice Translumenal Endoscopic Surgery (NOTES) J Gastrointest Surg. 2009;13:1401–1410. PubMed

Swanstrom LL, Volckmann E, Hungness E, Soper NJ. Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery. Surg Endosc. 2009;23:1519–1525. PubMed

R Foundation For Statistical Computing R Development Core Team. R: A language and environment for statistical computing. Vol. 1, Vienna, Austria: R Foundation for Statistical Computing; 2008. p. 2673.

Santos BF, Hungness ES. Natural orifice translumenal endoscopic surgery: progress in humans since white paper. World J Gastroenterol. 2011;17:1655–1665. PubMed PMC

Squirrell DM, Majeed AW, Troy G, Peacock JE, Nicholl JP, Johnson AG. A randomized, prospective, blinded comparison of postoperative pain, metabolic response, and perceived health after laparoscopic and small incision cholecystectomy. Surgery. 1998;123:485–495. PubMed

Eckardt AJ, Pinnow G, Pohl H, Wiedenmann B, Rösch T. Antireflux ‘barriers’: problems with patient recruitment for a new endoscopic antireflux procedure. Eur J Gastroenterol Hepatol. 2009;21:1110–1118. PubMed

Thele F, Zygmunt M, Glitsch A, Heidecke CD, Schreiber A. How do gynecologists feel about transvaginal NOTES surgery. Endoscopy. 2008;40:576–580. PubMed

Strickland AD, Norwood MG, Behnia-Willison F, Olakkengil SA, Hewett PJ. Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women’s views on a new technique. Surg Endosc. 2010;24:2424–2431. PubMed

Peterson CY, Ramamoorthy S, Andrews B, Horgan S, Talamini M, Chock A. Women’s positive perception of transvaginal NOTES surgery. Surg Endosc. 2009;23:1770–1774. PubMed

Comparison of Inflammatory Response to Transgastric and Transcolonic NOTES