الفهرس 
History and Evolution of NotesOnly 14 pages are availabe for public view
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Abstract
Natural orifice transluminal endoscopic surgery (NOTES) is an experimental surgical technique whereby ‘‘scarless’ abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, urethra, anus, etc.) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars (Kallo et al., 2006).
As the next wave of minimally invasive therapy, NOTES will be a reality. NOTES is a promising procedure that may be another favorable alternative to current types of surgical interventions. Many common operations performed today by laparoscopic could be converted to the NOTES approach and many patients will benefit from the implementation of NOTES.
Advantages of NOTES over Traditional Surgery include absence of incisional complications, including pain, hernias and external wound infections. Hopefully, there would be fewer adhesions, a decreased need for anesthesia and eventually a shorter hospital stay.
Many limitations of current NOTES techniques are evident. The patient might be susceptible to infectious and immunologic complications that are not present in laparoscopy and conventional surgery.
The unavailability of adequate instrumentation restricts the ability to perform meticulous dissection in NOTES. Endoscopic tools have a restricted range of motion and limited degrees of freedom. Triangulation of the visual field and instruments, a concept found to be critical in laparoscopy, cannot be achieved by a single conventional endoscope.. Hybrid procedures might lead to an overall reduction of potential complications and better complication management and might serve as a bridge to pure NOTES procedures.. In fact, first human NOTES procedures have been published and utilized mainly the hybrid approach (Kalloo et al.,2004)
Types of NOTES: divided into two categories;
1- Pure NOTES
2- Hybrid NOTES.
Types of approaches
1-Transgastric approach: such as: Trangastric Cholecystectomy and Trangastric Appendectomy
2-The transvaginal approach : such as : Transvaginal cholecystectomy, Appendectomies, Sigmoidectomy, right colectomy, Cancer diagnostic staging Liver resection, Partial gastrectomy, Sleeve gastrectomy.
Current knowledge support the potential advantages of the vagina as a NOTES approach. So far, this route represents the most successful and widely accepted among all the other possible NOTES approaches (Zornig et al., 2008) .
Perception of transvaginal notes :
Findings in Several surveys show that women accept this procedure if they are assured it is as safe and painless as conventional laparoscopic surgery and will be performed by a surgeon who is skilled in the technique.
There are some clearly age-related factors that play an important role in a patient’s decision-making: nulliparous and younger women express concerns regarding sexual function, fertility and cosmesis, whilst postmenopausal women or women who do not want further children are more disposed to accept this type of surgery.
These findings suggest that as more evidence regarding
safety emerges, the transvaginal route for NOTES procedures
will be better accepted (Swanstrom et al., 2009)
The Colorectal NOTES concept :
Colorectal surgery was somewhat late in adapting to a minimally invasive approach but the specialty is currently expanding even beyond laparoscopic techniques; particularly with regard to advanced therapeutic endoscopy and NOTES. Procedures that combine the use of laparoscopy and flexible endoscopy will undoubtedly become more common in the very near future (Zorron et al., 2008).
Device Development :
Most of the current animal studies in transgastric surgery used conventional, commercialized instruments.
They use either single channel or double channel endoscope systems. Instruments including biliary guidewires, needle-knife, pull-type sphincterotomes, and clips were used for creation and closure of the gastric access.
Current endoscopes and instruments are, obviously, inadequate to perform complex surgeries. One of the most crucial issues to the technical success of transgastric surgery is endoscopic suturing. Fast, simple and effective endoscopic suturing devices will be important for creating anastomoses, closure of access incisions and treating complications such as bleeding presently, extensive experimental animal researches should be carried out, more suitable endoscopic devices developed, and coordination between endoscopists and surgeons strengthened before NOTES is adopted as a viable technology (Rattner et al., 2006).