Endoscopy 2011; 43(1): 58-62
DOI: 10.1055/s-0030-1256033
Endoscopy essentials

© Georg Thieme Verlag KG Stuttgart · New York

Safety notes: how to avoid infections in natural orifice transluminal endoscopic surgery

A.  Fritscher-Ravens1 , A.  Arlt1
  • 1Interdisciplinary Endoscopy, Department of Internal Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Germany
Further Information

Publication History

Publication Date:
13 January 2011 (online)

When the first natural orifice transluminal endoscopic surgery (NOTES) approach of an anastomosis was presented during the new technology session of Digestive Disease Week 2002 [1], the audience raised questions about infection of the peritoneal cavity. Prevention of infection was defined as a fundamental challenge in the later White Paper of the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) in 2005 [2], and remained an all important topic at their meeting in 2010.

All NOTES procedures are characterized by the entry into a sterile, sealed environment from a space that is both contaminated with a multitude of pathogens and much more difficult to sterilize than the outer abdominal wall. The necessity to decontaminate these cavities and administer prophylactic treatment with antibiotics, as well as the methods used to achieve this have been much discussed but to date remain unsolved. The few available studies with varying settings and outcomes ([Table 1]) make it very difficult to set standards in relation to infection and its prevention. This uncertainty and lack of standards in this area remain major barriers to performing NOTES in the clinical setting. More recently, a few papers have addressed this safety issue and will be discussed here in detail.

Table 1 Summary of the literature results for infection in natural orifice transluminal endoscopic surgery (NOTES) procedures (studies discussed in the text are in bold). Reference Access and procedure* Duration, minutes Procedures compared Infection Key results of necropsy Procedure + infection prevention† Control Infection prevention Control Infection prevention Control Giday et al. 2010 3 Transgastric:Peritoneoscopy 40 1, 2, 3, 4, 5 NOTES Rate: 0 % Rate: 100 % Gross evidence of infection: 0 % Gross evidence of infection: 100 % Eickhoff et al. 2010 7 Transgastric:Exploration gallbladderTubal ligation 120 3, 4, 5, 6 NOTES Rate: 25 %Bacterial load: 282 CFU/mL Rate: 86 %Bacterial load: 3.2 × 105 CFU/mL Major peritonitis: 0 %Minor peritonitis: 25 % Major peritonitis: 14 %Minor peritonitis: 71 % Romagnuolo et al. 2010 4 Transgastric:Colon injury repair 70 34 (œ of the pigs) Laparoscopic surgery3 Rate: 38.9 % Rate: 60 % Focal peritonitis: 5.6 %Diffuse peritonitis: 11.1 % Focal peritonitis: 0 %Diffuse peritonitis: 0 % Buck et al. 2008 9 Transgastric:Abdominal wall mesh placement 90 3, 4 Laparoscopic surgery3, 4, 6 Rate: 36 % Rate: 0 % Grossly mesh infection: 36 % Grossly mesh infection: 0 % Bachman et al. 2009 8 Transcolonic:Peritoneoscopy 10 7 NOTES8 75 % infection overall No evidence of gross peritoneal infection Fong et al. 2007 16 Transcolonic:Peritoneoscopy 30 – 45 1, 3, 7 N/A Not analyzed No evidence of microscopic peritonitis in any of the pigs Wilhelm et al. 2007 18 Transcolonic:Peritoneoscopy > 30 1 (special device)3, 8 N/A Not analyzed No signs of infection or peritonitis Raju et al. 2008 19 Transcolonic:Closure of colon perforation 44 Laparoscopic surgery Not analyzed Peritonitis: 37 %Small pericolonic abscess: 13 % Peritonitis: 26 %Small pericolonic abscess: 17.4 % *All procedures were in swine.† 1, sterile material; 2, overtubes; 3, i. v. antibiotics; 4, antiseptic gastric lavage; 5, antiseptic mouth lavage; 6, proton pump inhibitor; 7, colon irrigation with Betadine and cephalosporine; 8, colon irrigation with antimicrobial solution.CFU, colony forming units; N/A, not applicable.


A. Fritscher-Ravens, MD 

Interdisciplinary Endoscopy
Department of Internal Medicine I
University Hospital Schleswig-Holstein
Campus Kiel

24105 Kiel

Fax: +49-4315971302

Email: Fri.rav@btopenworld.com