Developing essential tools to enable transgastric surgery.

Natural orifice transluminal endoscopic surgery (NOTES) is a largely theoretical but potentially exciting evolution of minimally invasive surgical care. Using technology borrowed from current diagnostic and therapeutic flexible endoscopy, the idea is to replicate current laparoscopic procedures in an "incisionless" manner. It is widely recognized that for NOTES to become a practical reality, many issues need to be resolved, both methodologic and political. One critical element of development will be the design of appropriate instrumentation for NOTES. This is currently happening and involves a complex collaboration between industry and clinicians both to adapt current equipment and to design and create new tools to enable the performance of transluminal procedures. This article describes the current process of such technology development as well as the resulting instrumentation that enables the performance of NOTES. The issues of access and platform stability, laparoscopic-like instruments, and secure tissue approximation are described, and the devices to solve these issues are detailed.