The natural orifice simulated surgical environment (NOSsE): exploring the challenges of NOTES without the animal model.

In this paper, we introduce an inexpensive, realistic, and robust simulator model for training and requirement assessment of natural orifice transluminal endoscopic surgery (NOTES). A laparoscopic box trainer is converted into an effective NOTES environment, in which many of the challenges facing this new approach can be explored first hand in a laboratory setting. Using this simulator, experiments researching this new surgical field can be refined before moving into in vivo trials, such that the number of animals required for acquiring basic skills and validating new surgical protocols can be reduced. Additionally, the simulator has the potential to be utilized as an effective platform for education and training in NOTES, although formal validation is required before this can truly be appreciated.