Natural orifice trans-luminal endoscopic surgery (NOTES) in thoracic surgery.

Natural orifice transluminal endoscopic surgery (NOTES) proposes the possibility of less-invasive, incisionless surgery. Initially conceived to replace abdominal procedures, more recently interest has focused on mediastinal and thoracic procedures as possible logical applications of transluminal approaches. A survey of the literature as well as the author's own experience is performed, examining experimental and increasingly human use of mediastinal and thoracoscopic flexible endoscopy. Issues regarding instrumentation, orientation, and best access are discussed. The literature describes both direct transesophageal access to the mediastinum and pleural cavities and submucosal flap access. Other techniques include transgastric, transvesicular, and percutaneous access via a neck incision. Overall, the early results of transesophageal Heller myotomy show the most promise for early clinical adoption. NOTES has an interesting role in thoracic and mediastinal surgery. Although initially thought of as a highly improbable application, the "home run" of per-oral endoscopic myotomy is indicating that the thorax may be one of the most useful places for NOTES.