Optimizing surgical approach for natural orifice translumenal endoscopic procedures.

Background: Natural orifice translumenal endoscopic surgery (NOTES) often requires some degree of retroflexion of the endoscopic operating system. This study investigates the impact of retroflexion on task performance in NOTES.
Methods: In a bench-top simulation, surgeons were required to manipulate a single-channel endoscope to touch 4 dots in a predetermined order. The task was performed under the forward-view and retroflexed-view conditions.
Results: Tasks performed under the forward-view condition were significantly faster than those performed under the retroflexed-view condition (P = .005). Also, 5 experienced surgeons completed tasks in less time than the novices (P = .043). Experienced surgeons were mildly affected by the inverted image, whereas the novices were vulnerable to image malalignment.
Conclusion: Careful selection of the surgical approach to avoid image malalignment is suggested for safe performance of NOTES. Extensive training is required for novices to overcome the vision-motion difficulty before they can perform NOTES safely and effectively.