Current trends and surgery and therapeutic endoscopy suggest that these fields are intersecting to perform certain types of procedures in an increasingly less invasive fashion. This intersection will require the development of new devices in order to perform these innovative procedures. Endoluminal techniques such as per oral endoscopic myotomy (POEM) for the treatment of achalasia and endoluminal mucosal as well as full-thickness resections are already being performed. For instance, in Asia endoscopic resection of very early malignancies is routinely performed on therapeutic endoscopic platforms. Further advancements in endoluminal therapies are on the forefront of surgery.

NOTES or surgery through natural orifices of the body, often referred to as “incisionless” surgery, has the potential to eliminate complications associated with incisions in surgery. There are several proposed benefits to patients with these approaches including decreased postoperative pain, shorter hospital stays, faster postoperative recovery, and elimination of surgical site infections and abdominal wall hernias. Performing surgery via transvaginal, transgastric, and transanal approaches is appealing, but is not a widely adopted practice at this time. There are many technical challenges associated with NOTES surgery, however, particularly associated with the technical difficulty of the procedures given the current instrument technologies. The majority of NOTES procedures are therefore performed as hybrid procedures with laparoscopic assistance.

There is a large amount of variation present in NOTES procedures at this time. The route of entry: transgastric versus transvaginal, rigid versus flexible endoscopes, and the number and site of access points: True NOTES versus hybrid notes with laparoscopic assistance. A literature review by Chellali et al. [3] showed that 90 % of NOTES procedures reported are performed with hybrid laparoscopic assistance, and that a transvaginal approach was employed in the majority of cases (86 %). The most common procedure performed was cholecystectomy, comprising 84 % of reported cases. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) created the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) in order to assess the feasibility and safety of NOTES procedures. EURO-NOTES was also established in Europe to serve similar purposes. A review of current literature does not clearly establish the role or safety for NOTES procedures, although it does provide a proof of concept with hundreds of procedures performed. NOSCAR is currently investigating the efficacy of NOTES cholecystectomy in a multicenter human clinical trial in the USA.

Analysis of current NOTES literature does support a prolonged operative time in both hybrid NOTES and total NOTES procedures. Chellali et al. [3] reviewed a series of NOTES cholecystectomies recorded on video and surmise that the prolonged operative time is, at least in part, a result of instrumentation that is not adequately designed for these newly appointed tasks [4]. Reviewed the currently available multibranched laparoscopic and endoscopic instrumentation in light of the criteria suggested by NOSCAR findings. Future facilitation of NOTES procedures will require the design and implementation of less cumbersome instruments that will allow the surgeon to perform more complex bimanual tasks requiring triangulation, such as intracorporeal suture tying.

POEM is a procedure in which a gastroesophageal myotomy is made using a therapeutic endoscope via a transmucosal incision in the mid-esophagus for the treatment of achalasia . A submucosal tunnel is made along the length of the esophagus and the circular muscle fibers are incised, performing the myotomy. POEM was initially described in 2008 by Inoue, and has subsequently come to be performed in more than 50 centers worldwide. Several studies comprising hundreds of patients have been reported, confirming the safety and efficacy of POEM. The success rates of achalasia treatment using POEM are greater than 90 %, generally evaluating the symptoms using the Eckhart score. Postoperative gastroesophageal reflux symptoms have been reported in patients greater than 1 year postoperatively at rates between 35 and 40 %. These results are consistent with postoperative reflux rates in laparoscopic Heller myotomy. POEM represents a minimally invasive, incision-free alternative to laparoscopic Heller myotomy that has been reported as successful treatment in nearly all types of achalasia, including patients with previous interventions, as well as patients with sigmoid esophagus.

The widespread adaptation of minimally invasive techniques faces several hurdles. One of the largest hurdles involves the dissemination of techniques and skills outside of residency training to surgeons in the community. Residency training represents the ideal setting for educating surgeons under the direct oversight of experienced surgeons on a day-to-day basis. New technologies and techniques are constantly under development throughout a surgeon’s career. There is a need to develop robust and validated assessment tools for surgical competency given growing potential for patient harm with more advanced surgical tools [5]. The current method for a surgeon to learn a new technique frequently involves a course or simulation that is insufficient to fully develop the necessary skills. A novel approach to the continued training of practicing surgeons has been implemented by a number of groups, including Ponsky et al. as described in 2014 [6]. The Karl Storz VisitOR1 telementoring robot cart was used to stream the procedure to a virtual mentor experienced in the procedure. The VisitOR1 robot cart allows the mentor to provide real-time advice on the procedure, including telestration capabilities. Previous studies have demonstrated equivalent levels of skill acquisition between surgeons that were remotely mentored and locally mentored in laparoscopic nephrectomy, Nissen fundoplication, and laparoscopic colectomies. This demonstrates the potential of telementoring to provide surgeons with the ability to further their training throughout their career irrespective of the availability of local expert mentors. Other questions arise around how best to prepare/rehearse given potential evidence about optimal techniques for performing physical rehearsal and warm-up. Preliminary findings suggest that preoperative rehearsal or warm-up can improve the performance of operators or operating teams, but there is a paucity of objective evidence and comparative clinical studies in the existing literature to support their routine use [7].

There is debate about the relationship between the telementor and practicing surgeon, and therefore the liability of the mentor. Some argue that the mentor is directly involved in intraoperative decision making, and therefore responsible for patient care. Other parties believe that the responsibility lies with the primary surgeon, and the mentor is only advising the primary surgeon, and not liable for patient care or outcome [8]. Currently, it is important that the primary surgeon be able to complete the procedure on his/her own, and that the mentor be present for guidance on optimal technique. Regardless, telementoring represents an avenue for continuing education and live intraoperative training of surgeons, without regard to geographic boundaries for the future (Fig. 10.4). Simulation-based training in conjunction with deliberate practice activities such as reflection, rehearsal, trial-and-error learning and feed- back in improving the quality of patient care will become mainstream in assessing expertise [9].