Transgastric appendicectomy (Br J Surg 2013; 100: 911–915)

The careful clinical study by Kaehler and colleagues from Mannheim regarding laparoscopically assisted transgastric appendicectomy is a further example that concepts relating to natural orifice transluminal endoscopic surgery (NOTES) are progressing towards routine clinical practice. Although its advancement has been by no means as rapid as that initially envisaged by many early enthusiasts, serious clinical investigators around the world show by their ongoing endeavours that it can prove a viable access modality for intra-abdominal operation1. The authors' experience demonstrates clearly two important aspects of the technical performance of NOTES in this specific setting. The first is that patients are understandably more cautious when faced with the actual, real prospect of undergoing a novel operation than when considering it in the abstract, with only 14 per cent of possible patients consenting to the hybrid operation in this unit as opposed to the near 50 per cent who claim positive intent to a questionnaire2. Although this may be due in part to the urgent setting of their presentation and to a rigorous consent process as the authors postulate, this level of acceptance seems more reflective of this access's niche value at least in its evaluation and development phases. Second, it is notable that the complications suffered related primarily to the target pathology and not to the transvisceral access, conduit or exit. Although the cohort was small, the operator could safely access the peritoneal cavity in every patient without injuring neighbouring organs in the absence of prior pneumoperitoneum creation or coincident transabdominal laparoscopic control. Furthermore, the gastrotomy could be closed safely in every patient by simple endoscopic clipping from within the stomach alone, even after the majority of the surgical intervention (with its associated strain on the visceral wound by torsion and torque of the flexible gastroscope) had been performed solely via this site. Although the authors make several plausible suggestions about how to improve technically the address of the infectious process by this route, what next-generation NOTES proceduralists may most need to develop is a specific targeted application more suited to its capability and limitations rather than compromised-through-adaptation replication of operations already performed very successfully in a minimally invasive fashion. In this way, innovative operations such as peroral endoscopic myotomy3 have begun to gain clinical traction by harnessing NOTES capability and technology in new directions that raise the challenge to us all of considering not just novel technology, but actual evolution of conventional operative blueprints. The author declares no conflict of interest.