The "Iceberg Phenomenon": As Soon as One Technological Problem in NOTES Is Solved, the Next One Appears!
OBJECTIVE
Though already proclaimed about 7 years ago, natural orifice transluminal endoscopic surgery (NOTES) is still in its early stages. A multidisciplinary working team tried to analyze the technical obstacles and identify potential solutions.


METHODS
After a comprehensive review of the literature, a group of 3 surgeons, 1 gastroenterologist, 10 engineers, and 1 representative of biomedical industry defined the most important deficiencies within the system and then compiled as well as evaluated innovative technologies that could be used to help overcome these problems. These technologies were classified with regard to the time needed for their implementation and associated hindrances, where priority is based on the level of impact and significance that it would make.


RESULTS
Both visualization and actuation require significant improvement. Advanced illumination, mist elimination, image stabilization, view extension, 3-dimensional stereoscopy, and augmented reality are feasible options and could optimize visual information. Advanced mechatronic platforms with miniaturized, powerful actuators, and intuitive human-machine interfaces could optimize dexterity, as long as enabling technologies are used. The latter include depth maps in real time, precise navigation, fast pattern recognition, partial autonomy, and cognition systems.


CONCLUSIONS
The majority of functional deficiencies that still exist in NOTES platforms could be overcome by a broad range of already existing or emerging enabling technologies. To combine them in an optimal manner, a permanent dialogue between researchers and clinicians is mandatory.
Technical University of Munich, Munich, Germany hubertus.feussner@tum.de.
Hubertus
H
Feussner
Technical University of Munich, Munich, Germany.
Adam
A
Fiolka
Technical University of Munich, Munich, Germany.
Armin
A
Schneider
Fraunhofer Project Group for Automation in Medicine and Biotechnology (PAMB), Mannheim, Germany.
Timo
T
Cuntz
Technical University of Munich, Munich, Germany.
Johannes
J
Coy
KUKA Laboratories GmbH, Augsburg, Germany.
Cyrill
C
von Tiesenhausen
Friedrich-Alexander University, Erlangen-Nürnberg, Germany.
Kurt
K
Höller
Karlsruhe Institute of Technology, Karlsruhe, Germany.
Oliver
O
Weede
German Aerospace Center, Oberpfaffenhofen-Wessling, Germany.
Rainer
R
Konietschke
Leibniz University of Hannover, Hannover, Germany.
Jan-Hinnerk
JH
Borchard
University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany.
Mark
M
Ellrichmann
Technical University of Munich, Munich, Germany.
Silvano
S
Reiser
Leibniz University of Hannover, Hannover, Germany.
Tobias
T
Ortmaier
D006801:Humans; D057605:Natural Orifice Endoscopic Surgery; D065287:Robotic Surgical Procedures
NOTES; actuation; autonomy; platforms; robotics; visualization