natural orifice transluminal endoscopic surgery ( notes ) has recently generated significant interest amongst surgeons and gastroenterologists .
pushing minimally invasive surgery a step forward , the concept of incisionless surgery is appealing to patients and physicians alike . accessing the abdominal cavity and its organs via natural orifices , such as the mouth , anus , vagina , and urethra , may enable surgeons in the future to approach operations they traditionally performed in open and laparoscopic fashions .
the potential benefits of such techniques include less physiologic stress and trauma ; faster recovery ; less pain ; fewer complications , such as intestinal adhesions and hernia ; better cosmesis ; and decreased healthcare cost by decreasing the rate of hospitalization .
several operations including cholecystectomy , splenectomy , appendectomy , gastrojejunostomy , and oophorectomy have been performed . however , little data are available in humans .
a 61-year - old woman with ulcerative colitis refractory to medical therapy presented to our department following numerous admissions for anemia requiring blood transfusions .
she had a history of deep venous thrombosis and pulmonary embolism status post placement of an inferior vena cava filter , cerebrovascular disease with left hemiplegia , and coronary artery disease .
she underwent an uneventful proctocolectomy with end ileostomy . on postoperative day 1 , the patient developed phlegmasia cerulea dolens , and an mri revealed thrombosis of her inferior vena cava and iliac veins .
transanal drainage through the anal cuff was performed at the bedside with irrigation of the lower pelvis with a mushroom catheter , and antibiotic therapy was instituted .
the patient remained septic and 2 days later underwent placement of a percutaneous drain by interventional radiology .
the drain was ineffective due to the organized nature of the infected hematoma with multiple septations and phlegmonous reaction .
re - exploration and drainage of the abdomen was entertained , but due to the frailty of the patient , a transanal endoscopic drainage was performed on postoperative day 17 in the endoscopy suite .
room air under pressure was used to insufflate the abdominopelvic cavity for visualization . a large , multiseptated and organized
intraperitoneal hematoma was encountered with the pigtail drain embedded in a fibrinous collection ( figure 2 ) .
following mechanical and hydrogen peroxide fragmentation , the hematoma was retrieved with suction , forceps , and baskets , and the pelvis and lower abdomen were cleared ( figure 3 ) .
ct scan images were used to guide the depth of intervention to minimize any injury to small bowel .
two 19 french round blake drains were introduced via the anal opening and guided into the abdomen with the use of an endoscopic snare .
the patient 's clinical status rapidly improved , and her white count normalized within 2 days .
the evolution of minimally invasive surgery over the last 2 decades has redefined the practice of surgery . driven by technological advances and supporting clinical data , the implementation of these new techniques has been remarkable and has stimulated inquiry into future directions .
undoubtedly , most of the initial human data will come from case reports and short series attesting to the feasibility , safety , and limitations of notes .
rao and colleagues from india have already demonstrated that appendectomy via a transgastric route is feasible in humans .
although transanal drainage of pelvic sepsis ( the bedside drainage we performed in our patient as initial intervention ) is a known procedure in the surgical armamentarium , this report illustrates the utilization of flexible endoscopy to reach a higher location in the abdominopelvic cavity and to perform more extensive drainage of a loculated infected hematoma .
none of these interventions were successful due to the location , extent , and nature of the organized hematoma , and the overall debilitated state of the patient .
although commonly used , percutaneous drainage is not always successful at controlling abdominal sepsis . in our case , re - exploratory laparotomy was the only remaining option to evacuate the patient 's infected hematoma .
considering her clinical status , such an intervention would have carried significant morbidity . with the patient 's full consent ,
obviously in this case , the rectum was surgically missing so access to the peritoneal cavity was unhindered , and it was not necessary to close the anorectal stump . had the rectum been present , a transanal proctotomy would have been necessary to gain access to the abdomen . but
this case illustrates that it is technically feasible to endoscopically tackle the postoperative abdomen , fragment , retrieve , and drain infected hematoma with current equipment .
the equipment and endoscopic expertise to perform such a task in a routine , reliable , and safe fashion are currently limited but growing .
in addition , several endoluminal methods and devices are being developed to gain entry access into the peritoneal cavity through the digestive tract .
notes is a field in its infancy , and whether it will gain widespread acceptance and application is yet to be determined .
although most advances in this field will be driven by animal experimentation , some may result from challenging situations such as our case that may provide opportunities to push the boundaries of our current surgical practices .
 natural orifice transluminal endoscopic surgery ( notes ) is an evolving experimental field exploring the technical feasibility and outcome of therapeutic interventions performed through the natural orifices of the body . 
 the knowledge accumulating in notes is the result of animal experimentation and ongoing early clinical experience in humans . in this report 
 we describe a patient treated with transanal endoscopic drainage of postoperative abdominopelvic sepsis . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION