natural orifice translumenal endoscopic surgery ( notes ) is on the forefront of surgical technique and is pushing the perceptions and boundaries of abdominal surgery , as laparoscopy did when first introduced .
however , in spite of enthusiasm on behalf of researchers for the technical aspects of notes , what will truly lead to its wider implementation will be improved patient outcomes and acceptance . while better patient outcomes ( less postoperative pain , fewer  if any  scars , and decreased length of hospital stay ) are touted to be the main goal of this technique
however , patient acceptance of the procedure and its risks can be assessed through surveys in advance of outcomes data .
though multiple studies have addressed attitudes towards this developing technique , the ability to interpret these variable study results is challenging .
secondly , the larger scale studies have come mainly from europe , thus making direct inferences to a north american population potentially incorrect .
finally , these surveys have emphasized gender and age as variables in assessing interest in notes but have not assessed whether previous surgery affects patients perceptions of scars and postsurgical pain .
it is known that obese patients are at higher risk for developing postoperative hernias and wound infections [ 14 ] and thus may be a group that could derive significant benefit from notes . in this paper , we surveyed a large number of patients at a canadian centre to assess opinions regarding scarless surgical procedures and whether increased risks would affect their choices . a large sample also allowed for subgroup analyses based on gender , age , and body mass index .
the survey instrument was developed by a team of general surgeons , gastroenterologists , and a statistician .
approval for the study was obtained from the queen 's university health sciences & affiliated teaching hospitals research ethics board .
a pilot study was performed with 10 people and feedback incorporated into the survey tool .
the final survey was comprised of demographic data ( age , gender , self - reported height and weight ) , as well as questions regarding previous surgery and presence and location of scars .
patients were then asked about the importance of scars , bother from scars , interest in scarless surgery , interest in scarless surgery if there were increased complications , acceptable complication rate ( from 0% to 20% ) , importance of research into the field , and importance of shorter recovery from surgery .
these were all graded on a five - point scale ( see the appendix ) .
all patients attending general surgery outpatient clinics ( excluding breast clinics ) at hotel dieu hospital  an ambulatory based hospital providing secondary and tertiary care to residents of kingston , ontario , and the surrounding area  were invited to fill out a short questionnaire regarding notes over a 6-month period in 2008 - 2009 .
surveys were distributed and collected by study hospital staff and deposited in a collection box , which was emptied on a weekly basis to avoid any chance of patient identification .
the actual response rate could not be calculated , as the surveys were anonymous and clinic staff did not track the number of patients who were uninterested in responding .
however , anecdotal evidence suggests that the patients were generally happy to complete the short survey while they waited . in the event that several appointments were scheduled , patients were asked to complete the survey only once .
data were entered into an excel spreadsheet designed for the study and entered into spss ( version 17.0 for windows , 2009 , chicago , il ) for statistical analysis .
body mass index ( bmi ) was calculated according to the standard formula of weight ( kg ) divided by height ( metres ) squared .
bmi was then classified using the standard cutpoints of 18.524.9 ( healthy weight ) , 2529.9 ( overweight ) , 3034.9 ( obese i ) , 3539.9 ( obese ii ) , and 35 ( obese iii ) .
two who were just below the 18.5 threshold were included with the healthy weight group .
data were initially assessed descriptively ( mean , standard deviation and range for continuous and ordinal data , frequency and percent for categorical data ) and graphed to assess the underlying distribution .
responses to the 5-level likert scales ( 1 = no importance , bother , or interest and 5 = extremely important , bothered , or interested ) were quantified so that means and standard deviations could be generated .
although the data are ordinal in nature and the use of inferential statistics is not optimal in this situation , they were used for several reasons .
first , this was considered preferable to a large volume of chi - square tests . a comparison of medians was also considered but
while groups often had similar median values , subtle differences emerged when means were used .
finally , the sample size for the majority of the comparisons was sufficiently substantial to allow the use of inferential statistics in this situation .
the associations of age and body mass index with the seven questions were assessed by means of the nonparametric spearman 's correlation .
the association of gender and presence of a previous surgical scar ( abdominal or nonabdominal ) with the seven questions was assessed by means of the mann - whitney u test , while the association for the three levels of age and bmi were assessed by means of the kruskal - wallis test . in order to provide an adequate sample to allow for subgroup analysis ,
for all analyses , the significance level was set at p < 0.05 ( two - sided ) , although results that fell short of statistical significance were noted if they were deemed to be of clinical interest .
nine percent were 29 years of age , 26% were 3049 years , and 64% were 50 years ; for bmi , 29.9% were at a healthy weight , 34.9% were overweight , and 29.6% were obese ( 6% were missing height and/or weight ) .
as this was a voluntary , anonymous survey , there were very few missing data ( see table 2 ) .
for the few items that were missing , analyses were completed on the subset without missing data , as the type of detailed information typically required for imputation was not collected .
younger respondents ( < 50 years of age ) , females , and those of a healthy weight indicated that cosmetic issues such as scars were more important , as compared to older , male , and heavier respondents ( p  0.001 for all three comparisons ) ( table 3 ) . amongst
of these , 58% indicated that it did not bother them at all , but 9.9% indicated that they were bothered quite a bit or extremely by their scar(s ) .
women placed significantly greater importance on abdominal scars than men and were more greatly impacted by them ; fifty - six percent of women were bothered by some degree by their current scars as compared with 23% of men ( p < 0.001 ) .
age ( as a continuous variable ) was negatively correlated with the importance and impact of abdominal scars ; in other words , as age increased , the importance and impact of abdominal scars decreased ( p < 0.001 , see figure 1 for importance ) .
similarly , as bmi increased , the importance of abdominal scars significantly decreased ( p < 0.001 , figure 2 . )   the majority ( 83% ) had at least some interest in a surgery that would leave no scars .
the two younger groups were more interested than those over 50 years ( p = 0.001 ) , with those between 30 and 49 years remaining the most interested in the face of increased risk ( p = 0.036 ) .
the two younger groups were comfortable with a risk up to 10% , while the older group was more conservative and was more comfortable with a risk close to 5% ( p = 0.003 ) .
there were also gender differences in the level of interest , with women expressing more interest than men ( p = 0.021 ) .
this difference disappeared when the question of risk was added ( p = 0.192 ) , although the women tended to accept an increased risk of close to 10% , while the men were closer to 5% ( p = 0.059 ) .
level of interest in notes was not significantly related to bmi , nor was acceptance of increased rate of complication , or the amount of acceptable risk . however , for all three questions , those at a healthy weight had the highest scores , suggesting more interest and less concern about risk .
those without previous abdominal scars were more interested in notes than those with scars ( p = 0.049 ) , but both groups lost interest when presented with increased risk .
the presence of other scars had little association with the responses to the three questions .  
over 80% of respondents felt that research into scarless surgery was of some importance , with 30.4% rating it as quite or extremely important . with age as a continuous variable ,
the spearman correlation suggested a negative but significant association ( rho = .205 , p < 0.001 ) ; using the categorical variable , those in the age group of 3049 years rated research as more important than the younger or older groups ( p = 0.040 ) .
bmi was also negatively and significantly associated with importance when using the continuous variable ( rho = .149 , p = 0.009 ) , but fell just short of significance when using the categorical variable ( p = 0.066 ) , although it was the healthy weight group that was more likely to rate it as important .
women rated it as more important than men , although it fell short of significance ( p = 0.084 ) .
one of the key proposed benefits of notes is a decreased length of stay in the hospital .
very few ( only 5.1% ) indicated that a shorter hospital stay was not important , with 64.8% indicating that it was quite or extremely important .
there was a weak , negative association with age using the spearman correlation ( rho = .109 , p = 0.049 ) , but this was no longer significant when using the categorical data ( p = 0.537 ) .
sex , bmi , and presence of scars also had little association with the importance of shorter in - hospital recovery time .
here , we captured the opinions of 335 north american patients to obtain their views on this developing technique .
several patient surveys have attempted to characterize those who would be most interested in this new method .
studies published to date have variable results , perhaps related to the population surveyed and questions asked .
some surveys have shown that patients prefer notes to laparoscopic surgery due to its improved cosmetic result with the potential for decreased pain also holding appeal in some studies [ 710 ] .
however , patients consistently had decreased interest as the potential rate of complication increased [ 7 , 9 ] .
single port surgery ( sps ) is a minimally invasive form of laparoscopic surgery and a large - scale british study ( n = 750 ) comparing patient views on it and notes showed that sps was significantly preferred over open surgery and notes .
although experts often point to women as being a target group who would be interested in notes , studies looking at the effect of gender on opinions of notes have led to conflicting results .
varadarajulu et al . did not find a significant preference by women for notes compared to men .
further to this , surveys targeted at women in the context of transvaginal notes have had variable results .
sixty - eight percent of women were interested in notes in a study by peterson et al .
however , in an australian study , three quarters of surveyed women were neutral or unhappy about transvaginal notes compared with standard laparoscopic surgery . in keeping with the results of previous surveys ,
women were significantly more concerned with the cosmetic results of surgery and were more bothered by current scars .
in addition , female patients are anatomically more versatile candidates for notes , with the potential for a transvaginal approach .
our study did support the theory that women would be more interested in notes than men , but this association was lost when additional risk was factored into the equation .
those under 50 years of age rated a scarless method as being more important and expressed more interest , even in the face of increased risk .
although there was a high interest in the concept of notes ( 83% showed at least slight interest ) , this dropped to 38% when an increased complication risk was proposed compared to traditional techniques .
however , this remains a significant proportion of the surveyed population , and provides impetus to further research and development in this field to make it a safe alternative to laparoscopic and open surgery .
this is borne out in our data where 81% of patients felt that research into notes held some level of importance .
one of the groups in the position to benefit the most from notes is obese patients , though our data show that level of interest in the technique is significantly and negatively associated with bmi , such that those of healthy weight expressed greater interest .
obese patients are especially at risk for hernias after transabdominal surgery [ 46 ] and notes could mitigate this risk .
the lack of abdominal wall incisions could also lead to earlier postoperative mobilization , better lung ventilation , decreased wound infections , all of which would lead to decreased length of hospital stay .
furthermore , notes - assisted bariatric surgery has now been successfully attempted   and in the authors ' opinion is one of the prime areas for notes development .
hence , further objective data and education will be necessary to garner the interest and support of this population in this new technique . though the capital investment required for the development and adoption of any new technique is significant , the potential for cost savings in projected shorter hospital stays could offset the cost .
ninety - five percent of patients indicated that a shorter in - hospital stay was important to them , adding to the attractiveness of this aspect of notes .
the reasons behind patient interest in shorter length of hospital stay were not explored further but could include less time away from home and increased awareness of hospital acquired infections .
third party payers ( insurance companies and governments ) would certainly also be interested in a technique that reduces hospital stay .
in addition , it has been proposed that once further developed notes would not require a traditional operating room , thus altering hospital utilization further .
the current study has some limitations . by dint of the survey population being from surgical clinics ,
while the self - administered survey prevented any bias that might have stemmed from a personal interview , patients were unable to ask for any more detail regarding the technique and complications than was included in the survey .
for example , when presented with potential complications such as dyspareunia and infertility , women may in fact be less interested in the transvaginal approach of notes .
this could also be extended to multiple centres to capture regional differences in opinion as the present study was performed in a single centre .
the technique is still in its early stage of acceptance , but our data lend support to this endeavour .
clearly , once techniques are further refined , hard data including complication rates , length of stay , and post - operative pain will be necessary to assess its utility and give patients adequate information for an informed choice .

 survey of opinions regarding a new surgical technique 
 age :   yearssex :  
 male (  ) female (  ) 
 height :   ( in feet and inches ) or 
( in centimetres)weight :   ( in pounds ) or   ( in kilograms)do you have an abdominal scar from a previous surgery ? 

yes (  ) no (  ) 
 do you have any other major scars ? 

yes (  ) no (  ) 
 if yes , where ?            

 
 age :   yearssex :  
 male (  ) female (  ) 
 height :   ( in feet and inches ) or 
( in centimetres)weight :   ( in pounds ) or   ( in kilograms)do you have an abdominal scar from a previous surgery ? 

yes (  ) no (  ) 
 do you have any other major scars ? 

yes (  ) no (  ) 
 if yes , where ?            
 
 male (  ) female (  ) 
  height :   ( in feet and inches ) or 
( in centimetres ) weight :   ( in pounds ) or   ( in kilograms )
if yes , where ?            for the following questions , please place a check mark in the box that  corresponds best with what you think 
 how important are cosmetic issues , like scars , to you in abdominal surgery ? 
 not at all important (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
 how do you feel about the scars you have ? 
 not applicable , no scars (  ) do not bother me at all (  ) bother me slightly (  ) bother me moderately (  ) bother me quite a bit (  ) extremely bothered (  ) 
 would you be interested in a surgery that would leave no scars ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
 would you be interested in a surgery that would leave no scars even if there was an increased risk of complications such as infection inside your abdomen ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
 how much increased risk would you be comfortable with if the surgery would leave no scar ?
for example , if you pick 5% , you are indicating that you 'd be comfortable with a 5 in 100 chance of having a complication such as infection just to have a scarless surgery . 

none , would not have scarless surgery (  ) 5% (  ) 10% (  ) 15% (  ) 20% or more (  ) 
 how would you rate the importance of further research and investment into scarless surgery ? 

not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
 how important is a shorter recovery time ( time spent in hospital recuperating from surgery ) to you ? 

not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 

  how important are cosmetic issues , like scars , to you in abdominal surgery ? 
 not at all important (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
  not at all important (  ) slightly important (  ) moderately important (  ) extremely important (  ) how do you feel about the scars you have ? 
 not applicable , no scars (  ) do not bother me at all (  ) bother me slightly (  ) bother me moderately (  ) bother me quite a bit (  ) extremely bothered (  ) 
  not applicable , no scars (  ) do not bother me at all (  ) bother me slightly (  ) bother me moderately (  ) bother me quite a bit (  ) extremely bothered (  ) would you be interested in a surgery that would leave no scars ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
  slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) would you be interested in a surgery that would leave no scars even if there was an increased risk of complications such as infection inside your abdomen ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
  slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) how much increased risk would you be comfortable with if the surgery would leave no scar ?
for example , if you pick 5% , you are indicating that you 'd be comfortable with a 5 in 100 chance of having a complication such as infection just to have a scarless surgery . 

none , would not have scarless surgery (  ) 5% (  ) 10% (  ) 15% (  ) 20% or more (  ) 
  none , would not have scarless surgery (  ) how would you rate the importance of further research and investment into scarless surgery ? 

not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
  not important at all (  ) slightly important (  ) moderately important (  ) extremely important (  ) how important is a shorter recovery time ( time spent in hospital recuperating from surgery ) to you ? 

not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
  not important at all (  ) slightly important (  ) moderately important (  ) extremely important (  )
 natural orifice translumenal endoscopic surgery ( notes ) is on the forefront of surgical technique , but existing research has produced mixed results regarding factors associated with interest in the procedure . 
 our objective was to ascertain patient opinions at a canadian centre regarding scarless surgery . 
 a survey comprising demographic data ( gender , age , body mass index [ bmi ] ) , interest in notes , impact of increased risk , as well as importance of further research and shorter recovery time was administered to volunteer patients at outpatient general surgery clinics . 
 nonparametric tests were utilized to examine difference in response by age , sex , bmi , and preexisting scars . 
 of the 335 participants ( 57% female , mean age of 54.5  15.9 years , mean bmi of 28.7  6.9 ) , the majority ( 83% ) showed some interest , but this dropped to 38% when additional risk was factored in . 
 generally , women , those under 50 years of age and those of healthy weight , were more interested than male , older , and/or heavier patients . 
 most felt that research into notes and reduced length of inpatient stay were important ( 80% and 95% , respectively ) . 
 further investigation into objective notes outcomes are needed to provide patients adequate data to make an informed choice regarding surgical route . 
1. Introduction
2. Methods
3. Results
4. Discussion
 Survey Instrument