NOTES from the Underground


Surgical innovation has always been a problem for medical ethics.  Surgeries are unregulated, and partly as a result, few are introduced to clinical practice having been validated in randomized controlled trials. Moreover, attempts at novel surgeries typically fly beneath the radar of ethical review, because they are viewed as innovative clinical practice rather than research. There are some good–and not so good– reasons for such “surgical exceptionalism.”

On Sunday, the Washington Post ran a story (“Scarless Surgery Uses Body’s Own Openings,” Rob Stein, Sept 21) on a new type of surgery, Natural Orifice Transluminal Endoscopy (NOTES), which avoids skin incisions by accessing organs through the mouth, anus, or vagina. Various teams are testing and/or using NOTES to remove gall bladder stones, to perform appendectomies and cholecystectomies, and to collect tumor tissue for cancer staging.

NOTES has the potential to reduce pain and scarring, and to hasten recovery. But the technique still requires validation in animal models. One major concern is infection: NOTES requires incisions through flora-rich environments like the rectum, stomach, or vagina.

Several U.S. and European medical societies have established initiatives aimed at guiding development of this technique. One example is NOSCAR (, which maintains an outcome registry and identifies unmet research needs. The group also urges surgeons to seek independent ethics review before attempting NOTES in humans.

However, many first tries at NOTES have been performed outside traditional centers of medical innovation. For instance, the first team to perform a NOTES appendectomy is based in Hyderabad, India; several surgical teams in Brazil are also publishing a disproportionately large volume of human case reports (the prominence of Latin America and Asia is briefly NOTEd in the Washington Post story). One searches far and wide for any commentary on this phenomenon. Why are Brazil and India at the vanguard of surgical innovation? Is this simply one manifestation of the knowledge economy moving overseas? Or does it have something to do with laxer regulations and safety standards? Are there characteristics of NOTES that make it particularly attractive for surgeons working in resource-limited circumstances? (photo credit: photosan0, Pink Floyd album, 2006)


    title = {NOTES from the Underground},
    journal = {STREAM research},
    author = {Jonathan Kimmelman},
    address = {Montreal, Canada},
    date = 2008,
    month = sep,
    day = 22,
    url = {}


Jonathan Kimmelman. "NOTES from the Underground" Web blog post. STREAM research. 22 Sep 2008. Web. 01 Mar 2021. <>


Jonathan Kimmelman. (2008, Sep 22). NOTES from the Underground [Web log post]. Retrieved from

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