When Dartmouth Medicine last visited Dr. Richard Rothstein, in 2005, he was sitting at a computer console at DHMC, manipulating a robot to perform virtual incisionless surgery on a research model.

Actual: Today he sits 3,300 miles away, at the Royal Veterinary College in London, performing actual incisionless surgery on pigs. The chief of gastroenterology at DHMC, Rothstein is on sabbatical, he explains by e-mail, to immerse himself "in the field of NOTES, to identify those emerging technologies that will have applicability to future human clinical work back at Dartmouth."

NOTES stands for Natural Orifice Translumenal Endoscopic Surgery. It means running an endoscope with miniature surgical tools through a natural opening in the body to reach an internal organ. For example, entry via the mouth and esophagus makes it possible to pass through the stomach wall to reach the abdominal cavity. Or the pelvic region can be reached via the penis, vagina, or anus.

So an operation that required an incision measured in inches when done by open surgery, then only a half-inch "band-aid" incision for laparoscopic surgery, may soon require no external incision at all. The reason for the evolution? Less pain, shorter recovery, and no visible scars.

In London Rothstein is "concentrating on identifying the most successful methods of endoscopic sewing." That, he says, is key to the acceptance of NOTES. "There are many hurdles for natural orifice surgery," he adds, including prevention of infection, visualization of the operative field, and control of hemorrhage. But "the show-stopper," he believes, will be "reliable closure technique—a tight seal is the key to surgical success. This is the reason for a focus on sewing devices and techniques during this sabbatical."

Why Royal Veterinary? He chose it, Rothstein says, "so that I could work with Professor C. Paul Swain, a long-time friend and academic gastroenterologist." Swain's team has been a pioneer in NOTES and in developing devices, including an endoscopic sewing machine.

Cavity: Describing his sabbatical work, Rothstein says that "after cutting an entry hole into the abdominal cavity through the stomach or colon, via natural orifices, we pass the endoscope into position to manipulate, biopsy, remove, or join various organs and structures." Then, because successful closure of the divided tissue is paramount, he is assessing the accuracy, ease, and effectiveness of various sewing devices and techniques.

U.S. surgeons have yet to perform a NOTES procedure on a human, but physicians in India and Brazil have. In India, Rothstein reports, "the patients did fine," though the devices and techniques proved difficult to use, so the clinicians imposed a moratorium on further procedures pending improvements.When asked how long he thinks it will be before NOTES is approved in the U.S., Rothstein looks to the past: "When laparoscopic surgery emerged as an alternative to open procedures, there was a great deal of skepticism, derision, and disbelief on the part of practicing surgeons." But the "patients pushed the skeptics, and the outcomes convinced everyone." The evolution of NOTES, he opines, will take a similar path.

Whatever the timing, he says that DHMC offers "a superb environment for the development of NOTES" and that his colleagues are "most supportive."

Rothstein serves on a national oversight committee called NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research). "Dartmouth was an early entrant into the field," he says, and has collaborated with institutions in Texas, England, Germany, and Sweden. As the discipline develops further, he adds, it will be important to continue "to promote collegiality and minimize competition."