NOTES (natural orifice transluminal endoscopic surgery) is a subset of minimally invasive surgery where a flexible endoscope inserted into a natural orifice (mouth, anus, vagina, nose, or urethra) is used to carry out a surgical procedure [1,2]. Both surgeons and endoscopists (gastroenterologists) have pioneered this discipline. From the second NOTES white paper:

For those skeptics who dismissed NOTES as a passing fad, the evidence to date suggests that this notion is wrong. NOTES is increasingly well established as a concept and methodology. Rather than being an end point in and of itself, NOTES is a way of thinking that regards the use of a natural orifice in conjunction with flexible instruments as a less invasive and more cosmetically appealing method of performing certain surgical procedures. The time line to widespread clinical adoption of NOTES and the ideal entry procedure is unknown and not critically important. The important thing is to properly develop NOTES procedures, assess them critically, and take advantage of the ideas and techniques that spin off along the NOTES developmental pathway.

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The concept of NOTES is well established. Many NOTES procedures have been described in the literature, and trials and outcomes have been published. So how do we approach training? There is an inevitable conflict that presents itself when considering training in NOTES: with some exceptions, surgeons tend to be poor endoscopists, and endoscopists (gastroenterologists) tend to be poor surgeons. NOTES is a true hybrid technique that straddles the crossroads between surgery and endoscopy and pushes the envelope in both. Few are able to be expert in both fields. Certainly there are some gastroenterologists who can perform endoscopic submucosal dissection (ESD), peroral endoscopic myotomy (POEM), and pyloromyotomy, which are surgical procedures after all, without the aid of a surgeon. Similarly, there are some surgeons, especially thoracic and foregut surgeons, who are sufficiently adept at endoscopy that they can perform NOTES procedures solo. However, natural orifice surgery can be very difficult, and the majority of surgeons do not possess the requisite endoscopic skills to become competent. Similarly, with few exceptions, most gastroenterologists have little or no formal training in surgery beyond that which occurred in medical school. Therefore gastroenterologists, although they may have the technical skill to perform NOTES, do not have the cognitive skills or experience required. This is why many successful NOTES programs are a hybrid, with equal participation by surgeons and gastroenterologists.

Given the limited number of NOTES centers and data concerning training in NOTES, this chapter will provide a rationale for making NOTES training a joint endeavor between surgeons and gastroenterologists and proposes a model of what a successful NOTES training program might look like. This is based primarily on the experience from my own institution as an example. It is not exhaustive, listing some of the most essential techniques/skills at the end of the first section. This is succeeded by some thoughts on credentialing.

It has not escaped my observation that NOTES training would have a positive impact on the field of advanced endoscopy. Many NOTES procedures are spin‐offs of ESD, endoscopic full‐thickness resection (EFTR), etc. The reverse is also true. NOTES procedures have spawned innovation in advanced endoscopy. The field of interventional endoscopy can only be favorably influenced by pursuit of advanced surgery (NOTES) procedures.

Training

How can someone train to become a competent NOTES surgeon? One could take an interventional endoscopist and make that physician take 2 or 3 years of surgical training, similar to residency. Conversely, one could take a surgeon and make him take a year or two of advanced endoscopy training. Neither of these options is practical. Current “surgical endoscopy” fellowships do not follow American Society for Gastrointestinal Endoscopy (ASGE) training guidelines in terms of number of procedures required to be eligible even to be assessed for competence. Many so‐called surgical endoscopy fellows spend most of their time doing surgery and finish these fellowships with fewer endoscopies than our first‐year fellows. So, short of making gastroenterologists do a surgical residency, and making surgeons do a gastroenterology fellowship, we must settle for some other kind of training.

One way around this dilemma would be for the putative NOTES surgeon to obtain one‐on‐one training in a particular procedure by experts. For example, I have personally mentored surgeons and gastroenterologists in POEM at five different medical centers. I received my own training in POEM by traveling to Japan with my surgery colleagues for 3 days to learn the technique from Dr. Haru Inoue. Training in third space endoscopy is discussed in great detail in Chapter 19

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