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Jeong et al. Mini-invasive Surg 2019;3:38 I http://dx.doi.org/10.20517/2574-1225.2019.42 Page 7 of 11

B

C
A

Figure 4. Considerations in pure NOTES. Preoperative considerations are anal sphincter condition (A), pelvic promontory (B), distance to
splenic flexure (C), operative history, etc. NOTES: natural orifice transluminal endoscopic surgery; LLQ: left low quadrant

Figure 5. Lap-bag application. Especially Lap-bag should be considered for prevention from soiling and spillage during intraperitoneal step

with a rectal stump in the Lap-bag. This prevents soiling or spillage and at the same time improves the field
of view because the rectal stump, including the lesion, is out of the center of the field of view [Figure 5].

In general, Hemo-loc or clip is usually used for ligation of IMA or IMV in laparoscopic surgery. However,
when implementing transanal NOTES, a series of operations such as loading, entering, and firing must
be performed several times in succession, and the moving range is relatively long. In this process, there is
the possibility of damaging surrounding organs or tissues by blindly reciprocating a fairly long section.
In contrast, when an energy device with a good sealing effect is used, the procedures can be carried out
continuously by using “Overlapping sealing technique” in the field without repeating the work carried out
during use of Hemo-loc or clips. Sealing power and security are also firm and safe enough. This can be said