Notes on NOTES: The emperor is not wearing any clothes.

Laparoscopic surgeons are a curious lot. When we were accused of surgical adventurism in the early 1990s and were ostracized from presenting our early findings at the American College of Surgeons, we decided to invest our academic achievements in the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). All of the early laparoscopic pioneers suffered the indignity of being the object of derogatory comments by the surgical establishment about ‘‘Nintendo’’ surgery (as if they knew what a video game was) and the ridiculousness of statements such as, ‘‘what’s wrong with a four-inch incision to remove the gallbladder that gets the patient back to work in 3 to 4 weeks?’’. We kept our council (silence), in spite of some misgivings, as the next technological revolution, robotics, swept the minimal invasive world. After the first year or so there were about 12–14 publications in our literature, all proclaiming this robotic surgery as being as ‘‘safe and effective’’ as laparoscopic surgery, but none actually proving it to be better. When the publications were looked at closely, all of the operations cost more and took longer (how is that effective?). While no one has actually said so, no one is taking robotics very seriously other than for its obvious use as a marketing tool. If there is anyone who thinks this million-dollar instrument has any utility in urology, I invite him or her to watch Dr. George Ferzli do a laparoscopic prostatectomy. Then, in 2006, we all heard about or saw a remarkable edited video of the removal of an appendix, albeit very normal appearing, through a gastroscope. By early 2007, there was one publication in a human subject about surgery done through a natural orifice transluminal endoscopic surgery (NOTES) technique, and that was about the rescue of a dislocated Percutaneous Endoscopic Gastrostomy (PEG), hardly something we see every day [1]. At the SAGES meeting in 2007 we were treated to edited videos that showed scopes introduced through the rectum, with stool affixed, used to guide surgery on gallbladders that were poorly grasped and dissected with no discernable anatomic landmarks, all often culminating in an explosion of bile. To those that state that these videos resemble the early era of laparoscopy, I paraphrase the Lloyd Bentsen/ Dan Quayle 1988 Vice Presidential debate: I knew the great surgical innovators of the early era of laparoscopy like Barry McKernan (gallbladder and hernia), Joe Petelin and Maurice Arregui (common bile duct), Dennis Fowler (colon), Lee Swanstrom (esophagus), Michel Gagner (adrenal and pancreas), and we never operated like that. If we did we certainly never filmed it. All of these pioneers did not work in traditional academic powerhouses but were rather busy general surgeons in smaller hospitals; such was the nature of early laparoscopy that in able hands it translated well from the open approach. At the SAGES 2007 meeting we were also treated to videos of endoscopic gastric plications (what exactly was plicated to what is difficult to determine), in the guise of performing an endoluminal vertical banded gastroplasty (VBG). In 2000 Michael Sarr’s group published excellent follow-up data on the VBG, showing that this operation worked to sustain weight loss less than 25% of the time and required reoperation about 20% of the time [2]. American surgeons have essentially abandoned this operation. It was Karl Marx who said that history repeats itself first as a tragedy and then as a farce. Why on Earth would we A. Pomp (&) Section of Laparoscopic and Bariatric Surgery, Frank Glenn Faculty Scholar in Surgery, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA e-mail: alp2014@med.cornell.edu