natural orifice translumenal endoscopic surgery ( notes ) is on the forefront of surgical technique and is pushing the perceptions and boundaries of abdominal surgery , as laparoscopy did when first introduced . however , in spite of enthusiasm on behalf of researchers for the technical aspects of notes , what will truly lead to its wider implementation will be improved patient outcomes and acceptance . while better patient outcomes ( less postoperative pain , fewer  if any  scars , and decreased length of hospital stay ) are touted to be the main goal of this technique however , patient acceptance of the procedure and its risks can be assessed through surveys in advance of outcomes data . though multiple studies have addressed attitudes towards this developing technique , the ability to interpret these variable study results is challenging . secondly , the larger scale studies have come mainly from europe , thus making direct inferences to a north american population potentially incorrect . finally , these surveys have emphasized gender and age as variables in assessing interest in notes but have not assessed whether previous surgery affects patients perceptions of scars and postsurgical pain . it is known that obese patients are at higher risk for developing postoperative hernias and wound infections [ 14 ] and thus may be a group that could derive significant benefit from notes . in this paper , we surveyed a large number of patients at a canadian centre to assess opinions regarding scarless surgical procedures and whether increased risks would affect their choices . a large sample also allowed for subgroup analyses based on gender , age , and body mass index . the survey instrument was developed by a team of general surgeons , gastroenterologists , and a statistician . approval for the study was obtained from the queen 's university health sciences & affiliated teaching hospitals research ethics board . a pilot study was performed with 10 people and feedback incorporated into the survey tool . the final survey was comprised of demographic data ( age , gender , self - reported height and weight ) , as well as questions regarding previous surgery and presence and location of scars . patients were then asked about the importance of scars , bother from scars , interest in scarless surgery , interest in scarless surgery if there were increased complications , acceptable complication rate ( from 0% to 20% ) , importance of research into the field , and importance of shorter recovery from surgery . these were all graded on a five - point scale ( see the appendix ) . all patients attending general surgery outpatient clinics ( excluding breast clinics ) at hotel dieu hospital  an ambulatory based hospital providing secondary and tertiary care to residents of kingston , ontario , and the surrounding area  were invited to fill out a short questionnaire regarding notes over a 6-month period in 2008 - 2009 . surveys were distributed and collected by study hospital staff and deposited in a collection box , which was emptied on a weekly basis to avoid any chance of patient identification . the actual response rate could not be calculated , as the surveys were anonymous and clinic staff did not track the number of patients who were uninterested in responding . however , anecdotal evidence suggests that the patients were generally happy to complete the short survey while they waited . in the event that several appointments were scheduled , patients were asked to complete the survey only once . data were entered into an excel spreadsheet designed for the study and entered into spss ( version 17.0 for windows , 2009 , chicago , il ) for statistical analysis . body mass index ( bmi ) was calculated according to the standard formula of weight ( kg ) divided by height ( metres ) squared . bmi was then classified using the standard cutpoints of 18.524.9 ( healthy weight ) , 2529.9 ( overweight ) , 3034.9 ( obese i ) , 3539.9 ( obese ii ) , and 35 ( obese iii ) . two who were just below the 18.5 threshold were included with the healthy weight group . data were initially assessed descriptively ( mean , standard deviation and range for continuous and ordinal data , frequency and percent for categorical data ) and graphed to assess the underlying distribution . responses to the 5-level likert scales ( 1 = no importance , bother , or interest and 5 = extremely important , bothered , or interested ) were quantified so that means and standard deviations could be generated . although the data are ordinal in nature and the use of inferential statistics is not optimal in this situation , they were used for several reasons . first , this was considered preferable to a large volume of chi - square tests . a comparison of medians was also considered but while groups often had similar median values , subtle differences emerged when means were used . finally , the sample size for the majority of the comparisons was sufficiently substantial to allow the use of inferential statistics in this situation . the associations of age and body mass index with the seven questions were assessed by means of the nonparametric spearman 's correlation . the association of gender and presence of a previous surgical scar ( abdominal or nonabdominal ) with the seven questions was assessed by means of the mann - whitney u test , while the association for the three levels of age and bmi were assessed by means of the kruskal - wallis test . in order to provide an adequate sample to allow for subgroup analysis , for all analyses , the significance level was set at p < 0.05 ( two - sided ) , although results that fell short of statistical significance were noted if they were deemed to be of clinical interest . nine percent were 29 years of age , 26% were 3049 years , and 64% were 50 years ; for bmi , 29.9% were at a healthy weight , 34.9% were overweight , and 29.6% were obese ( 6% were missing height and/or weight ) . as this was a voluntary , anonymous survey , there were very few missing data ( see table 2 ) . for the few items that were missing , analyses were completed on the subset without missing data , as the type of detailed information typically required for imputation was not collected . younger respondents ( < 50 years of age ) , females , and those of a healthy weight indicated that cosmetic issues such as scars were more important , as compared to older , male , and heavier respondents ( p  0.001 for all three comparisons ) ( table 3 ) . amongst of these , 58% indicated that it did not bother them at all , but 9.9% indicated that they were bothered quite a bit or extremely by their scar(s ) . women placed significantly greater importance on abdominal scars than men and were more greatly impacted by them ; fifty - six percent of women were bothered by some degree by their current scars as compared with 23% of men ( p < 0.001 ) . age ( as a continuous variable ) was negatively correlated with the importance and impact of abdominal scars ; in other words , as age increased , the importance and impact of abdominal scars decreased ( p < 0.001 , see figure 1 for importance ) . similarly , as bmi increased , the importance of abdominal scars significantly decreased ( p < 0.001 , figure 2 . )   the majority ( 83% ) had at least some interest in a surgery that would leave no scars . the two younger groups were more interested than those over 50 years ( p = 0.001 ) , with those between 30 and 49 years remaining the most interested in the face of increased risk ( p = 0.036 ) . the two younger groups were comfortable with a risk up to 10% , while the older group was more conservative and was more comfortable with a risk close to 5% ( p = 0.003 ) . there were also gender differences in the level of interest , with women expressing more interest than men ( p = 0.021 ) . this difference disappeared when the question of risk was added ( p = 0.192 ) , although the women tended to accept an increased risk of close to 10% , while the men were closer to 5% ( p = 0.059 ) . level of interest in notes was not significantly related to bmi , nor was acceptance of increased rate of complication , or the amount of acceptable risk . however , for all three questions , those at a healthy weight had the highest scores , suggesting more interest and less concern about risk . those without previous abdominal scars were more interested in notes than those with scars ( p = 0.049 ) , but both groups lost interest when presented with increased risk . the presence of other scars had little association with the responses to the three questions . over 80% of respondents felt that research into scarless surgery was of some importance , with 30.4% rating it as quite or extremely important . with age as a continuous variable , the spearman correlation suggested a negative but significant association ( rho = .205 , p < 0.001 ) ; using the categorical variable , those in the age group of 3049 years rated research as more important than the younger or older groups ( p = 0.040 ) . bmi was also negatively and significantly associated with importance when using the continuous variable ( rho = .149 , p = 0.009 ) , but fell just short of significance when using the categorical variable ( p = 0.066 ) , although it was the healthy weight group that was more likely to rate it as important . women rated it as more important than men , although it fell short of significance ( p = 0.084 ) . one of the key proposed benefits of notes is a decreased length of stay in the hospital . very few ( only 5.1% ) indicated that a shorter hospital stay was not important , with 64.8% indicating that it was quite or extremely important . there was a weak , negative association with age using the spearman correlation ( rho = .109 , p = 0.049 ) , but this was no longer significant when using the categorical data ( p = 0.537 ) . sex , bmi , and presence of scars also had little association with the importance of shorter in - hospital recovery time . here , we captured the opinions of 335 north american patients to obtain their views on this developing technique . several patient surveys have attempted to characterize those who would be most interested in this new method . studies published to date have variable results , perhaps related to the population surveyed and questions asked . some surveys have shown that patients prefer notes to laparoscopic surgery due to its improved cosmetic result with the potential for decreased pain also holding appeal in some studies [ 710 ] . however , patients consistently had decreased interest as the potential rate of complication increased [ 7 , 9 ] . single port surgery ( sps ) is a minimally invasive form of laparoscopic surgery and a large - scale british study ( n = 750 ) comparing patient views on it and notes showed that sps was significantly preferred over open surgery and notes . although experts often point to women as being a target group who would be interested in notes , studies looking at the effect of gender on opinions of notes have led to conflicting results . varadarajulu et al . did not find a significant preference by women for notes compared to men . further to this , surveys targeted at women in the context of transvaginal notes have had variable results . sixty - eight percent of women were interested in notes in a study by peterson et al . however , in an australian study , three quarters of surveyed women were neutral or unhappy about transvaginal notes compared with standard laparoscopic surgery . in keeping with the results of previous surveys , women were significantly more concerned with the cosmetic results of surgery and were more bothered by current scars . in addition , female patients are anatomically more versatile candidates for notes , with the potential for a transvaginal approach . our study did support the theory that women would be more interested in notes than men , but this association was lost when additional risk was factored into the equation . those under 50 years of age rated a scarless method as being more important and expressed more interest , even in the face of increased risk . although there was a high interest in the concept of notes ( 83% showed at least slight interest ) , this dropped to 38% when an increased complication risk was proposed compared to traditional techniques . however , this remains a significant proportion of the surveyed population , and provides impetus to further research and development in this field to make it a safe alternative to laparoscopic and open surgery . this is borne out in our data where 81% of patients felt that research into notes held some level of importance . one of the groups in the position to benefit the most from notes is obese patients , though our data show that level of interest in the technique is significantly and negatively associated with bmi , such that those of healthy weight expressed greater interest . obese patients are especially at risk for hernias after transabdominal surgery [ 46 ] and notes could mitigate this risk . the lack of abdominal wall incisions could also lead to earlier postoperative mobilization , better lung ventilation , decreased wound infections , all of which would lead to decreased length of hospital stay . furthermore , notes - assisted bariatric surgery has now been successfully attempted   and in the authors ' opinion is one of the prime areas for notes development . hence , further objective data and education will be necessary to garner the interest and support of this population in this new technique . though the capital investment required for the development and adoption of any new technique is significant , the potential for cost savings in projected shorter hospital stays could offset the cost . ninety - five percent of patients indicated that a shorter in - hospital stay was important to them , adding to the attractiveness of this aspect of notes . the reasons behind patient interest in shorter length of hospital stay were not explored further but could include less time away from home and increased awareness of hospital acquired infections . third party payers ( insurance companies and governments ) would certainly also be interested in a technique that reduces hospital stay . in addition , it has been proposed that once further developed notes would not require a traditional operating room , thus altering hospital utilization further . the current study has some limitations . by dint of the survey population being from surgical clinics , while the self - administered survey prevented any bias that might have stemmed from a personal interview , patients were unable to ask for any more detail regarding the technique and complications than was included in the survey . for example , when presented with potential complications such as dyspareunia and infertility , women may in fact be less interested in the transvaginal approach of notes . this could also be extended to multiple centres to capture regional differences in opinion as the present study was performed in a single centre . the technique is still in its early stage of acceptance , but our data lend support to this endeavour . clearly , once techniques are further refined , hard data including complication rates , length of stay , and post - operative pain will be necessary to assess its utility and give patients adequate information for an informed choice . survey of opinions regarding a new surgical technique 
 age :   yearssex :  
 male (  ) female (  ) 
 height :   ( in feet and inches ) or ( in centimetres)weight :   ( in pounds ) or   ( in kilograms)do you have an abdominal scar from a previous surgery ? yes (  ) no (  ) 
 do you have any other major scars ? yes (  ) no (  ) 
 if yes , where ?            

 
 age :   yearssex :  
 male (  ) female (  ) 
 height :   ( in feet and inches ) or ( in centimetres)weight :   ( in pounds ) or   ( in kilograms)do you have an abdominal scar from a previous surgery ? yes (  ) no (  ) 
 do you have any other major scars ? yes (  ) no (  ) 
 if yes , where ?            
 
 male (  ) female (  ) 
  height :   ( in feet and inches ) or ( in centimetres ) weight :   ( in pounds ) or   ( in kilograms ) if yes , where ?            for the following questions , please place a check mark in the box that  corresponds best with what you think 
 how important are cosmetic issues , like scars , to you in abdominal surgery ? 
 not at all important (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
 how do you feel about the scars you have ? 
 not applicable , no scars (  ) do not bother me at all (  ) bother me slightly (  ) bother me moderately (  ) bother me quite a bit (  ) extremely bothered (  ) 
 would you be interested in a surgery that would leave no scars ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
 would you be interested in a surgery that would leave no scars even if there was an increased risk of complications such as infection inside your abdomen ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
 how much increased risk would you be comfortable with if the surgery would leave no scar ? for example , if you pick 5% , you are indicating that you 'd be comfortable with a 5 in 100 chance of having a complication such as infection just to have a scarless surgery . none , would not have scarless surgery (  ) 5% (  ) 10% (  ) 15% (  ) 20% or more (  ) 
 how would you rate the importance of further research and investment into scarless surgery ? not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
 how important is a shorter recovery time ( time spent in hospital recuperating from surgery ) to you ? not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 

  how important are cosmetic issues , like scars , to you in abdominal surgery ? 
 not at all important (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
  not at all important (  ) slightly important (  ) moderately important (  ) extremely important (  ) how do you feel about the scars you have ? 
 not applicable , no scars (  ) do not bother me at all (  ) bother me slightly (  ) bother me moderately (  ) bother me quite a bit (  ) extremely bothered (  ) 
  not applicable , no scars (  ) do not bother me at all (  ) bother me slightly (  ) bother me moderately (  ) bother me quite a bit (  ) extremely bothered (  ) would you be interested in a surgery that would leave no scars ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
  slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) would you be interested in a surgery that would leave no scars even if there was an increased risk of complications such as infection inside your abdomen ? 
 not interested (  ) slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) 
  slightly interested (  ) moderately interested (  ) quite interested (  ) extremely interested (  ) how much increased risk would you be comfortable with if the surgery would leave no scar ? for example , if you pick 5% , you are indicating that you 'd be comfortable with a 5 in 100 chance of having a complication such as infection just to have a scarless surgery . none , would not have scarless surgery (  ) 5% (  ) 10% (  ) 15% (  ) 20% or more (  ) 
  none , would not have scarless surgery (  ) how would you rate the importance of further research and investment into scarless surgery ? not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
  not important at all (  ) slightly important (  ) moderately important (  ) extremely important (  ) how important is a shorter recovery time ( time spent in hospital recuperating from surgery ) to you ? not important at all (  ) slightly important (  ) moderately important (  ) quite important (  ) extremely important (  ) 
  not important at all (  ) slightly important (  ) moderately important (  ) extremely important (  )