In this paper, Autorino et al. [1] conducted a bibliometric assessment of available literature about natural orifice transluminal endoscopic surgery (NOTES). They concluded that this type of approach is progressively widened its indications in many surgical specialties. Nevertheless, the efficacy of such an approach remains to be demonstrated by randomised controlled trials [2]. It is known that when a novel technique is introduced we expect an evolution of the technique itself. The natural evolution of laparoscopy would have been the use of natural orifices to get the least invasiveness as possible. This has been spontaneous for gastrointestinal surgical procedures and uro-gynaecological procedures; specifically urethral and transvaginal accesses are natural for urologists. For the transvaginal access, as shown by Autorino et al., in most cases NOTES is assisted by standard laparoscopy introducing hybrid techniques [3–6]. Accordingly, the technical difficulties of this approach have stimulated research in this field: maybe this means that the pursuit towards mini-invasiveness is overcoming current limitations of pure NOTES highlighted by recent studies. It is evident that the support needed to increase safety means that the approach is still technically challenging. We confront a choice between continuing in the direction of pure NOTES or towards standard laparoscopic access eventually assisted by NOTES. If the main aim is getting a virtually ‘scarless’ surgery, maybe pure NOTES is not a step in the right direction: we have to consider it as a helpful tool to avoid surgical scaring, minimising derived surgical trauma.With this aim, we think that combined techniques of NOTES with transumbilical laparoendoscopic single-site surgery and/or mini-laparoscopy would be the best choice. Working in this direction, the future will not have a main character: all the techniques will have a role, with the common aim of achieving the least invasiveness without compromising the safety and efficacy of the procedure.
Achieving the least invasiveness
PORPIGLIA, Francesco
2013-01-01
Abstract
In this paper, Autorino et al. [1] conducted a bibliometric assessment of available literature about natural orifice transluminal endoscopic surgery (NOTES). They concluded that this type of approach is progressively widened its indications in many surgical specialties. Nevertheless, the efficacy of such an approach remains to be demonstrated by randomised controlled trials [2]. It is known that when a novel technique is introduced we expect an evolution of the technique itself. The natural evolution of laparoscopy would have been the use of natural orifices to get the least invasiveness as possible. This has been spontaneous for gastrointestinal surgical procedures and uro-gynaecological procedures; specifically urethral and transvaginal accesses are natural for urologists. For the transvaginal access, as shown by Autorino et al., in most cases NOTES is assisted by standard laparoscopy introducing hybrid techniques [3–6]. Accordingly, the technical difficulties of this approach have stimulated research in this field: maybe this means that the pursuit towards mini-invasiveness is overcoming current limitations of pure NOTES highlighted by recent studies. It is evident that the support needed to increase safety means that the approach is still technically challenging. We confront a choice between continuing in the direction of pure NOTES or towards standard laparoscopic access eventually assisted by NOTES. If the main aim is getting a virtually ‘scarless’ surgery, maybe pure NOTES is not a step in the right direction: we have to consider it as a helpful tool to avoid surgical scaring, minimising derived surgical trauma.With this aim, we think that combined techniques of NOTES with transumbilical laparoendoscopic single-site surgery and/or mini-laparoscopy would be the best choice. Working in this direction, the future will not have a main character: all the techniques will have a role, with the common aim of achieving the least invasiveness without compromising the safety and efficacy of the procedure.
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