#7 LESS and NOTES Applications


Minimally-invasive laparoscopic surgical approaches have been tried over the years in an effort to improve a variety of standard urological and gynecological surgeries. We now have two emerging innovations—LESS and NOTES—that allow doctors to perform surgeries with a minimum of cutting and virtually no scars. Pain levels are significantly reduced as well with these scarless surgeries, allowing patients to get home and back to activities of daily living much quicker.

Laparoscopy (from the Greek words lapara, or flank, and skopion, a means of viewing something) is a surgical procedure in which small (1-2 cm) incisions are made and plastic tubes (trocars) are inserted through them to keep the channel open so that tools—including surgical instruments and the viewing telescope (laparoscope) with its minicamera—can be inserted. When the abdomen is inflated with carbon dioxide, organs can be pushed out of the way for access and better vision, allowing the surgeon to work while watching an external video monitor. The tools can be manipulated to make necessary repairs, just as if the abdomen had been cut open the old-fashioned way, but without the surgeon’s hands ever entering the patient’s abdomen.

LESS (laparoendoscopic single-site surgery) takes laparoscopic surgery to an entirely new level by reducing the process to a small cut in the belly button. “LESS is performed through a single incision in the patient’s navel,” explains Inderbir S. Gill, M.D., Chairman of Urology at the Cleveland Clinic, and a pioneer who recently performed LESS live-donor nephrectomies in nine consecutive kidney donors for kidney transplantation. “All aspects of kidney harvesting were completed though the navel. Instead of a visible six-inch scar and a six-week recovery period, patients recovered within two weeks and had a tiny scar hidden by their belly button.”

Because it only uses one port with multiple channels for the surgeon to simultaneously pass various surgical instruments, LESS may also reduce complications that might occur after traditional open and even laparoscopic abdominal surgery. “My patients report less discomfort and have faster recoveries compared to those undergoing traditional laparoscopy,” Dr. Gill says. 

NOTES (natural orifice transluminal endoscopic surgery) bypasses normal laparoscopic incisions altogether. Instead, the surgeon gets to an appendix, prostate, kidney, or gallbladder through one of the body’s natural cavities, such as the mouth, vagina, or colon. “Being able to perform major surgery inside the abdomen and chest through natural orifices is a very intriguing concept,” reports Dr. Gill. “Potential advantages of this would be the ability to have scar-free and, hopefully, pain-free surgery. This is what has caught the imagination of the public.”

Where Are They Now

Laparoendoscopic single-site surgery (LESS) and Natural Orifice Transluminal Endoscopy Surgery (NOTES) allow doctors to perform surgeries with a minimum of cutting and virtually no scars. Pain levels and recovery times are significantly reduced with these scarless surgeries, allowing patients to return home and resume daily activities much more quickly.
LESS and NOTES have been successfully utilized and continue to evolve in multiple clinical areas. Urologic, gynecologic, and digestive-tract procedures have already been successfully completed. NOTES is still an investigational approach in urology while LESS is immediately applicable in the clinical field. Robotics are now the next frontier of LESS, however due to high costs, many surgeons are hesitant to invest millions into machines that have not been clinically proven to improve patient outcomes. Latest updates came from 2012 where the technology appeared promising but required more animal testing and further research in animal survival moving forward with the devices.

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