One of the most promising new endoscopic procedures is called natural orifice transluminal endoscopic surgery, or NOTES. A Sept. 22, 2008, report from medical market research firm Kalorama Information states that the procedure is part of a $19.7 billion minimally invasive market that is growing rapidly.Whereas traditional laparoscopy involves abdominal incisions, NOTES avoids external incisions entirely. Instead, the endoscope goes through a natural orifice such as the mouth, anus or vagina, and internal incisions are made to reach organs such as the stomach.Because only internal incisions are made, NOTES does not leave scars on the abdomen. According to a Nov. 3, 2008, article by Lindsay Lyon for U.S. News and World Report, a patient who had her gallbladder removed through her vagina using the NOTES procedure declared, “I can still get into a bikini.” NOTES clearly has cosmetic appeal.Whether vanity comes at a price is less clear. There is some pushback against transvaginal NOTES, according to Dr. Steven Schwaitzberg, a leading surgeon with the Harvard-affiliated Cambridge Health Alliance in Massachusetts. In a questionnaire published in the July 2008 issue of Endoscopy, gynecologists from various hospitals in Europe stated that they were concerned about increased complications.Images of an esophagus (left), colon (middle) and stomach (right), all healthy, recorded using traditional endoscopy. Courtesy of Dr. David L. Carr-Locke at Brigham and Women’s Hospital in Boston. On the other hand, the results of a patient questionnaire published in the same issue indicated that most patients are interested in scarless abdominal surgery. The lead author on that study, Dr. Monika Hagen from University Hospital Geneva said, “Currently, transvaginal access seems to be appealing because it is safe and easy. Still, only about 50 percent of the population has a vagina, which is probably the biggest limiting factor.”Schwaitzberg and Hagen agreed that surgery on the colon probably will become transanal, but Hagen mentioned a possible risk of contamination. “Transgastric access appears interesting because of the robust nature of the stomach, but access and closing are major hurdles at this time,” she said. “I am very conservative about the transesophageal route.”However, the Kalorama report states that, with more research, it could be determined that internal procedures such as NOTES cause less pain because pain receptors are mostly on the skin, and that infections are reduced because no opening is made in the skin. The internal incisions may be made with less blood loss and they may heal faster, leading to shorter hospital stays.Schwaitzberg commented, “There is no data that gets anywhere near ready to make those claims. We need prospective trials.” And Hagen said, “NOTES could potentially minimize all of the [above], but it will be hard to prove it … The biggest and easiest advantage of NOTES is still the cosmetic outcome.” NOTES could become an elective cosmetic procedure. Schwaitzberg said that health insurance companies and other payers must cover the procedure for it to become mainstream, and training programs must be established. According to Hagen, “The biggest problem is that we do not have specific NOTES instruments on the market.”There also has been a trend toward smaller instruments and toward in which only one external incision is made. “Robotic surgery is also very interesting,” Hagen commented, “but the policy of the monopoly holder Intuitive [Surgery] is making lots of surgeons hating this technology.” Minimally invasive surgeries such as NOTES are definitely part of a growing trend, but time will tell whether the techniques deliver on their promise.