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LESS is an extension (or "retraction") of laparoscopic surgery that uses standard techniques to perform surgery via a single incision, often hidden in the umbilicus. NOTES attempts to take this a step further by performing intra-abdominal surgery via natural body openings (ie, vagina, mouth).
Select centers have already accumulated significant clinical experience with LESS, including donor, radical, and partial nephrectomy (see, "LESS, NOTES procedures nearing clinical feasibility," page 1). The rapid entrance of LESS into the clinical realm is likely due to its similarity to standard laparoscopic techniques and the currently available instrumentation. In contradistinction, the limited clinical application of NOTES has been almost exclusively confined to general surgery. This is in part because, unlike general surgery, urology has no straightforward, routine intra-abdominal procedure to which NOTES might be readily applied.
LESS and NOTES require careful evaluation before widespread clinical application is considered. Of foremost importance is demonstrating the ability to perform these procedures safely and effectively. Once this step is taken, an appropriately designed comparison of these techniques to standard minimally invasive surgery must be performed to document whether these approaches offer clinical benefit to the patient. The answer to the question, "Can we?" (at least for LESS) seems to be "yes"; the more important question, "Should we?" remains to be answered.
Dr. Box is assistant professor and director of laparoscopic urologic surgery in the department of urology, The Ohio State University, Columbus.