NOTES, hybrid NOTES, NOTES-assisted kidney surgery: what has been achieved so far?

With improved technologies and the development of new techniques, has emerged the concept of "scarless surgery" in an attempt to treat certain diseases obviating the need for incisions to access the peritoneal cavity, resulting in direct benefit to patients and assuming an improvement in quality of life and offering an advantage over conventional laparoscopy. Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are evolutions of laparoscopy, and they are complementary techniques that should be included in this new concept. NOTES is an emerging surgical modality that uses endoscopic instruments through hollow viscera to enter the peritoneal cavity and allow surgical procedures without incisions. The NOTES procedure may provide additional benefits when compared with current minimally invasive procedures. Potential advantages include no skin incisions, improved cosmetic result, reduced postoperative pain, diminished risk of postoperative hernias, and earlier recovery. NOTES surgery has still some inconvenient regarding instrumentals, viewing orientation, control of complications. Attempts to overcome the current limitations of the technique have given rise to the concept of hybrid NOTES, which is performed with the assistance of transabdominal ports for the use of conventional laparoscopy equipment. NOTES is a very promising technique although further investigation is necessary until implementing NOTES surgery in the common clinical practice.