Editorial commentAccess to the heart by a trans-umbilical incision

Natural orifice translumenal endoscopic surgery (NOTES) is an intensely discussed and an emerging technique in visceral surgery today. Embracing the NOTES philosophy and principles, Dr Kalejs and his colleagues took an innovative approach to both access to the heart and closure of the perforated ventricle [1]. They introduced the concept of single-port surgery in trans-apical trans-catheter valve implantation, by combining endoscopic and endovascular techniques. The endoscopic part consisted of a subcutaneous tunnel from the umbilicus to the pericardium and its fenestration. The cardiac apex was dilated creating a 1-cm defect and was successfully closed by endovascular means using a guide wire, sheath and a preclotted Amplatzer septal defect occluder. The results in six animals of a porcine model showed successful haemostatic sealing, with an operation wound that would be normally obviscated in the human umbilicus ‘button’. As mentioned by the authors, single-port surgery or NOTES for valve replacement is not unrealistic, and may be a vision compatible with the future. Although trans-apical trans-catheter valve implantation requires only a small thoracotomy, the recommended trans-umbilical access is intriguing, as it is even less invasive with the potential of lowering morbidity. This technique could bring particular benefits in high-risk patients such as octogenarians with previous bypass surgery requiring valve replacement. In NOTES, considerable challenges remain, such as the safety of the access technique, the adequate closure of the perforated organ and sterility issues. The development of highly flexible instruments including triangulation of the visual field is crucial. Another objective is the achievement of adequate retraction of the organs while working through a single channel. Despite these difficulties and the fact that NOTES is technically extremely demanding with a steep learning curve, it obviously gains more and more momentum. However, ‘until we are forced to accept disruptive technologies … either driven by patient demand, … superiority of the therapy, and/or favourable reimbursement, most of us will not leave the comfort of our current practices … for something new [2].’ NOTES may have advantages and should be therefore considered as a promising new technique.