With the FDA's approval of Medtronic's Melody Transcatheter Pulmonary Valve and Ensemble Delivery System (see link), another step has been made toward eliminating traditional surgery — at least that's the idea. The ability to implant a valve via a percutaneous procedure advances the art of less invasive intervention in ways akin to laparoscopic surgery, albeit at lower volume.
Percutaneous, NOTES (natural orifice transluminal endoscopic surgery) and laparoscopic surgery are progressively removing the need for invasive traditional surgery.
It is precisely due to percutaneous procedures that coronary stents have been able to present such a clinical challenge to coronary artery bypass. Although minimally invasive approaches to CABG are an attempt to pull back some surgical caseload, they are technically complex, expensive and, therefore, are not likely to stem the tide toward the dominance of percutaneous procedures. Ironically, the one procedure that may save bypass is the transcatheter route. With the approval of the Melody approach, it is clear that that is not impossible.
The development of less invasive surgical procedures continues to move toward procedures that may be "incisionless" or only require small perforations to accommodate surgical tools. Principal among approaches that are under evaluation are NOTES procedures — Natural Orifice Transluminal Endoscopic Surgery — in which access is provided endoscopically via the mouth or vagina.
NOTES has recently been reviewed in "Faculty of 1000 Medicine Reports":
A recent review in Faculty of 1000 Medicine Reports, a publication in which clinicians highlight advances in medical practice, suggests regional pain relief could be used during abdominal surgery. In this review, Michael Schaefer recommends a new approach that can be performed without the need for general anaesthetics.
This type of surgery is not yet a mainstream procedure. "NOTES procedures in patients have been reported worldwide in only about 30 cases", Schaefer emphasizes. Patients may prefer it because of low postoperative pain discomfort and because of a lack of visible scarring. Schaefer points out that NOTES may also be beneficial from an anaesthetic point of view. The small perforations of the gastric or vaginal wall that are needed to accommodate the surgical tools and the low intra-abdominal pressure that is needed for best visibility may only require spinal or epidural anaesthesia.
Combined with a quick recovery time, low pain levels after surgery and complete absence of visible scars, this may eventually make NOTES the preferred method for abdominal surgeries. "NOTES has the potential to further improve the advantages of laparoscopy", writes Schaefer, but advises that "these findings need to be corroborated by further randomized controlled clinical trials."
There is a learning curve for surgeons to accomplish NOTES procedures, but with most surgeons having already adapted in the switch from open laparotomy to laparotomy, the curve may not be nearly as steep.