In these techniques, there are significantly fewer, or even no incisions at all. NOTES surgery is still very much in its infancy, but there are promising developments in Endoluminal surgery such as the Endoluminal Fundoplication (ELF) using the Esophyx® device. This creates a stomach wrap around the Oesophagus emulating a Laparoscopic Anti-Reflux procedure.

Single Port Access Surgery (SPA/SILS) is a more developed technique than NOTES. Surgeons perform identical procedures to traditional laparoscopic techniques with the benefit of a single incision at the Umbiliars. This gives a much improved cosmetic effect with no apparent difference in efficacy.

The are a number of challenges in SPA/SILS, perhaps the most obvious being the matter of instrument triagulation and "clash". Elemental Healthcare provide an exciting new range of instruments that allow excellent triagulation through the flexibility and angulation of the working ends.

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