In human POEM, patients are placed protocol on a clear liquid diet 24 hours and given a single preoperative dose of a first generation cephalosporin [46]. Although published series account for a short number of patients, no infectious complications were reported. Neither studies specify if the flexible endoscope was either completely sterilized or conventionally disinfected. 6. Conclusions Transesophageal NOTES offers new possibilities in less invasive access to mediastinal and thoracic cavities. Ongoing NOTES revolution permitted the development of esophageal submucosal endoscopic techniques with almost immediate human application. POEM is a perfect example of this. Theoretical advantages of transesophageal NOTES warrant the continuation of research, although some hurdles are to be overcome.

The critical nature of the organs that involve the esophagus, the risk of hemodynamic instability related to pressure pneumomediastinum and pneumothorax, and potential infectious complications call for caution when transition to human practice. A hybrid NOTES approach, adding transthoracic assistance, might be the key to safe human translation, as it gives visual control of transesophageal port creation (Figure 2), it may improve esophagotomy closure, it permits triangulation and countertraction using flexible instruments inserted through the gastroscope and rigid instruments inserted through the thoracoscope, and it gives a good intrathoracic pressure control and pneumothorax drainage. Figure 2 Transthoracic visual control of transesophageal port creation in the upper third of the esophagus (porcine model).

Laparoscopic surgery is a well-established surgical technique for a variety of procedures. In recent years, multiple attempts to decrease parietal trauma and visible scars have been proposed. These efforts include the reduction of the diameter of the port size, the reduction in the number of the laparoscopic access [1�C5], and the introduction of natural orifice transluminal endoscopic surgery (NOTES) [6�C8] and of single incision laparoscopic surgery (SILS) [9�C12]. SILS is a virtually ��scarless�� technique; the single port is hidden in the umbilicus. It is a rapidly evolving field: this approach is recently under investigation in some laparoscopic surgical centres to achieve less postoperative pain, less discomfort, and fewer surgical scares.

In a laparoscopic centre, a retrospective analysis is performed to evaluate an initial experience in laparoscopic surgery with the single-port technique and a periumbilical access; a detailed description of the SILS approach as a simple, safe, and cheap technique is done. 2. Patients and Methods 2.1. Patients In a surgical centre from January 2010 to October 2011 SILS was considered for minimally invasive approach for abdominal disease. All patients underwent surgery after obtaining an informed GSK-3 consent.