[Current state of single-port transumbilical surgery in urology: challenges and applications]

CONTEXT

Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology.

ACQUISITION OF EVIDENCE

A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described.

SYNTHESIS OF EVIDENCE

LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach.

CONCLUSIONS

Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

A modular magnetic platform for Natural Orifice Transluminal Endoscopic Surgery

Modern surgery is currently developing NOTES (Natural Orifice Translumenal Endoscopic Surgery) robotic approaches to enable scarless surgical procedures. Despite of the variegated devices proposed, they still have several limitations. In this work, we propose a surgical platform composed of specialized modules, in order to provide the overall system with adequate stability, dexterity and force generation. The concept behind the platform, the main modules and their performance are described to highlight the system potential to outperform current NOTES procedures.

The development of a haptic interface for the Virtual Translumenal Endoscopic Surgical Trainer (VTEST

Natural orifice translumenal endoscopic surgery (NOTES) is an experimental surgical technique with benefits including reduced pain, post operative recovery period and better cosmesis compared to traditional laparoscopic procedures. In a pure NOTES procedure, a flexible endoscope is used for performing the surgery and visualization. The Virtual Translumenal Endoscopic Surgical Trainer (VTEST(TM)) is being developed as a platform to train for NOTES procedures and innovate NOTES tools and techniques. In this work we report the design specification for the hardware interface to be used for VTEST(TM).

The use of rotational optical encoders for dial sensing in the Virtual translumenal Endoscopic Surgical Trainer (VTEST

Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive procedure, known for its scar-less nature and short post operative recovery periods. A critical skill necessary for a NOTES procedure is the surgeon's ability to navigate and gain visualization of the target organ, which is done by moving the endoscope tip using the dials on the handle. We have developed an accurate and high resolution optical encoder based system to measure that dial manipulations, as part of a larger project to develop a VR-NOTES surgical simulator.

Formulation of wire control mechanism for surgical robot to create virtual reality environment aimed at conducting surgery inside the body

We here report on the process of developing a surgical robot that can conduct operation "going inside the body without spreading the operational region". The endoscopic robot that we are developing now has a flexible cylindrical body with functions of a set of human arms at the tip and also with vision and haptic sense functions. We evaluated necessary technology factor to complete this robot into categories such as, transmission of energy, adaptation to insides of the body.

Objective performance measures using motion sensors on an endoscopic tool for evaluating skills in natural orifice translumenal endoscopic surgery (NOTES)

Natural orifice translumenal endoscopic surgery is an emerging procedure. High fidelity virtual reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing a Virtual Transluminal Endoscopic Surgery Trainer (VTEST TM) for this purpose. In this work, objective performance measures derived from motion tracking sensors attached to an endoscope was tested for the transgastric NOTES appendectomy procedure performed with ex-vivo pig organs using the EASIE-R(TM) trainer box. Results from our study shows that both completion time and economy of motion parameters were able to differentiate between expert and novice NOTES surgeons with p value of 0.039 and 0.02 respectively. Jerk computed on sensor 2 data also showed significant results (p = 0.02). We plan to incorporate these objective performance measures in VTEST(TM).

Feasibility of transumbilical flexible endoscopic preperitoneoscopy (FLEPP) and its utility for inguinal hernia repair: experimental animal study

BACKGROUND AND STUDY AIMS

Various NOTES (natural orifice translumenal endoscopic surgery) hernia repair techniques have been described. The aim of this study was to evaluate the feasibility of a transumibilically introduced conventional double-channel flexible endoscope for performing preperitoneoscopy (FLEPP, flexible endoscopic preperitoneoscopy technique) and to perform totally extraperitoneal (TEP) inguinal hernia meshplasty in an animal model.

MATERIAL AND METHODS

The study was done in 2 steps on 8 swines weighing 25 to 30 kg each: (1) establishing feasibility of preperitoneal dissection of the inguinal region using a conventional double-channel flexible gastroscope and making bed for mesh placement and (2) placement of a polypropylene mesh in the inguinal region to cover the myopectineal orifice.

RESULTS

The flexible endoscope provided good vision and maneuverability to identify preperitoneal structures--namely, the arcuate line, insertion of rectus abdominis on pubis symphysis, inferior epigastric vessels, deep inguinal ring, spermatic cord, pubic symphysis, and psoas muscle--without causing any damage to any of the structures. The spermatic cord could be dissected to identify the vas deference. A 9 × 7 cm(2) oval mesh was successfully placed over the myopectineal orifice of Fruchaud with good overlap. Average time required for the complete FLEPP procedure (including mesh placement) was 55 minutes (range 45-90 minutes).

CONCLUSIONS

This study demonstrates, for the first time, the feasibility of the transumbilical FLEPP technique and its utility for performing TEP inguinal hernia repair with prosthetic mesh placement in a swine model.

Transanal endoscopic surgery using single access and standard laparoscopic instrumentation

Transanal endoscopic microsurgery (TEM) or operation (TEO) refer to the concept of performing intraluminal excision of rectal lesions with specialized, high specification equipment that maintains a stable pneumorectum and allows either high definition or binocular optical visualization of the target site along with the capacity for using precise instrumentation (including electocautery) for tissue tensioning, dissection, resection and re-apposition. However, neither technology is widely available and capital set-up costs are high. Furthermore, the rigid, elongated cylindrical configuration of the rectoscope can prove restrictive for non-expert practitioners in that it demands a rarefied and hitherto relatively non-transferrable skill-set only achievable with high volume caseloads. The advent of single port minimally invasive surgery arising on a broadened background of widespread advanced laparoscopic skills and equipment among colorectal departments along with an increasing incidence of appropriate lesions (either large dysplastic tumors or early and neoadjuvantly downstaged rectal cancers) may, however, provide the means for this approach to become more integrated into mainstream practice by the removal of these barriers for interested practitioners. While early generation devices still need adaption for perfect applicability to transanal access and oncologic standards need to be carefully maintained in parallel with increased proliferation of technical capacity, the transfer of single port techniques and access platforms to transanal work has great potential through the convergence of practice of these two niche applications. Here we present a detailed analysis of currently available single port devices (including the table-side constructed "Glove TEM Port") in transanal application and define the ideal parameters required to make this a reality.

Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy

INTRODUCTION

A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC).

METHODS

Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.).

RESULTS

Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively.

CONCLUSIONS

This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.

LESS nephrectomy: technique and outcomes

Laparoendoscopic single-site surgery (LESS) represents the next step of laparoscopic surgery and a major advancement towards scarless surgery. LESS radical nephrectomy is an evolving technique based on technological advancement of laparoscopic instruments as well as the refinement of existing techniques.The current report describes LESS nephrectomy technique, presents the experience with the technique in a series of 42 patients and reviews current literature in the field of LESS nephrectomy.

First Croatian transvaginal laparoscopically assisted cholecystectomies

BACKGROUND/AIMS

The aim of this study was to determine the feasibility and technical aspects of a new endoluminal surgical procedure: transvaginal laparoscopically assisted endoscopic cholecystectomy.

METHODOLOGY

Three female patients underwent transvaginal laparoscopically assisted endoscopic cholecystectomy (aged 40, 61 and 33 years). Pneumoperitoneum was created through a 5mm supraumbilical incision. Through the posterior fornix of the vagina the second 10mm trocar, laparoscope and 5mm laparoscopic grasper were introduced. The gallbladder was dissected using standard 5mm laparoscopic grasper, hook, electrocoagulation and harmonic shears introduced supraumbilically. The dissected gallbladder was removed in a specimen retrieval bag.

RESULTS

Transvaginal laparoscopically assisted endoscopic cholecystectomy was feasible in all patients. No intraoperative or postoperative complications were observed and there was no need for extra-umbilical skin incisions. Total operative time ranged between 60 and 75 minutes. Median length of hospital stay was 1 day.

CONCLUSIONS

This was the first clinical application of transvaginal laparoscopically assisted cholecystectomy in Croatia. The initial clinical application of this technique in 3 female patients was feasible, effective and safe when performed by experienced laparoscopic surgeons using standard laparoscopic instruments.

Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

BACKGROUND

Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model.

METHODS

Cholecystectomies were attempted in five 88-130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route.

RESULTS

Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present.

CONCLUSIONS

NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.

Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study

BACKGROUND

Most natural orifice transluminal endoscopic surgery (NOTES) procedures to date rely on the hybrid technique with simultaneous laparoscopic access to protect against access-related complications and to achieve adequate triangulation for dissection. This is done at the cost of the potential benefits of this new minimally invasive technique. This study aimed to evaluate the feasibility and safety of a transgastric (TG) pure-NOTES procedure in a diagnostic setting.

METHODS

A TG pure-NOTES procedure with endoscopic ultrasonograpy (EUS)-guided access and over-the-scope-clip (OTSC) closure was performed for 10 pigs in a survival and feasibility study. A full macroscopic necropsy with subsequent histologic evaluation was performed on postoperative day (POD) 14. The outcome parameters were uncomplicated follow-up assessment, survival, intraoperative complications, intraabdominal pathology, macroscopic full-thickness closure, and histology-proven full-thickness healing of the gastrotomy.

RESULTS

An uncomplicated postoperative course was reported for 9 of the 10 pigs, and survival was reported for all 10 pigs. For all the pigs, EUS-guided access was performed successfully with a median duration of 25 min (range, 12-62 min) and without intraoperative complications or access-related lesions at necropsy. An OTSC closure was achieved with a median duration of 11 min (range, 3-28 min). The OTSC provided immediate closure, but according to the authors' definition of a full-thickness healing evaluated by histologic examination, this was not achieved in any of the cases. Although all the animals survived until POD 14, intraabdominal chronic abscesses were present in 3 of the 10 pigs at necropsy.

CONCLUSIONS

The EUS-guided TG access proved to be feasible without access-related complications. Although OTSC provided an immediate closure, the histopathology raised concerns regarding the risk of perforation. Together with the high risk of intraabdominal infection, TG pure-NOTES is not yet ready for routine clinical practice.

[Transanal single-port surgery for local excision of rectal tumours]

Transanal endoscopic microsurgery (TEM) is the technique of choice for rectum-preserving treatment of rectal tumours. However, the instruments are relatively expensive and TEM is a highly-complex technique. From 2010 a few case reports describing a new technique for local excision of rectal tumours using a single-access laparoscopic port have appeared. These single-access ports are flexible multichannel ports for transumbilical laparoscopic surgery. Even though not developed for transanal use these ports are ideal because of their shape and the material they are made from. Transanal surgery using a single-access port is a relatively simple procedure and does not require any investment in new instruments. This new technique will enable more surgeons to carry out transanal endoscopic surgery.

Comparison of anterior transgastric access techniques for natural orifice translumenal endoscopic surgery

BACKGROUND

The advancement of natural orifice translumenal endoscopic surgery (NOTES) into clinical practice is dependent on its safety, efficacy, and efficiency. Access is the obligatory first step in NOTES and serves as a surrogate to technical difficulties associated with this novel surgical approach. This study aimed to compare endoscopic transgastric access techniques in terms of safety, reproducibility, and efficiency.

METHODS

Seven variations for anterior transgastric NOTES access were evaluated with female domestic swine. After marking of an anterior site, electrocautery was used to create a small gastrotomy, followed by balloon dilation and entry into the peritoneal cavity. Methodologic variations incorporated the use of guidewires, electrocautery and dilation combined within a single device, support tubes, and dilation without electrocautery. Access times were recorded, and tissue injury was evaluated.

RESULTS

In 70 access attempts, the most serious complication was bleeding from the gastroepiploic vessel, controlled with electrocautery. High variability in access times was prevalent with almost all the access techniques.

CONCLUSIONS

This study supports the presumption that an anterior transgastric access technique for NOTES procedures is safe. The use of a wire to mark the site and another wire to retain the gastrotomy provided safe, efficient, and reproducible transgastric access. Comparison with laparoscopy exposed the disparity in technical challenges facing NOTES, suggesting that new technology and further refinement in methodology are required for NOTES to be clinically relevant.

Transoral gastroplasty for morbid obesity: a multicenter trial with a 1-year outcome

BACKGROUND

Bariatric surgery is associated with specific complications and mortality. Transoral gastroplasty (TOGA) is a transoral restrictive bariatric procedure that might offer the benefits of surgery with a reduced complication rate.

OBJECTIVE

To evaluate the safety and efficacy of TOGA at 12-month follow-up.

DESIGN

Prospective, multicenter, single-arm trial.

SETTING

Two tertiary-care referral medical centers.

PATIENTS

This study involved 67 patients (average age 41.0 years, 47 women, baseline body mass index [BMI] 41.5 kg/m(2); 20 patients with BMI <40).

INTERVENTION

The TOGA procedures were performed by using 2 stapling devices that were used to create a small, restrictive pouch along the lesser gastric curvature. The pouch is designed to give the patient a sustained feeling of satiety after small meals.

MAIN OUTCOME MEASUREMENTS

Excess weight loss, excess BMI loss, safety, and improvements in quality of life, obesity-related comorbidities, and medication use.

RESULTS

Fifty-three patients were available at the 12-month follow-up. Excess BMI loss was 33.9%, 42.6%, and 44.8% at 3, 6, and 12 months, respectively. At 12 months, excess BMI loss was 52.2% for patients with a baseline BMI of <40.0 and 41.3% for patients with a baseline BMI of ≥ 40.0 (P < .05). At 12 months, hemoglobin A(1c) levels decreased from 7.0% at baseline to 5.7% (P = .01); triglyceride levels decreased from 142.9 mg/dL to 98 mg/dL (P < .0001); high-density lipoprotein levels increased from 47.0 mg/dL to 57.5 mg/dL (P < .0001). Two complications occurred: a case of respiratory insufficiency and an asymptomatic pneumoperitoneum treated conservatively.

LIMITATIONS

Small number of patients. Short-term follow-up. Twenty-one percent of patients were not available for the 12-month follow-up.

CONCLUSION

The TOGA procedure allowed a substantial weight loss 1 year after the operation without severe complications. A long-term evaluation is needed before definitive conclusions can be drawn.

New methods for innovation: the development of a toolbox for natural orifice translumenal endoscopic surgery (NOTES) procedures

BACKGROUND

Devices used for flexible intralumenal procedures are inadequate when used for intraperitoneal surgical procedures such as cholecystectomy.

OBJECTIVE

To assess/address limitations of flexible endoscopic devices in intraperitoneal surgery.

DESIGN

To describe processes used to invent new devices to facilitate this new surgical genre.

SETTING

Engineering laboratory.

PATIENTS

None. INTERVENTIONS AND INVENTIONS: Reviews of the limitations of flexible endoscopic instruments and instrumentation/invention needs for a "NOTES cholecystectomy" were completed.

MAIN OUTCOME MEASURES

The appropriateness of existing methods of device innovation was evaluated against an inventory of new technologies necessary to perform NOTES. The deficiencies in traditional innovation methods led to the creation of a novel process for invention of new medical devices: the "Inventorama."

METHODS

Cooperation between clinicians and industry to develop device concepts to enable NOTES.

RESULTS

The devices included: (1) steerable flex trocar, (2) rotary access needle, (3) bipolar hemostasis forceps, (4) Maryland dissectors, (5) articulating hook knife, (6) rotating hook knife, (7) articulating graspers, (8) scissors, (9) ligating clip applier, and (10) tissue apposition system. Six of these ten were built and tested as initial crude prototypes in the Inventorama process; two underwent major modifications. Three were invented via alternate methods, including by independent clinicians.

CONCLUSIONS

A new method for efficient medical device invention and development was created to address key technology needs for NOTES. The result was a "toolbox" of devices designed to address the key surgical activities necessary for advanced intralumenal and translumenal flexible endoscopic procedures.

Indications and techniques of transanal endoscopic microsurgery (TEMS)

Transanal endoscopic microsurgery (TEMS) has recently reemerged as a valuable technique for the management of rectal neoplasms - both benign and malignant. Since the original description of this technique in the early 1980s, TEMS has emerged as the approach of choice for most benign rectal tumors because of the excellent views provided and superior dissection techniques possible when compared to traditional transanal excision. Many published reports demonstrate that the lowest rates of recurrence are associated with TEMS probably because of full-thickness excision with negative margins. Increasingly, TEMS is being applied to primary rectal cancer when used alone as a full-thickness excision alone or in combination with additional therapies, depending on tumor stage. There is now a significant evidence base to suggest that this approach should be considered as part of a multidisciplinary approach to rectal cancer. This paper describes indications and techniques for this technology.

NOTES spin-off for the therapeutic gastroenterologist: natural orifice surgery

Natural orifice transluminal endoscopic surgery (NOTES) has ushered in a new era in flexible endoscopy. Over the past decade, modest advances have been made in addressing the fundamental challenges of NOTES surgery including transluminal access and closure techniques, and advancement of NOTES-specific technology. Despite these encouraging initial efforts significant obstacles to widespread acceptance of NOTES as a surgical option persist. Moreover, due to the well-documented safety and efficacy of laparoscopic techniques, the question remains as to the best candidate NOTES procedure. Presently, interest has shifted from true NOTES to hybrid procedures and single incision laparoscopic surgery, due to the lure of more immediate success. Additionally, there is also a growing awareness of the potential applications of natural orifice surgery techniques to the present field of therapeutic endoscopy. Research into transluminal access and closure has born several techniques and devices that are now being explored in endoscopic procedures such as full-thickness resection, endoscopic myotomy, direct endoscopic pancreatic necrosectomy and bariatric endoscopy. Such NOTES "spin-off" procedures are expanding the armamentarium of today's therapeutic endoscopists, and a growing body of literature suggests that they will play a significant role in the evolution of therapeutic endoscopy in the future.

Enhancement of a master-slave robotic system for natural orifice transluminal endoscopic surgery

INTRODUCTION

A novel robotic platform for Natural Orifice Transluminal Endoscopic Surgery (NOTES) is presented in this paper. It aims to tackle two crucial technical barriers which hinder its smooth transition from animal studies to clinical trials: providing effective instrumentations to perform complex NOTES procedures and maintaining the spatial orientation for endoscopic navigation.

MATERIALS AND METHODS

The technical barriers are overcome by the design of the robotic system considering size, triangulation, dexterity, maneuverability and complexity. It is also shown that haptic feedback and interventional navigation system could solve the problem of off-axis manipulation of the camera angle and loss of spatial orientation upon entering the peritoneal cavity in transgastric NOTES procedure, respectively.

RESULTS

Successful ESD (endoscopic submucosal dissection) and wedge hepatic resection have been performed on live pigs with our Master And Slave Transluminal Endoscopic Robot (MASTER) system, showing its capability to perform advanced endoscopic surgical and NOTES procedures. It is found that the MASTER exhibited good grasping and cutting efficiency. And the lesion resection time could be significantly reduced with more practice between the endoscopist and the robot operator.

CONCLUSION

This study evaluates the feasibility of MASTER system as a platform overcoming the barriers to NOTES. It is also demonstrated that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures.

Multifunction robotic platform for natural orifice surgery

A new robotic platform for natural orifice surgery is described. The robot is designed to carry multiple tool tips in a single end-effector arm. Design and experimental validation are presented. Although the design is still being improved, results suggest that the new robotic tool will enable dexterous abdominal surgery with improved force transmission capability.

Histological evaluation of pure NOTES - related complications in a survival animal study

Considered as an extension of both laparoscopic surgery and interventional endoscopy, natural orifice transluminal endoscopic surgery (NOTES) is emerging as a new alternative of minimal invasive surgery. Literature on the gastrointestinal complications of this novel technique is sparse. The goal of this study was the histopathologic evaluation of postoperative complications in a NOTES experimental animal group. Ten female pigs (Sus scrofus domesticus) underwent transgastric endoscopic oophorectomy and tubectomy followed by gastric closure using OTSC clips. Fourteen days after surgery, the animals were sacrificed. Based on the gross examination during necropsy focused excisional biopsies were performed. Gross and microscopic evidence of gastric ulcer distal to the puncture site and perigastric lymph node abscess were found on one animal. Histological evaluation plays a determinant role in the correct evaluation of postoperative complications of pure NOTES procedures.

SPIDER and flexible laparoscopy: the next frontier in abdominal surgery

With the introduction of natural orifice translumenal endoscopic surgery (NOTES), there has been interest in the general surgery community for developing safe, scarless surgery. NOTES itself brought additional risks to GI surgery, and as such it has not achieved mainstream acceptance. Single site is considered by many surgeons as a bridge between traditional laparoscopic surgery and NOTES without the inherent risks of NOTES. However, initial single-site procedures using standard instrumentation are technically challenging due to the absence of instruments that facilitate triangulation, avoid conflicts between the instruments and the camera, maintain pneumoperitoneum, and reduce operative stress. The TransEnterix SPIDER platform has been created to overcome these difficulties. The SPIDER is a sterile and disposable device that contains 4 working channels (2 flexible instrument delivery tubes positioned laterally and 2 rigid channels, superiorly and inferiorly to accommodate an endoscope or any of the shelf rigid surgical instruments). Procedures facilitated by this platform are considered to use a hybrid flexible laparoscopic technique. Initial experience in over 100 cases with the SPIDER, including colectomy, cholecystectomy and adjustible gastric banding, has shown this system to be effective. Technical pearls when using the SPIDER include pulling rather than pushing, and increased use of electrocautery. These learning curve lessons for flexible laparoscopy will be described in detail, including a discussion of advantages and disadvantages. The SPIDER platform facilitates safe and straightforward single-site laparoscopic surgery.