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Abstract
More than 10 years have passed since endoscopic submucosal dissection (ESD) was first developed in Japan. ESD enables en bloc complete resection of superficial gastrointestinal neoplasms regardless of the size and location of the lesions. With improvements in techniques and devices, excellent therapeutic results have been achieved despite the inherent technical difficulties of this procedure. ESD aiming for curative treatment can be performed for gastrointestinal neoplasms without risk of lymph node metastasis. Accurate histopathologic examination of the resected specimen is required to determine the risk of lymph node metastasis, for which en bloc resection is beneficial. Owing to the high success rate of en bloc complete resection and accurate histopathologic examination, tumour recurrence rates after ESD are reported to be very low in Japan. Excellent results of ESD in a large number of cases have also been reported from other Asian countries such as South Korea, Taiwan and China. Although scepticism exists among Western clinicians regarding the application of ESD, it is developing slowly and reports indicate promising results in some European countries. With further development of technologies, such as endoscopic robotics, ESD could become the worldwide treatment of choice for early gastrointestinal neoplasms.
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Affiliation(s)
- Hironori Yamamoto
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.
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A technical review of flexible endoscopic multitasking platforms. Int J Surg 2012; 10:345-54. [PMID: 22641123 DOI: 10.1016/j.ijsu.2012.05.009] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/04/2012] [Accepted: 05/19/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Further development of advanced therapeutic endoscopic techniques and natural orifice translumenal endoscopic surgery (NOTES) requires a powerful flexible endoscopic multitasking platform. METHODS Medline search was performed to identify literature relating to flexible endoscopic multitasking platform from year 2004-2011 using keywords: Flexible endoscopic multitasking platform, NOTES, Instrumentation, Endoscopic robotic surgery, and specific names of various endoscopic multitasking platforms. Key articles from articles references were reviewed. RESULTS Flexible multitasking platforms can be classified as either mechanical or robotic. Purely mechanical systems include the dual channel endoscope (DCE) (Olympus), R-Scope (Olympus), the EndoSamurai (Olympus), the ANUBIScope (Karl-Storz), Incisionless Operating Platform (IOP) (USGI), and DDES system (Boston Scientific). Robotic systems include the MASTER system (Nanyang University, Singapore) and the Viacath (Hansen Medical). The DCE, the R-Scope, the EndoSamurai and the ANUBIScope have integrated visual function and instrument manipulation function. The IOP and DDES systems rely on the conventional flexible endoscope for visualization, and instrument manipulation is integrated through the use of a flexible, often lockable, multichannel access device. The advantage of the access device concept is that it allows optics and instrument dissociation. Due to the anatomical constrains of the pharynx, systems are designed to have a diameter of less than 20 mm. All systems are controlled by traction cable system actuated either by hand or by robotic machinery. In a flexible system, this method of actuation inevitably leads to significant hysteresis. This problem will be accentuated with a long endoscope such as that required in performing colonic procedures. Systems often require multiple operators. To date, the DCE, the R-Scope, the IOP, and the Viacath system have data published relating to their application in human. CONCLUSION Alternative forms of instrument actuation, camera control and master console ergonomics should be explored to improve instrument precision, sphere of action, size and minimize assistance required.
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Wang J, Zhang L, Wu W. Current progress on natural orifice transluminal endoscopic surgery (NOTES). Front Med 2012; 6:187-94. [PMID: 22570129 DOI: 10.1007/s11684-012-0198-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 03/26/2012] [Indexed: 12/21/2022]
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has received considerable interest in recent years as a novel surgical technique. Here, we aim to review the current progress on NOTES, particularly focusing on the advantages and complications related to NOTES, the recent advances of surgical approaches, new instruments for closure of the natural orifice incision, and the newly developed platform for NOTES. Finally, we make a prediction of the conceivable applications of NOTES on human subjects.
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Affiliation(s)
- Junqing Wang
- Department of General Surgery, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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Natural orifice transesophageal endoscopic surgery: state of the art. Minim Invasive Surg 2012; 2012:896952. [PMID: 22567228 PMCID: PMC3337494 DOI: 10.1155/2012/896952] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 02/09/2012] [Indexed: 12/21/2022] Open
Abstract
The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome.
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Cassera MA, Zheng B, Spaun GO, Swanström LL. Optimizing surgical approach for natural orifice translumenal endoscopic procedures. Surg Innov 2012; 19:433-7. [PMID: 22393077 DOI: 10.1177/1553350612438410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES) often requires some degree of retroflexion of the endoscopic operating system. This study investigates the impact of retroflexion on task performance in NOTES. METHODS In a bench-top simulation, surgeons were required to manipulate a single-channel endoscope to touch 4 dots in a predetermined order. The task was performed under the forward-view and retroflexed-view conditions. RESULTS Tasks performed under the forward-view condition were significantly faster than those performed under the retroflexed-view condition (P = .005). Also, 5 experienced surgeons completed tasks in less time than the novices (P = .043). Experienced surgeons were mildly affected by the inverted image, whereas the novices were vulnerable to image malalignment. CONCLUSION Careful selection of the surgical approach to avoid image malalignment is suggested for safe performance of NOTES. Extensive training is required for novices to overcome the vision-motion difficulty before they can perform NOTES safely and effectively.
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Affiliation(s)
- Maria A Cassera
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 1040 NW 22nd Ave, Suite 560, Portland, OR 97210, USA.
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Huang C, Huang RX, Qiu ZJ. Natural orifice transluminal endoscopic surgery: New minimally invasive surgery come of age. World J Gastroenterol 2011; 17:4382-8. [PMID: 22110263 PMCID: PMC3218151 DOI: 10.3748/wjg.v17.i39.4382] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 06/21/2011] [Accepted: 06/28/2011] [Indexed: 02/06/2023] Open
Abstract
Although in the past two decades, laparoscopic surgery, considered as a great revolution in the minimally invasive surgery field, has undergone major development worldwide, another dramatic surgical revolution has quietly appeared in recent years. Ever since Kalloo’s first report on transgastric peritoneoscopy in a porcine model in 2004, interest in a new surgical procedure named natural orifice transluminal endoscopic surgery (NOTES) has blossomed worldwide. Considering that a NOTES procedure could theoretically avoid any abdominal incision, operation-related pain and scarring, many surgeons and endoscopists have been enthusiastic in their study of this new technique. In recent years, several NOTES studies have been carried out on porcine models and even on humans, including transvaginal cholecystectomy, transgastric appendectomy, transvaginal appendectomy, and transvesical peritoneoscopy. So what is the current situation of NOTES and how many challenges do we still face? This review discusses the current research progress in NOTES.
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von Renteln D, Vassiliou MC, Rösch T, Rothstein RI. Triangulation: the holy grail of endoscopic surgery? Surg Endosc 2011; 25:1355-7. [PMID: 21424191 DOI: 10.1007/s00464-011-1650-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Kume K, Kuroki T, Sugihara T, Shinngai M. Development of a novel endoscopic manipulation system: The Endoscopic operation robot. World J Gastrointest Endosc 2011; 3:145-50. [PMID: 21860684 PMCID: PMC3159503 DOI: 10.4253/wjge.v3.i7.145] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 06/22/2011] [Accepted: 07/01/2011] [Indexed: 02/05/2023] Open
Abstract
AIM: To develop and evaluate the endoscopic operation robot (EOR). The EOR is a robot system designed specifically for remote manipulation of the scope during gastrointestinal endoscopy by a seated endoscopist.
METHODS: Total colonoscopy examinations using a colonoscopy training model were performed compared conventional insertion by manual manipulation and remote-controlled insertion, using the EOR. The author investigated the time taken for each of the 50 examinations.
RESULTS: The median insertion time (in minutes) for each 10 examinations (EOR vs manual manipulation) was 73.70 ± 25.37 vs 3.77 ± 1.34 in the first group, 38.40 ± 6.24 vs 3.40 ± 0.97 in the second group, 27.6 ± 4.01 vs 2.70 ± 0.95 in the third group, 23.8 ± 3.65 vs 3.10 ± 0.88 in the fourth group, and 22.9 ± 5.02 vs 2.60 ± 1.08 in the fifth group.
CONCLUSION: The study suggested the possibility of the clinical application of the EOR.
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Affiliation(s)
- Keiichiro Kume
- Keiichiro Kume, K's Device; Laboratory for Endoscopy and Third Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyusyu 807-8555, Japan
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Milsom J, Trencheva K, Pavoor R, Dirocco J, Shukla PJ, Kawamura J, Sonoda T. Endoscopic fixation of the rectum for rectal prolapse: a feasibility and survival experimental study. Surg Endosc 2011; 25:3691-7. [PMID: 21643879 DOI: 10.1007/s00464-011-1778-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 05/14/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND In recent years, there has been considerable interest in developing technology as well as techniques that could widen the therapeutic horizons of endoscopy. Rectal prolapse, a benign localized condition causing considerable morbidity, could be an excellent focus for new endoscopic therapies. The aim of this study was to assess the feasibility and safety of endoluminal fixation of the rectum to the anterior abdominal wall, after pushing it up inside the body, using an in vivo animal model. METHODS We performed an in vivo comparative surgical study in a porcine model, including laparoscopic mobilization of the rectum and posterior rectopexy (standard surgical method) or endoluminal tacking of the rectum. After proving feasibility in ex vivo and acute studies, we performed a survival study to evaluate the safety of endoluminal tacking of the mobilized rectum to the anterior abdominal wall. The main outcome measures were successful completion of the tasks, maintenance of the fixation, complications associated with the methods, and survival studies including histopathological examinations of the fixation sites. RESULTS There were two groups: laparoscopic rectopexy (8 animals) and endoluminal fixation of the rectum to the anterior abdominal wall (10 animals). There were no differences between these two groups in their postoperative recovery. The group with the endoluminal fixation was found to have adequate attachment of the rectum to the anterior abdominal wall (measured attachment pressure in the endoluminal group = 6.06 ± 0.52 ft-lb, in the control group = 4.86 ± 2.00 ft-lb) on both gross and microscopic evaluation. CONCLUSION Endoscopic fixation of the mobilized rectum is feasible and safe in this model and in the future may provide an effective alternative to current treatment options for rectal prolapse.
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Affiliation(s)
- Jeffrey Milsom
- Section of Colorectal Surgery, Department of Surgery, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
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Auyang ED, Santos BF, Enter DH, Hungness ES, Soper NJ. Natural orifice translumenal endoscopic surgery (NOTES(®)): a technical review. Surg Endosc 2011; 25:3135-48. [PMID: 21553172 DOI: 10.1007/s00464-011-1718-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2010] [Accepted: 03/11/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The clinical NOTES literature continues to grow. This review quantifies the published human NOTES experience to date, examines instrument use in detail, and compiles available perioperative outcomes data. METHODS A PubMed search for all articles describing human NOTES cases was performed. All articles providing a technical description of procedures, excluding cases limited to diagnostic procedures, specimen extraction, fluid drainage or gynecological procedures, were reviewed. Two reviewers systematically cataloged the technical details of each procedure and performed a frequency analysis of instrument use in each type of case. Available outcomes data were also compiled. RESULTS Forty-three discrete articles were reviewed in detail, describing a total of 432 operations consisting of transvaginal (n = 355), transgastric (n = 58), transesophageal (n = 17), and transrectal (n = 2) procedures, with 90% of cases performed in hybrid fashion with laparoscopic assistance. Cholecystectomy (84% of cases) was the most common procedure. Analysis of key steps included choice of endoscope, establishment of peritoneal access, dissection, specimen extraction, and closure of the access site. Analysis of instrument use during transvaginal cholecystectomy revealed variation in the choice of endoscope and the technique for establishment of access. A majority of these procedures relied heavily on the use of rigid and transabdominal instrumentation. Closure of the vaginotomy site was found to be well standardized, performed with an open suturing technique. Similar analysis for transgastric procedures revealed consistency in the choice of flexible endoscope as well as access and closure techniques. Perioperative outcomes from NOTES procedures were reported, but the data are currently limited due to small case numbers. CONCLUSIONS NOTES is most commonly performed using a hybrid, transvaginal approach. Although some aspects of these procedures appear to be well standardized, there is still significant variability in technique. More outcomes data with standardized reporting are needed to determine the actual risks and benefits of NOTES.
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Affiliation(s)
- Edward D Auyang
- Department of Surgery, Northwestern University, Chicago, IL 60611, USA
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61
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Abstract
INTRODUCTION The clinical NOTES literature continues to grow. This review quantifies the published human NOTES experience to date, examines instrument use in detail, and compiles available perioperative outcomes data. METHODS A PubMed search for all articles describing human NOTES cases was performed. All articles providing a technical description of procedures, excluding cases limited to diagnostic procedures, specimen extraction, fluid drainage or gynecological procedures, were reviewed. Two reviewers systematically cataloged the technical details of each procedure and performed a frequency analysis of instrument use in each type of case. Available outcomes data were also compiled. RESULTS Forty-three discrete articles were reviewed in detail, describing a total of 432 operations consisting of transvaginal (n = 355), transgastric (n = 58), transesophageal (n = 17), and transrectal (n = 2) procedures, with 90% of cases performed in hybrid fashion with laparoscopic assistance. Cholecystectomy (84% of cases) was the most common procedure. Analysis of key steps included choice of endoscope, establishment of peritoneal access, dissection, specimen extraction, and closure of the access site. Analysis of instrument use during transvaginal cholecystectomy revealed variation in the choice of endoscope and the technique for establishment of access. A majority of these procedures relied heavily on the use of rigid and transabdominal instrumentation. Closure of the vaginotomy site was found to be well standardized, performed with an open suturing technique. Similar analysis for transgastric procedures revealed consistency in the choice of flexible endoscope as well as access and closure techniques. Perioperative outcomes from NOTES procedures were reported, but the data are currently limited due to small case numbers. CONCLUSIONS NOTES is most commonly performed using a hybrid, transvaginal approach. Although some aspects of these procedures appear to be well standardized, there is still significant variability in technique. More outcomes data with standardized reporting are needed to determine the actual risks and benefits of NOTES.
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Pérez RC, González LRA, Reyes ED, Fernández JCD, Arias LER, Estrada MO. [The transvaginal approach in acute appendicitis]. Cir Esp 2011; 89:517-23. [PMID: 21514578 DOI: 10.1016/j.ciresp.2011.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 01/17/2011] [Accepted: 02/14/2011] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The purpose of this work is to present 8 minilaparoscopic-assisted transvaginal appendectomies using rigid instruments in patients with acute appendicitis. MATERIAL AND METHODS Eight minilaparoscopic-assisted transvaginal appendectomies were performed from the 10th of August 2009 to the 30th of June 2010. The inclusion criteria were women between 18 and 65 years of age with a diagnosis of acute appendicitis. The exclusion criteria were palpable masses, appendicular abscesses, ASA III and IV; morbid obesity (BMI > 35); gynaecological infections; virgin patients and pregnant women. The surgical intervention was performed with rigid instruments. Surgical time, the need for post-operative analgesics, and post-surgical complications. RESULTS The age range varied between 18 and 42 years, with a mean of 29.6 years. The mean surgical time was 48.3 minutes (37-75). Analgesics were given to 2 patients after surgery (1 parenteral and 1 oral). Five patients were discharged before 24 hours and 3 at 48 hours. There were no post-operative complications. CONCLUSIONS Minilaparoscopic-assisted transvaginal appendectomy with rigid instruments, in selected women is a feasible and safe method, and with better aesthetic results than laparoscopic appendectomy, but future studies will be required that can demonstrate its advantages.
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Affiliation(s)
- Raúl Castro Pérez
- Servicio de Cirugía General, Hospital Provincial Docente Abel Santamaría Cuadrado, Ciudad de Pinar del Río, Provincia de Pinar del Río, Cuba.
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Teoh AYB, Chiu PWY, Lau JYW, Ng EKW. Randomized comparative trial of a novel one-step needle sphincterotome versus direct incision and balloon dilation used to create gastrotomies for natural orifice translumenal endoscopic surgery (NOTES) in the porcine model. Surg Endosc 2011; 25:3116-21. [PMID: 21487882 DOI: 10.1007/s00464-011-1653-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 02/20/2011] [Indexed: 01/09/2023]
Affiliation(s)
- Anthony Yuen Bun Teoh
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China
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64
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Affiliation(s)
- Lee L Swanstrom
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA.
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Shi H, Jiang SJ, Li B, Fu DK, Xin P, Wang YG. Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model. World J Gastroenterol 2011; 17:926-31. [PMID: 21412502 PMCID: PMC3051143 DOI: 10.3748/wjg.v17.i7.926] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 11/17/2010] [Accepted: 11/24/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model.
METHODS: The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy.
RESULTS: Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels.
CONCLUSION: The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.
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Ikeda K, Sumiyama K, Tajiri H, Yasuda K, Kitano S. Evaluation of a new multitasking platform for endoscopic full-thickness resection. Gastrointest Endosc 2011; 73:117-22. [PMID: 21074762 DOI: 10.1016/j.gie.2010.09.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/07/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND The advent of natural orifice transluminal endoscopic surgery (NOTES) has accelerated the development of new technology in the field of GI endoscopy. Various suturing devices or multitasking platforms are expected to be valuable for endoluminal surgery as well as for NOTES. OBJECTIVE To evaluate a new multitasking platform in performing endoscopic full-thickness resection (EFTR). DESIGN Bench-top comparison study. SETTING Research laboratory study of 10 ex vivo porcine models. INTERVENTION Ten EFTRs (5 with a double-channel endoscope vs 5 with a new multitasking platform) assisted with percutaneous gastric lifting. Each group was given the task of resecting a full-thickness specimen of the gastric wall including a pseudolesion 10 mm in diameter with an effective margin. MAIN OUTCOME MEASUREMENTS Outcome measurements included time to perform the procedure, accuracy of the resection, and efficiency for the task. Accuracy was assessed according to variability of the surgical margin and misalignment between the mucosal layer and the seromuscular layer. Efficiency was assessed according to the duty ratio, which is the percentage of time spent for the main purposes compared with the total procedure time. RESULTS Mean diameter of the specimen was not significantly different between the groups. All other assessment items were significantly superior in group B to those in group A (P < .05). LIMITATIONS Ex vivo animal model study. CONCLUSION We were able to perform EFTR procedures precisely and effectively by using a new multitasking platform compared with use of a conventional endoscope in a porcine model. A multitasking platform developed for NOTES procedures would be useful for advanced endoluminal surgery such as endoscopic submucosal dissection or EFTR as well as NOTES.
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Affiliation(s)
- Keiichi Ikeda
- Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan.
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Voermans RP, van Berge Henegouwen MI, de Cuba E, van den Broek FJC, van Acker G, Timmer R, Fockens P. Randomized, blinded comparison of transgastric, transcolonic, and laparoscopic peritoneoscopy for the detection of peritoneal metastases in a human cadaver model. Gastrointest Endosc 2010; 72:1027-33. [PMID: 20850736 DOI: 10.1016/j.gie.2010.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 06/10/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery peritoneoscopy may be able to replace laparoscopic peritoneoscopy (LAP) for staging of GI malignancies if it is proven to be equally accurate and safe. OBJECTIVE To compare transgastric peritoneoscopy (TGP) and transcolonic peritoneoscopy (TCP) to LAP, pairwise, in a randomized, blinded (to location and number of beads) human cadaver model with simulated peritoneal metastases. DESIGN Metastases were simulated by 2.5-mm, color-coded beads, which were placed into the peritoneal cavity via an open approach. In previous porcine experiments, LAP resulted in a yield of 95%. By using a noninferiority design with a margin of equivalence of 15%, we needed a sample size of 34 beads for 80% power. Randomization was performed for number and location of beads. Eighteen experiments were performed on 6 fresh-frozen human cadavers. SETTING Experimental surgical laboratory. INTERVENTION LAP, TGP, and TCP were performed in randomized order by one of two surgeons/endoscopists blinded for location and number of beads. MAIN OUTCOME MEASUREMENTS Number of beads detected and touched. RESULTS LAP found and touched 33 beads (yield 97%), TGP 26 beads (76%; difference in yield vs LAP was -20.5 [95% CI, -26.3 to -9.27]), and TCP 29 beads (85%; difference in yield vs LAP was -11.8 [95% CI, -14.6 to 4.98]). Beads that were missed were mostly located at the inferior liver surface: TGP missed 6 of 9 of these beads (67%), TCP 4 of 9 (44%). LIMITATIONS Cadaver model. CONCLUSION In this prospective, blinded, comparative trial in a human cadaver model, TCP was comparable to LAP in detecting simulated metastases. TGP was inferior to LAP. Future development should focus on improved visualization of the inferior surface of the liver.
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Affiliation(s)
- Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, The Netherlands
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Teoh AYB, Chiu PWY, Ng EKW. Current developments in natural orifices transluminal endoscopic surgery: An evidence-based review. World J Gastroenterol 2010; 16:4792-9. [PMID: 20939107 PMCID: PMC2955248 DOI: 10.3748/wjg.v16.i38.4792] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access, safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in humans has yet to be determined. Reports of human NOTES procedures are emerging, and the possibility of accomplishing human NOTES based on existing technology has been demonstrated. However, dedicated platforms and devices are still lacking to allow for pure NOTES procedures, and whether NOTES can deliver the postulated benefits of earlier recovery and improved cosmesis remains uncertain.
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Ho KY, Phee SJ, Shabbir A, Low SC, Huynh VA, Kencana AP, Yang K, Lomanto D, So BYJ, Wong YYJ, Chung SCS. Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER). Gastrointest Endosc 2010; 72:593-9. [PMID: 20646698 DOI: 10.1016/j.gie.2010.04.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 04/05/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Performing endoscopic submucosal dissection (ESD) by using standard endoscopy platforms is technically challenging because of the equipment's lack of dexterity. OBJECTIVE To explore the feasibility of using the Master and Slave Transluminal Endoscopic Robot (MASTER), a novel robotics-enhanced endosurgical system, to perform ESD. DESIGN ESD was performed on simulated gastric lesions in 5 Erlangen porcine stomach models (ex vivo) and 5 live pigs (in vivo). Performance of ESD by using the MASTER was compared with that using the insulation-tipped (IT) diathermic knife. SETTING SMART Laboratory, Advance Surgical Training Centre, National University Hospital, Singapore. SUBJECTS Five Erlangen porcine stomach models and 5 pigs, 5 to 7 months old, each weighing about 35 kg. INTERVENTIONS ESD. MAIN OUTCOME MEASUREMENTS Lesion resection time, grasper and hook efficacy grade, completeness of resection, and presence of procedure-related perforation. RESULTS In the Erlangen stomach models, 15 simulated lesions from the cardia, antrum, and body were removed en bloc (mean dimension, 37.4 x 26.5 mm) by electrocautery excision using the MASTER. The mean ESD time was 23.9 minutes (range 7-48 minutes). There was no difference in the dissection times of lesions at different locations (P = .449). In the live pigs, the MASTER took a mean of 16.2 minutes (range 3-29 minutes) to complete the ESD of 5 gastric lesions, whereas the IT diathermic knife took 18.6 minutes (range 9-34 minutes). There was no significant difference in the times taken (P = .708). All lesions were excised en bloc; the mean dimensions of lesions resected by the MASTER and the IT diathermic knife were 37.2 x 30.1 mm and 32.78 x 25.6 mm, respectively. The MASTER exhibited good grasping and cutting efficiency throughout. Surgical maneuvers were achieved with ease and precision. There was no incidence of excessive bleeding or stomach wall perforation. LIMITATIONS Exploratory study with limited sample size. CONCLUSIONS Performing ESD by using the MASTER is feasible.
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Affiliation(s)
- Khek-Yu Ho
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore
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Chukwumah C, Zorron R, Marks JM, Ponsky JL. Current Status of Natural Orifice Translumenal Endoscopic Surgery (NOTES). Curr Probl Surg 2010; 47:630-68. [DOI: 10.1067/j.cpsurg.2010.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Shaikh SN, Thompson CC. Natural orifice translumenal surgery: Flexible platform review. World J Gastrointest Surg 2010; 2:210-6. [PMID: 21160877 PMCID: PMC2999243 DOI: 10.4240/wjgs.v2.i6.210] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 02/18/2010] [Accepted: 02/25/2010] [Indexed: 02/06/2023] Open
Abstract
Natural orifice translumenal surgery (NOTES) has garnished significant attention from surgeons and gastroenterologists, due to the fusion of flexible endoscopy and operative technique. Preliminary efforts suggest that NOTES holds potential for a less invasive approach with certain surgical conditions. Many of the hurdles encountered during the shift from open to laparoscopic surgery are now being revisited in the development of NOTES. Physician directed efforts, coupled with industry support, have brought about several NOTES specific devices and platforms to help address limitations with current instrumentation. This review addresses current flexible platforms and their attributes, advantages, disadvantages and limitations.
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Affiliation(s)
- Sohail N Shaikh
- Sohail N Shaikh, Christopher C Thompson, Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
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