Natural-orifice transluminal endoscopic surgery

Transareolar Video-Assisted Thoracoscopic Surgery in Females: A Novel Incision for Pulmonary Ground Glass Nodule Resection

Purpose: Uniportal video-assisted thoracoscopic surgery (VATS) is recognized for its minimally invasive nature, widely adopted globally. However, the evident scarring it leaves often triggers psychological apprehension and resistance to surgery. Transareolar incision, known for its superior cosmetic outcome with no visible scars, poses challenges in women due to the risk of mammary gland damage. In this report, we present successful pulmonary ground glass nodule (GGN) resection using transareolar VATS in female patients, aiming to address these concerns. Materials and Methods: We retrospectively analyzed the clinical data of 35 female patients who underwent GGN resection through transareolar VATS between August 2020 and March 2022. Results: There were no serious complications or perioperative deaths in this cohort of 35 female patients undergoing GGN resection through transareolar VATS. The operations, including local resection or segmentectomy, had an average duration of 70.1 ± 26.4 minutes, with a tube duration of 4.7 ± 2.1 days and a hospitalization time of 7.2 ± 2.3 days. The surgical approach varied, with 21 cases using transareolar uniport, 8 cases assisted by a 3-mm tiny port, and 6 cases converted to two-port VATS. Scar outcomes varied, with 21 cases showing no scar, 8 cases displaying a microscar, and 6 cases presenting a dominant scar of 1.7 ± 0.5 cm. Postoperative pain scores at 1 week and 1 month were 1.9 ± 0.9 and 1.0 ± 0.9, respectively, and the wound numbness occurred in 2.86% (1/35) of cases. Regarding breast complications, 2 patients suffered delayed healing of the incision. No damage and inflammation of glands were detected by breast B-mode ultrasonography. Conclusions: The transareolar incision emerges as a novel approach for VATS in female patients, offering advantages in terms of pain management and cosmetic outcomes.

Acute Care Surgery: Navigating Recent Developments, Protocols, and Challenges in the Comprehensive Management of Surgical Emergencies

Acute care surgery (ACS) is a crucial medical field that specifically deals with the rapid treatment of surgical emergencies. This investigation encompasses the most recent progress, procedures, and obstacles in ACS, utilizing various sources such as scholarly articles, clinical trials, and expert statements. The development of ACS as a specialized field is a significant area of concentration, particularly emphasizing its contribution to improving patient care. An examination is conducted on the efficacy of contemporary triage systems and prompt response mechanisms, specifically in diminishing the incidence of illness and death rates associated with illnesses such as trauma, acute appendicitis, and obstructed viscera. The emphasis is placed on the surgical protocols and principles that form the basis of ACS. Examining regional and international approaches provides insight into the distinctions and commonalities in surgical techniques. An assessment is conducted to determine the effects of the transition to minimally invasive procedures on patient outcomes, recuperation periods, and healthcare expenses. The assessment also examines the logistical obstacles that ACS encounters, such as resource allocation and managing diverse teams. The examination focuses on the delicate equilibrium between prompt decision-making and care grounded in evidence. It also evaluates the possible contribution of technical breakthroughs such as telemedicine and AI to improving patient care and overcoming current obstacles. The topic of training and education for surgeons in ACS is of utmost importance and requires careful consideration. The evaluation evaluates the sufficiency of existing educational frameworks and the necessity of specific training to equip surgeons for the requirements of ACS. This analysis explores the current discourse surrounding the standardization of ACS training, considering its potential ramifications for the future of surgical procedures. Exploring ethical and legal problems in ACS also includes situations when prompt decision-making may clash with patient autonomy and informed consent. The significance of proficient communication with patients and their families during emergency surgical scenarios is underscored, emphasizing the necessity for ethical awareness and interpersonal aptitude. The investigation of ACS demonstrates its dynamic character, signifying notable advancements while recognizing enduring obstacles. Continual research, interdisciplinary collaboration, and policy adjustments are necessary to improve ACS procedures. This thorough investigation offers valuable insights for professionals and researchers, facilitating future progress in managing surgical crises.

Repeated transvaginal natural orifice transluminal endoscopic surgery: An initial Chinese experience

AIMS

To investigate the perioperative outcomes and sexual function of patients undergoing repeated transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

METHODS

We retrieved the records of patients who underwent vNOTES twice at our institute between April 2019 and December 2022 and analyzed their baseline information and perioperative complications, and compared the pre- and postoperative sexual function of both vNOTES.

RESULTS

Patients' mean age and body mass index were 29.00 ± 3.59 and 30.4 ± 4.00 years and 21.89 ± 3.69 and 22.76 ± 3.88 kg/m2 , respectively, when receiving the first and second vNOTES. Ectopic pregnancy was the most frequent indication for vNOTES, with 7 cases in the first vNOTES and 11 cases in repeated vNOTES. The interval between the two vNOTESs ranged from 9 days to 38 months. The operation duration (63.33 ± 13.71 vs. 67.33 ± 22.51 min, p = 0.723), intraoperative estimated blood loss (32.00 ± 20.42 vs. 30.00 ± 9.26 mL, p = 0.429), and duration of postoperative hospital stay (2.20 ± 0.56 vs. 2.40 ± 0.51 days, p = 0.082) of both vNOTESs were comparable. No significant differences were found in any of the domains in the comparison of pre-first and post-first vNOTES, pre-second and post-second vNOTES, and pre-first and post-second vNOTES female sexual function index. None of the patients delivered after the second vNOTES.

CONCLUSION

Repeated vNOTES is safe and feasible. No significant change in the patients' sexual function was found in our cohort after the first and second vNOTES.

Transgastric versus transrectal: Which access route is the best for NOTES gallbladder-preserving gallstone therapy?

OBJECTIVES

To compare the effectiveness and safety of transgastric and transrectal pure natural orifice transluminal endoscopic surgery (NOTES) for cholecystolithotomy.

METHODS

This was a single-center retrospective comparative study of consecutive patients who underwent pure NOTES for either transrectal or transgastric gallbladder-preserving cholecystolithotomy between September 2017 and April 2020. Patients with symptomatic cholelithiasis were assigned for transrectal or transgastric NOTES based on the patients' choice. Treatment success, postoperative pain, peritonitis, time to resume normal diet, and duration of hospitalization were compared.

RESULTS

The technical success rate was 100%. Forty-eight patients underwent successful NOTES cholecystolithotomy via the transrectal (n = 26) or transgastric route (n = 22). One (3.8%) patient in the transrectal NOTES group experienced postoperative abdominal pain compared to 6 (27.3%) in the transgastric NOTES group (P = 0.04). Fever and bile peritonitis developed in one (3.8%) patient in the transrectal NOTES group versus 8 (36.4%) in the transgastric NOTES group (P = 0.005). A postoperative fluid diet was commenced at 6 h with the transrectal approach versus on day 3 for the transgastric NOTES group. The mean postoperative hospitalization for transrectal and transgastric NOTES groups was 4.5 days versus 7 days (P = 0.001). Three patients in the transgastric NOTES group developed postoperative gastric fistula.

CONCLUSIONS

Transrectal NOTES has advantages over transgastric NOTES, including preserved spatial orientation, relatively easier removal of specimens, early food intake, shorter hospitalization, fewer postoperative complications and less pain. Multicenter clinical trials with long-term follow-up are needed to confirm the safety and efficacy of both approaches.

Feasibility and Safety of Transgastric Natural Orifice Transluminal Endoscopic Surgery in the Diagnosis of Ascites of Unknown Origin

Objective: The purpose of this study was to evaluate the feasibility and safety of transgastric natural orifice transluminal endoscopic surgery (TG-NOTES) combined with biopsy in the diagnosis of unknown ascites. Method: This retrospective study used data from the first affiliated hospital of Nanchang university on 51 patients who were diagnosed with ascites of unknown origin between January 2013 and May 2019 and experienced peritoneal biopsy through TG-NOTES. The outcome measures included diagnostic accuracy and procedure-related adverse events. Results: TG-NOTES was performed successfully in 46 of 51 patients, tuberculous ascites in 38 cases, carcinomatous ascites in 4 cases, cirrhotic ascites in 1 case, and 3 cases showed no obvious abnormalities in pathological result. Five cases failed to be diagnosed because of abdominal adhesions. The diagnostic rate of TG-NOTES was 84.3%. There were no severe procedure-related adverse events and no mortality. All patients had good wound healing and no complaint of discomfort on follow-up. Conclusion: The majority of ascites of unknown origin can be expounded through TG-NOTES combined with biopsy without severe complication, therefore, it is a feasible and safe method to detect the cause of unexplained ascites.

Women's Perception of Transgastric and Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) - Impact of Medical Education, Stage of Life and Cross-Cultural Aspects

Introduction

Despite that NOTES produces at least matchable clinical long-term results when compared to laparoscopy, still a restraint within the medical community and among patients is evident. Consequently, it might be meaningful to evaluate factors of patient's NOTES perception to promote its acceptance. NOTES is still quite novel and questionnaires regarding its perception by the public is still lacking even so in the Middle East. Aim of our survey is to investigate the viewpoint of female healthcare staff on NOTES.

Materials and Methods

A total of 350 questionnaires along with written information about Minimally Invasive Surgery and NOTES were distributed among the female staff in a Tertiary-care Hospital in Abu Dhabi, 257 were returned completely anonymously and voluntarily and entered into a database with a response rate of 73%. We surveyed factors like religion, medical background, age as well as history of previous laparoscopy, endoscopy, birth and other aspects that may impact a woman's perception of both transgastric and transvaginal NOTES for cholecystectomy and ovariectomy, respectively.

Results

Univariate analyses revealed the majority of Muslim women to be more receptive to NOTES as a choice of surgical technique for cholecystectomy and for ovariectomy, respectively, when compared to Christians and Hindus. However, when compared to Muslims, Christian and Hindu groups had a larger share of medical professions. Women with a medical background would opt significantly less for NOTES. Among younger women, NOTES cholecystectomy was refused due to anxiety concerning future pregnancies and sexual dysfunction. Multinomial logistic regression analysis determined medical background and with independent predictive value for the overall choice of interventional technique (p<0.001). Marital status played a significant role only in the comparison of laparoscopy vs transgastric NOTES when performing cholecystectomy and ovariectomy (p<0.01).

Conclusion

In this first study emanating from the Middle East, medical education and partly life stage rather than cross-cultural differences seem to influence NOTES perception in women.

Single-port laparoscopic sacrospinous ligament suspension via the natural vaginal cavity (SvNOTES) for pelvic prolapse: The first feasibility study

Objective

This study aims to investigate the feasibility and short-term efficacy of single-port laparoscopic-assisted transvaginal natural cavity endoscopic sacrospinous ligament suspensions (SvNOTES).

Methods

A total of 30 patients diagnosed with anterior or/and middle pelvic organ prolapse Stages III and IV underwent natural vaginal cavity (SvNOTES), and 30 patients who underwent conventional sacrospinous ligament (SSLF) were used as a control group. The operation time, blood loss, postoperative POP-Q score, length of hospital stay, and complications were compared between the two groups.

Results

The operation time for SvNOTE was (60 ± 13) min, which was longer than (30 ± 15) min for SSLF (P = 0.04). However, the bleeding amount in SvNOTE was 29.44 ± 2.56, significantly lower than that in the SSLF group (80 ± 10; P = 0.02), and the postoperative hospital stay in the SvNOTE group was (4 ± 2) days, longer than (3 ± 1) days in SSLF (P = 0.02). However, there were no intraoperative complications in the SvNOTE group, whereas one ureteral injury occurred in the SSLF group; in addition, the postoperative POP-Q score was significantly better in the SvNOTE group than that in the SSLF group with increasing time (P < 0.001).

Conclusion

Compared with SSLF, single-port laparoscopic sacrospinous ligament suspension via the natural vaginal cavity is visualized, greatly improving the success rate of sacrospinous ligament fixation, with less blood loss and fewer complications, arguably a safer and minimally invasive surgical approach.

Oncologic outcomes of single-incision laparoscopic surgery versus conventional laparoscopic surgery for colorectal cancer (CSILS): study protocol for a multicentre, prospective, open-label, noninferiority, randomized controlled trial

Background

In most previous studies, single-incision laparoscopic surgery (SILS) for colorectal cancer (CRC) was feasible and safe in the short term. However, long-term oncologic outcomes remain uncertain, as only a few studies contained long-term survival data. SILS for CRC is still in the early stages of research. Further studies, particularly large-scale, prospective randomized controlled trials, are necessary to assess the value of SILS for CRC.

Methods

This study is a prospective, multicentre, open-label, noninferiority, parallel-group randomized controlled trial that investigates the long-term oncologic outcomes of SILS compared to conventional laparoscopic surgery (CLS) for CRC. A total of 710 eligible patients will be randomly assigned to the SILS group or the CLS group at a 1:1 ratio using a central, dynamic, and stratified block randomization method. Patients with ages ranging from 18 to 85 years old, of both sexes, with CRC above the peritoneal reflection diagnosed as cT1-4aN0-2M0 and a tumour size no larger than 5 cm will be considered for the study. The primary endpoint is 3-year disease-free survival (DFS). The secondary endpoints include: intraoperative outcomes, postoperative recovery, postoperative pain assessment, pathological outcomes, early morbidity and mortality rate, cosmetic effects, quality of life, 3-year overall survival (OS), incidence of incisional hernia, 5-year DFS and 5-year OS. The first two follow-up visits will be scheduled at one month and three months postoperatively, then every three months for the first two years and every six months for the next three years.

Discussion

Currently, no randomized controlled trials (RCTs) have been designed to investigate the long-term oncologic outcomes of SILS for CRC. This study is expected to provide clinical evidence of the oncologic outcomes of SILS compared to CLS for CRC to promote its widespread use.

Trial registration

ClinicalTrials.gov: NCT 04527861 (registered on August 27, 2020).

A New and Alternative Route: Transvaginal Natural Orifice Transluminal Endoscopic Scarless Surgery (vaginal natural orifice transluminal endoscopic surgery) For Class 2 and Class 3 Obese Patients Suffering From Benign and Malignant Gynecologic Pathologies

Background. This study was conducted to investigate the effectiveness of vaginal natural orifice transluminal endoscopic surgery (vNOTES) gynecologic scarless surgery in benign and malignant class 2 and class 3 obese patients. Materials and methods. The class 2 and class 3 obese women undergoing vNOTES scarless surgery for benign and malign indications at a tertiary referral medical center between January 2019 and April 2021 were retrospectively analyzed and surgical outcomes were measured. Results. In this study, 81 class 2 and class 3 obese patients underwent gynecological procedures using vNOTES scarless surgery. Of the 81 operations, 55 of the class 2 obese patients with benign pathologies, and 26 of the class 3 obese patients had malign pathologies. No conversion to conventional laparoscopy or even laparotomy was needed in any of the procedures. All of the surgeries were performed by the same surgeon (Prof. Dr Ahmet Kale). vNOTES scarless surgery was performed on 26 class 3 obese patients with malign pathologies. Of the 26 class 3 obese patients, 22 of the class 3 obese patients with early-stage endometrial carcinoma had very high mean body mass index 41.5 kg/m2 (range 20.6-56) and 4 of the class 3 obese patients had ascites with unknown cause and diagnosed with peritoneal carcinomatosis. The mean postoperative pain VAS scores of class 2 obese patients undergoing vNOTES scarless surgery with benign pathology at 6, 12, and 24 h were 3.19, 1.11, and .66, respectively, and the mean postoperative pain VAS scores of class 3 obese patients underwent vNOTES scarless surgery with malign pathology at 6, 12, and 24 h were 3.30, 1.76, and 1.03, respectively. Conclusion. vNOTES scarless surgery is an alternative surgical method for diagnosis and treatment not only in benign obese cases, but also in severely obese patients with early stage endometrial cancer and patients had with ascites with unknown cause. In the near future, vNOTES scarless surgery will become more preferable by experienced surgeons in benign and malignant obese cases as it has increased satisfaction with esthetic results such as less pain, and improved postoperative quality of life in the short and long term.

Gallbladder-preserving cholecystolithotomy

INTRODUCTION

Cholecystectomy is the preferred option for symptomatic gallstones. Gallbladder-preserving cholecystolithotomy (GPC) is proposed to satisfy the specific surgical patients with high-risks, biliary deformity and suffered from concomitant gallstone and choledocholithiasis.

AREAS COVERED

This review summarizes and compares the various GPC operations for cholelithiasis in some specific cases.

EXPERT OPINION

Transmural GPC mainly focuses on the gallstones, including endoscopic minimally invasive cholecystolithotomy (EMIC)-, natural orifice transluminal endoscopic surgery-, and endoscopic ultrasonography (EUS)-GPC. These GPC procedures potentially preserve gallbladder integrity and function after clearance of gallstones. Additionally, transmural GPC may overcome the disadvantages of cholecystectomy, including cosmetic considerations and postoperative complications. However, the stone recurrence rate of EMIC varies greatly from 4.92% to 40.0%, and based on limited studies, long-term adverse events due to gallbladder mucosa and natural lumen injury are largely unknown in transmural GPC. Thus, transmural GPC may be an alternative to cholecystectomy for surgical patients with high-risks and abnormal biliary anatomy. Endoscopic retrograde cholangiopancreatography-based transcystic GPC may be promising for some specific patients with concomitant gallstones and choledocholithiasis, since gallbladder integrity and function may be completely preserved as the gallbladder wall was hardly injured and the function of sphincter of Oddi was retained.

Recent Technical Developments in the Field of Laparoscopic Surgery: A Literature Review

The benefits of laparoscopic surgery (LS) include a speedy recovery, shorter duration of hospital stay, minimal postoperative pain, discomfort and disabilities, and better cosmetic outcomes (less scarring) that help an individual to resume normal daily activities and return to work. A comprehensive literature search on laparoscopic surgeries was conducted using different Internet-based search engines and databases from August 2021 to October 2021. The search was limited to articles published in the English language and those published between years 2005 and 2021. A total of 126 articles were initially identified. Two independent reviewers thoroughly examined the quality and content of the articles. Articles with duplicate data were excluded, and the remaining articles were screened and assessed by the titles and abstracts. After a vigorous assessment, we included data from 49 articles for this review process. Bibliographic management was done using the software “EndNote” (Thomson Reuters, New York, NY, USA).

It was concluded that LS has become the technique of choice for virtually every kind of abdominal surgery, evident by numerous scholarly publications in this field. Level I evidence demonstrating the advantage of LS over open surgery has been reported for numerous operations, including fundoplication for gastroesophageal regurgitation disease, bariatric surgery for weight loss, and cancer resection. Advanced LS has subsequently been expanded to include hepatectomy, pancreatectomy, urology, and gynecology. Patients who are at risk of having elevated abdominal pressure during LS, however, should proceed with care. Recent advances in natural orifice transluminal endoscopic surgery, single-incision laparoscopic surgery, and robot-assisted laparoscopic surgery are promising.

A Novel Asymmetric Pneumatic Soft-Surgical Endoscope Design with Laminar Jamming

Soft pneumatic endoscopes developed for Minimally Invasive Surgeries (MIS) are designed upright which means that the starting positions straight. As the internal chambers are pressurized the endoscopic module starts bending. The relation between the pneumatic pressure and bending is nonlinear as the air needs first to fill the chamber before bending, and additionally frictional interaction to the sheath adds more to this start-up transient behaviour. This highly nonlinear behaviour severely limits the actuator sensitivity, accuracy, and repeatability near the endoscope's center of operating range. This paper introduces a novel pre-bent MR-compatible soft-surgical pneumatic endoscope design aimed to improve the bending performance of soft endoscopes by shifting the start-up transient out of the operating range. The pre-bent design of 12 mm diameter consists of an actuation and stiffening chamber, inextensible shell reinforcement with a backbone and rings, and external sheathing. The design parameters that include cross-sectional area, number of rings and backbone width are determined using Finite Element (FE) analysis. The motion profile of the fabricated endoscope, determined via experimentation, shows a successful shift of the start-up transient while the jamming structure increases the stiffness of the endoscope but limits the bending range. Further design developments of the endoscope are required for clinical application.

Single-Incision vs. Conventional Laparoscopic Surgery for Colorectal Cancer: An Update of a Systematic Review and Meta-Analysis

Background: Although the advantages of single-incision laparoscopic surgery have been reported in several meta-analyses, the low quality of studies included in the meta-analyses limits the reliability of such a conclusion. In recent years, the number of randomized controlled trials on the efficacy of SILS in colorectal cancer has been on the rise. This update systematic review and meta-analysis of RCTs aims to compare efficacy and safety of SILS and CLS in the patients with colorectal cancer. Methods: Relevant data was searched on the CNKI, Wanfang, VIP, Sinomed, PubMed, Embase, and Cochrane CENTRAL databases from inception until February 5th, 2021. All RCTs comparing SILS and CLS were included. The main outcomes were 30 days of mortality, postoperative complications, intraoperative complications, whereas secondary outcomes were the number of lymph nodes removed, duration of hospital stay, intraoperative blood loss, abdominal incision length, reoperation, readmission, conversion to laparotomy, operation time and anastomotic leakage. Results: A total of 10 RCTs were included, involving 1,133 participants. The quality of the included studies was generally high. No significant difference was found between SILS and CLS in the 30 days mortality rate. The results showed that SILS group had a lower rate of postoperative complications (RR = 0.67, 95% CI: 0.49-0.92), higher rate of intraoperative complications (RR = 2.26, 95%CI: 1.00-5.10), shorter length of abdominal incision (MD = -2.01, 95% CI:-2.42-1.61) (cm), longer operation time (MD = 11.90, 95% CI: 5.37-18.43) (minutes), shorter hospital stay (MD = -1.12, 95% CI: -1.89-0.34) (days) compared with CLS group. However, intraoperative blood loss (MD = -8.23, 95% CI: -16.75-0.29) (mL), number of lymph nodes removed (MD = -0.17, 95% CI: -0.79-0.45), conversion to laparotomy (RR=1.31, 95% CI: 0.48-3.60), reoperation (RR = 1.00, 95% CI: 0.30-3.33) and readmission (RR =1.15, 95% CI: 0.12-10.83) and anastomotic leakage were not significantly different between the two groups. Conclusion: These results indicate that SILS did not has a comprehensive and obvious advantage over the CLS. Surgeons and patients should carefully weigh the pros and cons of the two surgical procedures. Further RCTs are needed to prove long-term outcomes of SILS in colorectal cancer.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Hybrid natural orifice transluminal endoscopy surgery (NOTES) to perform bilateral ovariectomy in mares

OBJECTIVES

To combine laparoscopic techniques with natural orifice transluminal endoscopic surgery (hybrid NOTES) to minimize number and enlargement of paralumbar laparoscopic portals for bilateral ovariectomy in standing, sedated mares.

STUDY DESIGN

Case series.

ANIMALS

Six horses.

MATERIALS AND METHODS

Six mares with palpably normal ovaries were restrained in stocks, sedated, and had caudal epidural anesthesia performed. A 7.5 MHz ultrasound probe was used transvaginally to select placement of vaginotomy. An attempt was made to remove both ovaries with 70 cm esophageal forceps through the vaginotomy, while visualized and transected via ipsilateral paralumbar fossa laparoscopic portals. Surgical time, intraoperative, and postoperative complications were recorded. Vaginoscopy was performed at days 0, 3, 7, and 14 postoperatively. After 14 days, mares were euthanized and necropsied.

RESULTS

Hybrid NOTES allowed successful bilateral ovariectomy in all six mares, with a mean surgical time of 70 ± 25 min. In two mares, one ovary was dislodged from the forceps during vaginotomy extraction. Abdominal retrieval of the ovary was successful with reapplication of forceps or a surgeon's hand via vaginotomy. At necropsy, five mares had no adhesions within the abdominal cavity or at the vaginotomy site. One mare in which hand retrieval of the ovary was necessary, developed an adhesion between the bladder and the vaginotomy.

CONCLUSIONS

This technique appears to offer a safe alternative for bilateral ovariectomy with minimal postoperative complications.

CLINICAL SIGNIFICANCE

Decreased number and size of paralumbar laparoscopic incisions could decrease complications associated with exteriorization of ovaries through the flank.

Robotic Natural Orifice Transluminal Endoscopic Surgery Hysterectomy and Salpingo-Oophorectomy in a Porcine Model

Purpose. The emergence of robotic-assisted surgical techniques has gained significant indications in terms of reduced trauma, shortened recovery, and higher patients' satisfaction. However, limitations by present surgical robotic systems used in natural orifice transluminal endoscopic surgery (NOTES) gynecology still exists, such as arm collisions, countertraction, instrument dexterity, and, in particular, space confinement due to the narrow pelvic anatomy. The current study evaluated the use of a miniaturized single-site surgical robotic system and its feasibility in performing robotic NOTES gynecological procedures using a live porcine animal model. Methods. Using a transrectal approach, the fully internalized robotic arms were deployed in a reverse configuration to access the lower pelvic cavity of the animals to perform NOTES gynecological procedures. Results. Robotic-assisted transrectal gynecological procedures were successfully performed using the new robotic system. A hemi-hysterectomy with unilateral salpingo-oophorectomy was completed in the first animal and a total hysterectomy with bilateral salpingo-oophorectomy in the second animal with an average docking time of 22.5 minutes and console time of 63 minutes and 58 minutes, respectively. The overall blood loss for each procedure was estimated to be <20 mL per animal with no intraoperative complications. Conclusions. The reverse configuration of the miniaturized surgical robotic system has demonstrated its capability to provide a potential solution to maintain clear visualization of the surgical field, optimal triangulation, and dexterity robotic NOTES gynecological procedures within the deep confined space of the pelvic cavity.

Disseminated ovarian granulosa cell tumor after laparoscopic surgery: Two case reports

RATIONALE

Granulosa cell tumors (GCT) have an incidence of 0.6 to 0.8/100,000. Short-term relapsed ovarian GCT is extremely rare. Herein, this report aims to present 2 rare cases of disseminated ovarian GCT and analyze the causes of recurrence.

PATIENT CONCERNS

The 2 patients presented with abdominal pain.

DIAGNOSIS

Both the patients were diagnosed with relapsed ovarian GCT (IIIc stage) in the adult type.

INTERVENTIONS

The 2 patients had a medical history of surgery for ovarian GCT by using laparoscopic with power morcellators (LPM). They experienced relapsed ovarian GCT postoperatively. Subsequently, they received a repeated operation through a laparotomy approach. Numerous malignant metastasis neoplasms were detected at the port-sites. Then, tumor resection was performed.

OUTCOMES

The postoperative pathologies of both case 1 and case 2 reported ovarian GCT (IIIc stage) in adult type. The 2 patients presented disease-free survival for more than 33 months follow-up period.

LESSONS

The application of LPM may be a risk factor of disseminated ovarian GCT. However, laparoscopic surgery is still an optimal treatment strategy for ovarian tumors. Besides, gynecologists should comply with the tumor-free principle during surgery.

Short-term Outcomes of Single-port Versus Multiport Laparoscopic Surgery for Colon Cancer: The SIMPLE Multicenter Randomized Clinical Trial

OBJECTIVE

To compare short-term perioperative outcomes of single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for colon cancer.

SUMMARY BACKGROUND DATA

Although many studies reported short- and long-term outcomes of SPLS for colon cancer compared with MPLS, few have reported results of randomized controlled trials.

METHODS

This was a multicenter, prospective, randomized controlled trial with a noninferiority design. It was conducted between August 2011 and June 2017 at 7 sites in Korea. A total of 388 adults (aged 19-85 yrs) with clinical stage I, II, or III adenocarcinoma of the ascending or sigmoid colon were enrolled and randomized. The primary endpoint was 30-day postoperative complication rates. Secondary endpoints were the number of harvested lymph nodes, length of the resection margin, postoperative pain, and time to functional recovery (bowel movement and diet). Patients were followed for 30 days after surgery.

RESULTS

Among 388 patients, 359 (92.5%) completed the study (SPLS, n = 179; MPLS, n = 180). The 30-day postoperative complication rate was 10.6% in the SPLS group and 13.9% in the MPLS group (95% confidence interval, -10.05 to 3.05 percentage points; P < 0.0001). Total incision length was shorter in the SPLS group than in the MPLS group (4.6 cm vs 7.2 cm, P < 0.001), whereas the length of the specimen extraction site did not differ (4.4 cm vs 4.6 cm, P = 0.249). There were no significant differences between groups for all secondary endpoints and all other outcomes.

CONCLUSIONS

Even though there was no obvious benefit to SPLS over MPLS when performing colectomy for cancer, our data suggest that SPLS is noninferior to MPLS and can be considered an option in selected patients, when performed by experienced surgeons.Trial registration: ClinicalTrials.gov Identifier: NCT01480128.

The Relationship Between the Number of Ports and Surgical Outcomes in Laparoscopic Hepatectomy

INTRODUCTION

Reduced port surgery (RPS) has been garnering interest as a novel minimally invasive surgery lately.

AIM

The authors examined the relationship between the number of ports and surgical outcomes after laparoscopic hepatectomy (LH).

MATERIALS AND METHODS

Between January 2012 and April 2019, 209 patients who underwent laparoscopic partial resection and lateral sectionectomy were retrospectively analyzed with respect to operative variables and surgical outcomes. Patients were divided into 5 groups by the number of ports used. Student's t test, the χ test, the likelihood-ratio test, Fisher exact test, or Mann-Whitney U test were used to analyze the data.

RESULTS

Operative duration was significantly longer in patients with a larger number of ports than in those with a smaller number of ports. Chronological pain scores according to the visual analog scale (VAS) on postoperative days 1, 2, 4, and 7 were not associated with the number of ports and wound length in the umbilical region. The frequency of using additional analgesic agents was not significantly different between the groups. VAS scores and the number of additional analgesic agents used were smaller in patients in whom non-steroidal anti-inflammatory drugs were regularly administered postoperatively than in those in whom the drug was not regularly administered postoperatively. LH had a 3.4% complication rate (Clavien-Dindo classification >IIIA); however, this was not significantly different between the groups.

CONCLUSIONS

No significant difference in postoperative pain was observed between RPS and conventional methods, although operative durations were shorter with RPS. However, RPS for LH may be associated with excellent cosmetic results compared with conventional methods.

Alternative method for the diagnosis of acid cases of unknown cause: Transvaginal natural orifice transluminal endoscopic surgery

AIM

To evaluate the efficacy and reliability of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) technique in making the diagnosis of ascites with unknown cause.

METHODS

Seven patients with ascites with unknown cause and diagnosed with vNOTES between November 2018 and May 2019 were analyzed retrospectively. The following data were collected retrospectively: body mass index, age, parity, previous abdominal or pelvic surgery, total operating time, perioperative complications and visual analog scale scores for evaluation of postoperative pain. After general anesthesia and disinfection, a 2-3 cm incision was made in the posterior fornix of the vagina. In all of the vNOTES procedures, a handmade glove port system comprised of a glove-wound retractor NOTES port was used.

RESULTS

Transvaginal natural orifice transluminal endoscopic surgery for diagnostic peritoneoscopy was successfully performed in seven patients. Following postoperative pathological examination; three patients were established to have peritoneal carcinomatosis, one patient abdominal tuberculous, one patient ovarian fibroma, one patient ovarian mature cystic teratoma and one patient stomach cancer. In 1-year follow-up period after vNOTES procedure, no adverse events occurred in patients.

CONCLUSION

In making histological diagnosis of ascites with unknown cause, vNOTES is a feasible, safe and efficient technique. Due to its high performance in diagnosis, this technique helps to initiate treatment early in some diseases in addition to preventing unnecessary treatment and examination in benign diseases. Besides, via obtaining a detailed and enlarged image of abdominal cavity, this procedure also guides the clinician in the evaluation of the suitability of patient for operation.

Next-generation robotics in gastrointestinal surgery

The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.

Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy

Objectives

The vaginal surgical approach has not become the standard of care, despite its advantages. The Hominis™ Surgical System is a humanoid shaped robot-assisted system that was designed specifically for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES). We aimed to present our experience with the first RvNOTES bilateral salpingo-oophorectomy (BSO) performed by the Hominis system.

Study design

A two-center prospective study of BSO by RvNOTES in women with nonmalignant indications conducted between August and December 2018. Women older than 18 years were offered to participate. Exclusion criteria included a history of abdominal malignancy, pelvic or abdominal irradiation, Crohn's disease, pelvic inflammatory disease, severe infections in the lower abdomen, active diverticulitis, deep infiltrating recto-vaginal endometriosis, and an active vaginal infection. The primary outcome of the study was the rate of conversion to open or laparoscopic approaches. Secondary outcomes included intra- and postoperative adverse events, operative time, estimated blood loss, length of hospital stay, and 6-week follow-up assessment.

Results

Eight women aged 50–70 years with BMI of 19–30 kg/m² were recruited. All the procedures were completed successfully without conversions to open surgery. No intraoperative complications were observed. Median blood loss was 10 mL (range: 10−50). The median duration of the procedure was 45 min (range: 38−91), and decreased over the study period. Surgeons’ usability assessment was very favorable, with a median of 5 on a 1–5 scale. The median visual analog scale (VAS) score was 1 (range: 1–3).

Conclusions

This is the first documentation of a surgery performed via the vagina using robotic instrumentation developed for this purpose. The disruptive technology of RvNOTES, with its fast learning curve, will make gynecological surgeries accessible to more women.

Transvaginal laparoscopic appendectomy using innovative submucosal tunnels: a conducive modification for improving hybrid NOTES access and its critical appraisal

Currently, transvaginal natural orifice transluminal endoscopic surgery (NOTES), the most minimally invasive option for laparoscopic surgery, suffers various technological restraints limiting its implementation. We discuss a simple modification for vaginal access to improve the existing hybrid NOTES technique. We retrospectively studied 18 women at our rural hospital in central India, who, under defined criteria, underwent transvaginal appendicectomy using innovative strategically designed submucosal tunnels. The procedure was successfully completed in all but the first three cases. None required additional abdominal trocar or analgesia beyond the first 6 h. The mean operative and hospitalisation times were 27.5 min and 18.5 h, respectively. We had no intraoperative complications and only one patient experienced postoperative self-limiting vaginal spotting. All patients were very pleased with the cosmetic results and sexual life as assessed by locally devised scales. On regular follow-up, all were progressing well. We recommend the method presented, as it is not only feasible and safe but has the potential to improve overall results. Clearly, a larger volume randomised trial would be optimal to confirm our conclusion.

Mechanical Follow-the-Leader motion of a hyper-redundant surgical instrument: Proof-of-concept prototype and first tests

One of the most prominent drivers in the development of surgical procedures is the will to reduce their invasiveness, attested by minimally invasive surgery being the gold standards in many surgical procedures and natural orifices transluminal endoscopic surgery gaining acceptance. A logical next step in this pursuit is the introduction of hyper-redundant instruments that can insert themselves along multi-curved paths referred to as Follow-the-Leader motion. In the current state of the art, two different types of Follow-the-Leader instruments can be distinguished. One type of instrument is robotized; the movements of the shaft are controlled from outside the patient by actuators, for example, electric motors, and a controller storing a virtual track of the desired path. The other type of instrument is more mechanical; the movements of the shaft are controlled from inside the patient by a physical track that guides the shaft along the desired path. While in the robotized approach all degrees of freedom of the shaft require an individual actuator, the mechanical approach makes the number of degrees of freedom independent from the number of actuators. A desirable feature as an increasing number of actuators will inevitably drive up costs and increase the footprint of an instrument. Building the physical track inside the body does, however, impede miniaturization of the shaft's diameter. This article introduces a new fully mechanical approach for Follow-the-Leader motion using a pre-determined physical track that is placed outside the body. This new approach was validated with a prototype called MemoFlex, which supports a Ø5 mm shaft (standard size in minimally invasive surgery) that contains 28-degrees-of-freedom and utilizes a simple steel rod as its physical track. Even though the performance of the MemoFlex leaves room for improvement, especially when following multiple curves, it does validate the proposed concept for Follow-the-Leader motion in three-dimensional space.

A Radial Clutch Needle for Facile and Safe Tissue Compartment Access

Efficient and safe access to targeted therapeutic sites is a universal challenge in minimally invasive medical intervention. Percutaneous and transluminal needle insertion is often performed blindly and requires significant user skill and experience to avoid complications associated with the damage of underlying tissues or organs. Here, we report on the advancement of a safer needle with a radial mechanical clutch, which is designed to prevent overshoot injuries through the automatic stopping of the needle once a target cavity is reached. The stylet-mounted clutch system is inexpensive to manufacture and compatible with standard hypodermic or endoscopic needles, and therefore can be adapted to achieve safe access in a myriad of minimally invasive procedures, including targeted drug delivery, at-home and in-hospital intravenous access, laparoscopic and endo- and trans-luminal interventions. Here, we demonstrate the clutch needle design optimization and illustrate its potential for rapid and safe minimally invasive cannulation.

A review on recent advances in soft surgical robots for endoscopic applications

BACKGROUND

Soft materials, with their compliant properties, enable conformity and safe interaction with human body. With the advance in actuation and sensing of soft materials, new paradigm in robotics called "soft robotics" emerges. Soft robotics has become a new approach in designing medical devices such as wearable robotic gloves and exoskeleton. However, application of soft robotics in surgical instrument inside human body is still in its infancy.

AIMS

In this paper, current application and design of soft robots specifically applied for endoscopy are reviewed.

MATERIALS & METHODS

Different aspects in the implementation of soft robotics in endoscope design were reviewed. The key studies about MIS and NOTES were reviewed to establish the clinical background and extract the limitations of current endoscopic device in the last decade.

RESULTS AND DISCUSSION

In this review study, the implementation of soft robotics concepts in endoscopic application, with highlights on different features of several soft endoscopes, were evaluated. The progress in different aspects of soft robotics endoscope, current state, and future perspectives were also discussed.

CONCLUSION

Based on the survey on the structural specification, actuation, sensing, and stiffening the future soft surgical endoscopes are recommended to fulfil the following specifications: safe especially from pressure leakage, fully biocompatible materials, MR-compatible, capable for large bending in at least two antagonistic directions, modularity, adjustable stiffness.

Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia: Outcomes From 200 Consecutive Cases With Midterm Follow Up

OBJECTIVE

This study describes the outcomes for 200 consecutive transanal minimally invasive surgery (TAMIS) local excision (LE) for rectal neoplasia.

BACKGROUND

TAMIS is an advanced transanal platform that can result in high quality LE of rectal neoplasia.

METHODS

Consecutive patients from July 1, 2009 to December 31, 2015 from a prospective institutional registry were analyzed. Indication for TAMIS LE was endoscopically unresectable benign lesions or histologically favorable early rectal cancers. The primary endpoints were resection quality, neoplasia recurrence, and oncologic outcomes. Kaplan-Meier survival analyses were used to describe disease-free survival (DFS) for patients with rectal adenocarcinoma that did not receive immediate salvage radical surgery.

RESULTS

There were 200 elective TAMIS LE procedures performed in 196 patients for 90 benign and 110 malignant lesions. Overall, a 7% margin positivity and 5% fragmentation rate was observed. The mean operative time for TAMIS was 69.5 minutes (SD 37.9). Postoperative morbidity was recorded in 11% of patients, with hemorrhage (9%), urinary retention (4%), and scrotal or subcutaneous emphysema (3%) being the most common. The mean follow up was 14.4 months (SD 17.4). Local recurrence occurred in 6%, and distant organ metastasis was noted in 2%. Mean time to local recurrence for malignancy was 16.9 months (SD 13.2). Cumulative DFS for patients with rectal adenocarcinoma was 96%, 93%, and 84% at 1-, 2-, and 3-years.

CONCLUSIONS

For carefully selected patients, TAMIS for local excision of rectal neoplasia is a valid option with low morbidity that maintains the advantages of organ preservation.

Transvaginal natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin

BACKGROUND AND AIMS

Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies, but few clinical studies have investigated transvaginal NOTES in the diagnosis of unexplained refractory ascites. We aimed to assess the feasibility, efficacy, and safety of transvaginal NOTES for the diagnosis of unexplained ascites in female patients.

METHODS

A prospective study was done involving 3 female patients with unexplained ascites. After general anesthesia and disinfection, a 1.0-cm incision was made in the posterior fornix of the vagina. A gastroscope was inserted into the abdominal cavity through the transvaginal incision and an artificial pneumoperitoneum was created; NOTES peritoneoscopy was performed to scrutinize the pathologic changes. Endoscopic biopsy specimens were obtained for pathologic examination. The transvaginal incision was closed by direct suturing.

RESULTS

Transvaginal NOTES for diagnostic peritoneoscopy was successfully performed in 3 patients. The mean operative time was 61 minutes. The estimated blood loss was 5 to 10 mL. The pathologic diagnoses were tuberculosis for all patients, and the symptoms and ascites disappeared after antituberculosis therapy. During the 4-year follow-up, no clinically significant adverse events occurred in any patient after NOTES. No patient experienced an annex inflammation, vaginitis, dyspareunia, or sexual dysfunction. All patients were comfortable and satisfied with the nonscarring surgical procedure.

CONCLUSIONS

Transvaginal NOTES for the diagnosis of unexplained ascites is feasible, effective, and safe. This method had no long-term effect on female sexual function and is particularly suitable for women who have special aesthetic requirements. (Clinical trial registration number: ChiCTR-TRC-10001053.).

Transluminal Cancer Surgery

Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.

What the radiologist needs to know about gastrointestinal endoscopic surgical procedures

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical approach, currently performed for an array of conditions. Endoscopic procedures offer significant benefits, including lower cost, no surgical incisions, and shorter hospital stays. These advantages align with the current trends in health care, namely a push for "cost-effective care." There are a multitude of health issues which are now being addressed by the endoscopic surgical approach, including peroral endoscopic myotomy (POEM), which is a relatively new technique used in the treatment of achalasia. Endoscopic treatment utilized for GERD includes transoral incisionless fundoplication. Endoscopic bariatric surgical procedures include intragastric balloon placement, endoscopic sleeve gastroplasty, and revision of prior bariatric procedures including Roux-en-Y gastric bypass and conventional gastric sleeve procedures. Endoscopic clips are routinely utilized for achieving hemostasis, treating iatrogenic gastric and bowel ulcerations and perforations and for the closure of enteric fistulization. Novel endoscopic procedures are now replacing conventional surgery due to their non-invasive nature, faster recovery and lower healthcare costs. Radiologists need to understand how these procedures are performed, as well as expected post-procedural imaging appearance and potential complications.

Direct target NOTES: prospective applications for next generation robotic platforms

BACKGROUND

A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative.

METHODS

During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy.

RESULTS

Feasibility was demonstrated in all cases using the Flex^® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min.

CONCLUSIONS

A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Gynecology

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging field in minimally invasive surgery. NOTES can be performed via a variety of approaches, including through the stomach, esophagus, bladder, and rectum, but the majority of cases have been performed transvaginally. Potential advantages of natural orifice surgery in gynecology include the lack of abdominal incisions, less operative pain, shorter hospital stay, improved visibility, and the possibility to circumvent extensive lysis of adhesion to reach the pelvic cavity. This chapter provides a historical overview and the potential application of NOTES.

Single port access for laparoscopic lateral segmentectomy

Introduction

Single-port access laparoscopic lateral segmentectomy (LLS) has been developed as a novel minimally invasive surgery. We have experience with this LLS technique.

Aim

To report our technique and patients' postoperative course in a series of single-port access LLS performed in our department. We also examine the cosmetic outcome, safety, and utility of the procedure.

Material and methods

Between February 2010 and October 2016, 54 patients who underwent single- or multiple-port laparoscopic or open lateral segmentectomy (LS) were retrospectively analyzed with respect to cosmetic outcome, safety, and utility.

Results

In the single LLS group, the laparoscopic procedure was successfully completed for all 14 patients. The median operative time was significantly shorter in the single LLS group (123 min; range: 50-270 min) than in the other groups. Estimated blood loss was also significantly lower in the single LLS group (10 ml; range: 0-330 ml). During the first 7 postoperative days, the visual analog scale pain score and the use of additional analgesia were not significantly different between groups. The single LLS group had a 7.1% complication rate (Clavien-Dindo classification > IIIA); this was not significantly different between groups.

Conclusions

Single-port access LLS is a procedure with excellent cosmetic results, although, with regard to invasiveness, there are no major differences from conventional LLS.

Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery

Background

Hybrid natural-orifice transluminal endoscopic surgery (NOTES), combining access through a natural orifice with small-sized abdominal trocars, aims to reduce pain and enhance recovery. The objective of this systematic review and meta-analysis was to compare pain and morbidity in hybrid NOTES and standard laparoscopy.

Methods

A systematic literature search was performed to identify RCTs and non- RCTs comparing hybrid NOTES and standard laparoscopy. The main outcome was pain on postoperative day (POD) 1. Secondary outcomes were pain during the further postsurgical course, rescue analgesia, complications, and satisfaction with the cosmetic result. The results of meta-analysis in a random-effects model were presented as odds ratio (ORs) or standard mean differences (MDs) with 95 per cent confidence intervals.

Results

Six RCTs and 21 non-randomized trials including 2186 patients were identified. In hybrid NOTES the score on the numerical pain scale was lower on POD 1 (−0·75, 95 per cent c.i. −1·09 to −0·42; P = 0·001) and on POD 2–4 (−0·58, −0·91 to −0·26; P &lt; 0·001) than that for standard laparoscopy. The need for rescue analgesia was reduced in hybrid NOTES (OR 0·36, 0·24 to 0·54; P &lt; 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P &lt; 0·001) was not significant when only RCTs were considered (OR 0·83, 0·43 to 1·60; P = 0·570). The score for cosmetic satisfaction was higher after NOTES (MD 1·14, 0·57 to 1·71; P &lt; 0·001).

Conclusion

Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.

Transumbilical laparoscopic-assisted appendectomy is a useful surgical option for pediatric uncomplicated appendicitis: a comparison with conventional 3-port laparoscopic appendectomy

Purpose

Transumbilical laparoscopic-assisted appendectomy (TULA) is a single incision technique that uses a combined intra- and extracorporeal method. The aim of this study was to compare surgical outcomes of TULA with conventional 3-port laparoscopic appendectomy (LA).

Methods

A retrospective review of medical records between 2010 and 2014 identified 303 pediatric patients who underwent LA with uncomplicated acute appendicitis. Of these, 85 patients underwent TULA and 218 patients underwent conventional LA. Demographic data, clinical characteristics, perioperative outcomes and postoperative complications were compared between the 2 groups.

Results

The mean operation time in the TULA group was 30.39 minutes, which was significantly shorter than that of the LA group (47.83 minutes) (P < 0.001). The first day of oral intake after surgery was earlier (1.05 days vs. 1.32 days; P < 0.001) and the length of hospital stay was also shorter (2.54 days vs. 3.22 days; P < 0.001) for the TULA group than the LA group. Furthermore, the postoperative complication rate was lower in the TULA group (1 of 85, 1.25%) compared to the LA group (19 of 218, 8.7%) (P = 0.018).

Conclusion

In conclusion, TULA procedure is recommended for uncomplicated appendicitis in children due to its simplicity and better postoperative outcomes.

[Individualized or standard approach to the abdomen : Currently available data]

BACKGROUND

Every abdominal incision can lead to early (e. g. abdominal infection) and late complications (e. g. hernia). The correct incision is often important to have optimal access to the surgical area and to keep complications low.

OBJECTIVE

An analysis of the recent literature was carried out to clarify which access routes have advantages over other types of incision.

MATERIAL AND METHODS

A literature search was carried out in the following databases: Cochrane database of systematic reviews (CDSR), Cochrane library, Medline and PubMed. Systematic reviews and studies with large numbers of cases were used for the evaluation, whereas studies with small numbers of cases and case reports were not taken into account.

RESULTS

Midline incisions are the first choice for acute and elective abdominal surgery because of a good view into and rapid access to the abdominal cavity. For large upper abdominal operations transverse incisions can be considered of equal value due to excellent exploration possibilities, e.g. of the liver and pancreas. 25 years after the introduction of laparoscopy, this technique has become established for cholecystectomy, fundoplication and bariatric surgery. For appendix and colon surgery laparoscopy has the advantage of being less traumatic, whereby postoperative pain and hospitalization are reduced but under circumstances longer operating times must be expected. The single incision laparoscopic surgery (SILS) technique is beneficial in cosmetic outcome; however, incisional hernias, prolonged operating times and higher complication rates are limiting factors for this technique. Natural orifice transluminal endoscopic surgery (NOTES) and atypical incisions are rarely used.

Stereotactic navigation for TAMIS-TME

Stereotactic navigation allows for real-time, image-guided surgery, thus providing an augmented working environment for the operator. This technique can be applied to complex minimally invasive surgery for fixed anatomic targets. Transanal minimally invasive surgery represents a new approach to rectal cancer surgery that is technically demanding and introduces the potential for procedure-specific morbidity. Feasibility of stereotactic navigation for TAMIS-TME has been demonstrated, and this could theoretically translate into improved resection quality by improving the surgeon's spatial awareness. The future of minimally invasive surgery as it relates to augmented reality and image-guided surgery is discussed.

Comparison between the perioperative results of single-access and conventional laparoscopic surgery in rectal cancer

INTRODUCTION

Laparoscopic surgery for rectal cancer has low rates of morbidity and mortality and achieves comparable pathologic outcomes. With improved instruments and surgical techniques, many surgeons have recently begun using single-access laparoscopic surgery (SALS) to minimize scars and pain. Since 2011, most reports of SALS for rectal cancer have shown comparable pathologic outcomes to those of conventional laparoscopic surgery (CLS). However, SALS is said to be superior to CLS in reducing complications, producing less discomfort, and faster recovery rates. This study aimed to compare the technical feasibility and early postoperative outcomes of these approaches.

METHODS

From January 2011 to January 2014, 78 cases of adenocarcinoma of the rectum and anal canal were enrolled in the study. Anterior, low anterior, intersphincteric, and abdominoperineal resections were performed. Data collected included technical feasibility and outcomes of operation, such as morbidity, mortality, severity of pain, analgesic usage, and length of hospital stay.

RESULTS

SALS was performed on 35 patients, and CLS was performed in 36 cases. Demographic data, including age, sex, BMI, ASA classification and clinical staging, were similar between the groups. Operative time, blood loss, and conversion rate were similar (P > 0.05). Postoperatively, the only significant difference between the groups was pain score, which was significantly lower in the SALS group (P < 0.001).

CONCLUSION

SALS and CLS for rectal and anal cancer had the same intraoperative, pathologic, and early postoperative results. However, SALS patients had slightly better pain scores in the first 24 and 48 h postoperatively.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Transumbilical thoracic sympathectomy: a single-centre experience of 148 cases with up to 4 years of follow-up†

OBJECTIVES

Thoracic sympathectomy is considered as the most effective method to treat palmar hyperhidrosis (PH). Here, we report our experience of transumbilical thoracic sympathectomy with an ultrathin flexible endoscope for PH in a series of 148 patients with up to 4 years of follow-up.

METHODS

A prospective database was used in this retrospective analysis of 148 patients (61 males, 87 females, with a mean age of 21.3 years) with PH who were operated on by the same surgeon in a single institution from April 2010 to March 2014. All procedures were performed under general anaesthesia involving intubation with a double-lumen endotracheal tube. Demographic, postoperative and long-term data of patients were recorded and statistical analyses were performed. All patients were followed up at least 6 months post procedure through clinic visits or telephone/e-mail interviews.

RESULTS

The procedure was performed successfully in 148 of the 150 patients. Two patients had to be converted to conventional thoracoscopic procedure because of severe pleural adhesions. The mean operating time was 43 min (ranging from 39 to 107 min) and the mean postoperative length of stay was 1 day (range 1-4 days). All patients were interviewed 6-48 months after surgery and no diaphragmatic hernia or syndrome was observed. The rate of resolution of PH and axillary hyperhidrosis was 98 and 74.6%, respectively. Compensatory sweating was reported in 22.3% of patients. Almost all of the patients were satisfied with the surgical results and the cosmetic outcome of the incision.

CONCLUSIONS

This preliminary human experience suggested that transumbilical thoracic sympathectomy was a safe and efficacious alternative to the conventional approach. This technique avoided the chronic pain and chest wall paraesthesia that are associated with the chest incision. In addition, this novel procedure afforded maximum cosmetic benefits.

Recent advances in natural orifice transluminal endoscopic surgery†

Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.