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Abstract
PURPOSE OF REVIEW The recent developments and clinical applications of natural orifice translumenal endoscopic surgery (NOTES)-procedures and technologies are going to be presented. RECENT FINDINGS In experimental as well as clinical settings, NOTES-procedures are predominantly performed in hybrid technique. Current experimental studies focus on the implementation of new surgical approaches as well as on the training of procedures. One emphasis in the clinical application is transrectal and transanal interventions. Transanal total mesorectal excision is equivalent to laparoscopic procedures but with the benefit of an even less invasive access. Transvaginal cholecystectomy can achieve results that are comparable to surgeries that are performed with laparoscopic techniques alone. An analysis of the German NOTES-Register concerning appendectomies as well as the national performance of NOTES-interventions in Switzerland is presented. Apart from intraabdominal approaches, several centers proclaim transoral thyroidectomies and transoral mediastinoscopies. SUMMARY NOTES-procedures are performed in animal experiments as well as in clinical setting although with less frequency. At this time, hybrid techniques using rigid instruments are mainly applied.
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Abstract
Gastrointestinal surgery, with its emphasis on endoscopy, has renewed interest in teaching surgical endoscopy. The field is rapidly evolving, with innovative techniques emanating from the laboratory to the operating room and endoscopy suite. To ensure that surgeons spearhead the field of endoscopic surgery, a new strategy for teaching surgical endoscopy to residents and practicing surgeons must be developed.
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Affiliation(s)
- Jonathan P Pearl
- Department of Surgery, Case Western Reserve University School of Medicine, USA
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Vahdad MR, Rahmanian E, Moslemi S, Najafi SM, Foroutan HR. Totally Transanal Laparo-Endoscopic Single-Site ProctoColectomy-Ileoanal J-Pouch (TLPC-J): An Experimental Study of a Novel Approach. IRANIAN JOURNAL OF MEDICAL SCIENCES 2015; 40:425-9. [PMID: 26379349 PMCID: PMC4567602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 03/26/2014] [Accepted: 04/28/2014] [Indexed: 10/31/2022]
Abstract
BACKGROUND The natural orifice transluminal endoscopic surgery (NOTES) has become a commonly considered novel approach in the surgical field. The NOTES provide possibility of operation through the natural orifice and decreases the intentional puncture of the systemic organ and subsequent complications. Totally transanal laparo-endoscopic single-site proctoColectomy-Ileoanal J-Pouch (TLPC-J) is a novel method in minimally invasive surgery for total colectomy. The main goal of this study is to perform this new method on an animal model, to assess probable complication and to resolve probable issues by using patients that are candidate for total colectomy. METHOD Five dogs were prepared in lithotomy position. The TLPC-I procedure consists of endorectal technique with full thickness rectal dissection starting 1 cm orally from the dentate line above the peritoneal reflection and the proximal bowel was replaced into the abdominal cavity. Afterwards, the TriPort system was inserted in the anal canal and mesentrial resection of the total colon, mobilization of a distal ileal segment and intracorporeal suture of an ileal J-loop was accomplished by this system. An incision in the J-loop was conducted transanally. The J-pouch was created with an Endo-GIA® and sutured to the rectal wall. RESULTS All animals survived and passed stool with clear post operation situation. There was no infection in site of anastomosis. CONCLUSION The TLPC-I provides the possibility of surgery without abdominal wall incision and decreases post operation complication such as pain, abdominal wound infection and wound dehiscence. This technique increases the quality of life and surgeons can discharge the patients early.
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Affiliation(s)
- Mohammad Reza Vahdad
- Department of Pediatric Surgery, Catholic Foundation Marienhospital Herne, Ruhr-University of Bochum, Herne, Germany
| | - Ehsan Rahmanian
- Department of General Surgery, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sam Moslemi
- Colorectal Research Center, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sultan Mohsen Najafi
- Department of Pediatric Surgery, Namazi Hospital, Shiraz University Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Foroutan
- Department of Pediatric Surgery, Namazi Hospital, Shiraz University Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence: Hamid Reza Foroutan, MD; Department of Pediatric Surgery, Shiraz University Laparoscopy Research Center, Namazi Hospital, P.O. Box 7141995377, Shiraz, Iran Tel: +98 71 36279622 Fax: +98 71 32279721
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Clinical NOTES appendectomy study: comparison of transvaginal NOTES appendectomy in hybrid technique with laparoscopic appendectomy. Int J Colorectal Dis 2015; 30:259-67. [PMID: 25533898 DOI: 10.1007/s00384-014-2081-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The proposed advantages of NOTES are aimed to assess the comparison with standard procedures. Complications are a major focus of its evaluation. We initiated a prospective comparison between transvaginal hybrid appendectomy versus laparoscopic appendectomy. PATIENTS AND METHODS For each, NOTES and laparoscopic appendectomy, 10 consecutive female patients participated in the study with follow-up documentation for 35 days and after 1 year. Transvaginal appendectomy was considered a non-standard medical procedure and required individual patient's consent. Pre- and postoperative gynecological examinations were performed. Questionnaire-based evaluation included issues related to quality of life in addition to objective clinical findings. The study is approved by the ethics committee of the University of Rostock. RESULTS All women returned questionnaires for evaluation. Age and BMI are comparable. Overall procedure time was significantly shorter in laparoscopy. The only postoperative complication consisted of an intra-abdominal abscess after laparoscopic appendectomy. One patient of the NOTES group suffered from new abdominal pain 3 weeks postoperatively; a mini-laparoscopy showed a normal situation. Significant differences (p < 0.05) of the questionnaire-based comparison with advantages for the NOTES group were found in following items: reduced activity at day 1-14, postoperative pain at day 1, general health conditions at day 1-3 and quality of life at day 3. NOTES patients wished significantly earlier to be discharged and started significantly earlier with activities, but no differences existed after 4 weeks. CONCLUSIONS Transvaginal flexible appendectomy appears to be a safe procedure performed in hybrid technique. Data from the study point to shortened recovery intervals and improved quality of life.
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Koehestanie P, Betzel B, Dogan K, Berends F, Janssen I, Aarts E, Groenen M, Wahab P. The feasibility of delivering a duodenal–jejunal bypass liner (endobarrier) endoscopically with patients under conscious sedation. Surg Endosc 2013; 28:325-30. [DOI: 10.1007/s00464-013-3143-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
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Robotic control of a traditional flexible endoscope for therapy. J Robot Surg 2013; 7:227-34. [PMID: 27000918 DOI: 10.1007/s11701-013-0405-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 04/11/2013] [Indexed: 12/19/2022]
Abstract
In therapeutic flexible endoscopy a team of physician and assistant(s) is required to control all independent translations and rotations of the flexible endoscope and its instruments. As a consequence the physician lacks valuable force feedback information on tissue interaction, communication errors easily occur, and procedures are not cost-effective. Current tools are not suitable for performing therapeutic procedures in an intuitive and user-friendly way by one person. A shift from more invasive surgical procedures that require external incisions to endoluminal procedures that use the natural body openings could be expected if enabling techniques were available. This paper describes the design and evaluation of a robotic system which interacts with traditional flexible endoscopes to perform therapeutic procedures that require advanced maneuverability. The physician uses one multi-degree-of-freedom input device to control camera steering as well as shaft manipulation of the motorized flexible endoscope, while the other hand is able to manipulate instruments. We identified critical use aspects that need to be addressed in the robotic setup. A proof-of-principle setup was built and evaluated to judge the usability of our system. Results show that robotic endoscope control increases efficiency and satisfaction. Participants valued its intuitiveness, its accuracy, the feeling of being in control, and its single-person setup. Future work will concentrate on the design of a system that is fully functional and takes safety, cleanability, and easy positioning close to the patient into account.
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Singhal S, Le DL, Duddempudi S, Anand S. The role of endoscopy in bariatrics: past, present, and future. J Laparoendosc Adv Surg Tech A 2013; 22:802-11. [PMID: 23039704 DOI: 10.1089/lap.2012.0091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The exponential increase in the rate of obesity and its associated co-morbidities has increased the demand for bariatric surgery. Over the past few decades, surgical weight reduction by gastric restriction, malabsorption, or a combination of both has been the preferred approach to achieve sustained weight loss in the morbidly obese. Although extremely effective, surgical procedures carry significant complications and risk with mortality rates of 1%. Because of the cost, surgical risk, and complications, there is a demand for less invasive procedures. Endoscopic approaches include placement of endoluminal space-occupying devices, stapling devices to reduce gastric volume, barrier devices to reduce small bowel absorptive area, and methods to regulate gastric emptying. Current and ongoing studies have delivered promising results across many aspects of endoscopic approaches. However, many technical obstacles still exist that have to be resolved with further research before endoscopic bariatrics can be widely deployed. At present the role of endoscopy is well established in preoperative evaluation as well as in recognition and management of many postoperative complications in bariatrics. In this article, we review the current and future endoscopic methods for weight reduction that are either in practice or in testing.
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Affiliation(s)
- Shashideep Singhal
- Division of Gastroenterology, Department of Internal Medicine, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA.
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Tolcher MC, Kalogera E, Hopkins MR, Weaver AL, Bingener J, Dowdy SC. Safety of culdotomy as a surgical approach: implications for natural orifice transluminal endoscopic surgery. JSLS 2013; 16:413-20. [PMID: 23318067 PMCID: PMC3535790 DOI: 10.4293/108680812x13462882735854] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES). METHODS A retrospective chart review of women undergoing culdotomy for tubal sterilization (N 219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications. RESULTS No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P = .068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI <30 (11.4% versus 1.5%, P = .011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries. CONCLUSION Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.
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Abstract
Rectal cancer is a distinct subset of colorectal cancer where specialized disease-specific management of the primary tumor is required. There have been significant developments in rectal cancer surgery at all stages of disease in particular the introduction of local excision strategies for preinvasive and early cancers, standardized total mesorectal excision for resectable cancers incorporating preoperative short- or long-course chemoradiation to the multimodality sequencing of treatment. Laparoscopic surgery is also increasingly being adopted as the standard rectal cancer surgery approach following expertise of colorectal surgeons in minimally invasive surgery gained from laparoscopic colon resections. In locally advanced and metastatic disease, combining chemoradiation with radical surgery may achieve total eradication of disease and disease control in the pelvis. Evidence for resection of metastases to the liver and lung have been extensively reported in the literature. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases is showing promise in achieving locoregional control of peritoneal dissemination. This paper summarizes the recent developments in approaches to rectal cancer surgery at all these time points of the disease natural history.
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Navarra G, Currò G. Trans-vaginally assisted single incision laparoscopic right hemicolectomy. ANZ J Surg 2010; 80:872-3. [DOI: 10.1111/j.1445-2197.2010.05548.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zorron R, Palanivelu C, Galvão Neto MP, Ramos A, Salinas G, Burghardt J, DeCarli L, Henrique Sousa L, Forgione A, Pugliese R, Branco AJ, Balashanmugan TS, Boza C, Corcione F, D'Avila Avila F, Arturo Gómez N, Galvão Ribeiro PA, Martins S, Filgueiras M, Gellert K, Wood Branco A, Kondo W, Inacio Sanseverino J, de Sousa JAG, Saavedra L, Ramírez E, Campos J, Sivakumar K, Rajan PS, Jategaonkar PA, Ranagrajan M, Parthasarathi R, Senthilnathan P, Prasad M, Cuccurullo D, Müller V. International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients. Surg Innov 2010; 17:142-58. [PMID: 20504792 DOI: 10.1177/1553350610370968] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases. METHODS Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented. RESULTS Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients. CONCLUSIONS Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.
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Affiliation(s)
- Ricardo Zorron
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro, Brazil.
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Zorron R, Goncalves L, Leal D, Kanaan E, Cabral I, Saraiva P. Transvaginal Hybrid Natural Orifice Transluminal Endoscopic Surgery Retroperitoneoscopy—The First Human Case Report. J Endourol 2010; 24:233-7. [DOI: 10.1089/end.2009.0230] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ricardo Zorron
- Department of Surgery, University Hospital Teresopolis HCTCO–FESO, Rio de Janeiro, Brazil
- Department of Surgery, Hospital Municipal Lourenco Jorge, Rio de Janeiro, Brazil
| | - Lessandro Goncalves
- Department of Urology, Hospital Municipal Lourenco Jorge, Rio de Janeiro, Brazil
| | - Daniel Leal
- Department of Surgery, Hospital Municipal Lourenco Jorge, Rio de Janeiro, Brazil
| | - Eduardo Kanaan
- Department of Surgery, Hospital Municipal Lourenco Jorge, Rio de Janeiro, Brazil
| | - Isaias Cabral
- Department of Surgery, Hospital Municipal Lourenco Jorge, Rio de Janeiro, Brazil
| | - Priscila Saraiva
- Department of Surgery, Hospital Municipal Lourenco Jorge, Rio de Janeiro, Brazil
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Bittner JG, Mellinger JD, Imam T, Schade RR, Macfadyen BV. Face and construct validity of a computer-based virtual reality simulator for ERCP. Gastrointest Endosc 2010; 71:357-64. [PMID: 19922914 DOI: 10.1016/j.gie.2009.08.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 08/28/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Currently, little evidence supports computer-based simulation for ERCP training. OBJECTIVE To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool. DESIGN Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II. SETTING Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia. MAIN OUTCOME MEASUREMENTS Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential. RESULTS Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training. LIMITATIONS Small sample size, single institution. CONCLUSIONS The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulator's ability to differentiate skill levels based on ERCP-specific metrics.
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Affiliation(s)
- James G Bittner
- Department of Surgery, Medical College of Georgia School of Medicine, Augusta, Georgia, USA.
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Decarli LA, Zorron R, Branco A, Lima FC, Tang M, Pioneer SR, Sanseverino JI, Menguer R, Bigolin AV, Gagner M. New hybrid approach for NOTES transvaginal cholecystectomy: preliminary clinical experience. Surg Innov 2009; 16:181-6. [PMID: 19546124 DOI: 10.1177/1553350609339375] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Natural orifice translumenal endoscopic surgery (NOTES) represents the first step toward scar-less surgery. The objective of this study is to evaluate early clinical results of transvaginal cholecystectomy using a new technique. METHODS Institutional review board approval was obtained and transvaginal NOTES cholecystectomy was performed in 12 women for cholelithiasis. A 2-channel videoendoscope was inserted in the abdominal cavity through a posterior colpotomy. Two 3-mm trocars were inserted deep in the umbilicus, and a 10-mm trocar was placed through the colpotomy parallel to the endoscope. Dissection was performed with endoscopic instruments combined with 3-mm laparoscopic instruments. RESULTS Mean operative time was 125.8 minutes. All procedures occurred without intraoperative complications or conversions, except for 1 vulvar laceration. There were no postoperative complications in the clinical follow-up. CONCLUSION Transvaginal NOTES is a feasible and safe alternative for cholecystectomy in this preliminary clinical experience, allowing good cosmetic benefits and low analgesic requirement.
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Affiliation(s)
- Luiz Alberto Decarli
- Department of Surgery, Hospital Irmandade Santa Casa da Misericordia Porto Alegre, Porto Alegre, Brazil.
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Abstract
BACKGROUND In performing "traditional" laparoscopic colectomy for left-sided colonic tumors, specimen retrieval necessitates a mini-laparotomy which often is the cause of postoperative pain, wound infection, and other pain-related complications. Here we describe a new technique of endo-laparoscopic anterior resection without mini-laparotomy, where specimen retrieval and colorectal anastomosis can be safely achieved with the use of the transanal endoscopic operation (TEO) device set-up. METHODS This hybrid natural orifice transluminal endoscopic surgery (NOTES) technique involves insertion of the TEO device in the lower rectum and luminal extraction of the specimen via the device. The technique is applicable to patients with small tumors (4 cm or less) in the left-sided colon or upper rectum, where transanal construction of a stapled colorectal anastomosis is intended. RESULTS The technique was attempted in ten patients (male:female 4:6) with median age of 66 years (range: 55-81 years). Five patients suffered from rectosigmoid tumors, whereas four patients had lesions in the sigmoid colon and one had a lesion in the descending colon. The median operating time was 127.5 min (range: 105-170 min) and the median blood loss was 20 ml (range: 20-50 ml). The median hospital stay was 7 days (range: 4-18 days), while the median maximum pain score (visual analog score) was 2 (range: 2-3) during in-hospital stay in this small series. CONCLUSIONS Our preliminary experience indicates this new technique of endo-laparoscopic colectomy is feasible for selected patients with left-sided colonic tumors. Complications related to mini-laparotomy can be abolished entirely with this hybrid approach.
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Ellsmere JC, Thompson CC, Brugge WR, Chuttani R, J Desilets D, Rattner DW, E Tarnoff M, Kaplan LM. Endoscopic interventions for weight loss surgery. Obesity (Silver Spring) 2009; 17:929-33. [PMID: 19396074 DOI: 10.1038/oby.2008.588] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this paper we review the state-of-the-art in endoscopic interventions for obesity treatment and make best practice recommendations for weight loss surgery (WLS). We performed a systematic search of English-language literature published between April 2004 and June 2008 in MEDLINE and the Cochrane Library on WLS and endoscopic interventions, endoscopically placed devices, minimally invasive surgery, image-guided surgery, endoluminal surgery, endoscopic instrumentation, interventional gastroenterology, transluminal surgery, and natural orifice transluminal surgery. We also searched the literature on endoscopic interventions and WLS and patient safety. We identified 36 pertinent articles, all of which were reviewed in detail; assessed the current science in endoscopic interventions for WLS; and made best practice recommendations based on the latest available evidence. Our findings indicate that endoscopic interventions and endoscopically placed devices may provide valuable approaches to the management of WLS complications and the primary management of obesity. Given the rapid changes in endoscopic technologies and techniques, systematic literature review is required to address issues related to the emerging role of endoluminal surgery in the treatment of obesity. These interventions should be a high priority for development and investigation.
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Affiliation(s)
- James C Ellsmere
- Section of Minimally Invasive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Kano N. The future of NOTES from the conservative point of view. ACTA ACUST UNITED AC 2009; 16:288-91. [PMID: 19350194 DOI: 10.1007/s00534-009-0086-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 02/27/2009] [Indexed: 11/25/2022]
Abstract
Recently, the unfamiliar term "natural orifice transluminal endoscopic surgery (NOTES)" appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper, I will review some references and try to establish my position toward NOTES. The author has been skeptical and ironical about the clinical potentiality of NOTES since hearing the presentation about NOTES for the first time. I have been concerned about making a puncture in the gastrointestinal tract as an old surgeon who believes that intestinal injury must not occur during surgery. However, recent advances in the research of NOTES are changing my stubborn belief. What I have to do is to avoid interrupting or disturbing young surgeons' challenges to develop NOTES. I remember that some senior surgeons were against us when we started laparoscopic surgery around 1990. Senior surgeons and physicians must be generous, considerate, helpful and supportive to our followers. I have been enthusiastic about the development and spread of laparoscopic surgery since 1987 and have been doing various surgical procedures myself, including those involving the biliary tract, pancreas, spleen, upper and lower gastrointestinal tract, adrenal, kidney and gynecologic organs. Recently, the unfamiliar term "NOTES" appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper I will review some references and try to establish my position toward NOTES.
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Affiliation(s)
- Nobuyasu Kano
- KAMEDA Medical Center, 929 Higashicho, Kamogawa, Chibaken, 2968602, Japan.
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Navarra G, Rando L, La Malfa G, Bartolotta G, Pracanica G. Hybrid transvaginal cholecystectomy: a novel approach. Am J Surg 2009; 197:e69-72. [PMID: 19249734 DOI: 10.1016/j.amjsurg.2008.07.059] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Revised: 07/28/2008] [Accepted: 07/28/2008] [Indexed: 12/15/2022]
Abstract
Natural Orifice Transluminal Endoscopic Surgery (NOTES) allows cholecystectomy to be performed by means of a flexible scope introduced through the stomach, rectus, bladder, or vagina. However, available endoscopes have several limitations if used in the peritoneal cavity. The hybrid technique reported overcomes these limitations by using conventional 5-mm laparoscopic instruments through the umbilical scar and transabdominal sutures for retraction. After creating the pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the umbilicus followed by a 5-mm, 30 degrees scope. A culdotomy then is performed under direct and laparoscopic views. The flexible endoscope is inserted into the pelvis through the vagina and advanced to expose the gallbladder. Three or more transabdominal sutures are placed through the gallbladder wall for retraction. Cholecystectomy then is performed using conventional 5-mm laparoscopic instruments through the 5-mm umbilical port. Finally, stay sutures are removed and the specimen is retrieved through the vagina. Six patients successfully have undergone this new procedure. In our opinion this hybrid approach increases safety, overcomes the limitation of the current instrumentation, and maintains most of the advantages of Natural Orifice Transluminal Endoscopic Surgery.
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Affiliation(s)
- Giuseppe Navarra
- Department of Surgical Sciences, Faculty of Medicine, University of Messina, G. Martino University Hospital, Messina, Italy.
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Affiliation(s)
- Denise W Gee
- Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA 02114, USA
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Bittner JG, Mellinger JD, Macfadyen BV. Reply to: Future Directions in Training Surgical Residents to Perform Endoscopic Examinations. Am Surg 2009. [DOI: 10.1177/000313480907500124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Zorrón R, Soldan M, Filgueiras M, Maggioni LC, Pombo L, Lacerda Oliveira A. NOTES: Transvaginal for Cancer Diagnostic Staging: Preliminary Clinical Application. Surg Innov 2008; 15:161-165. [DOI: 10.1177/1553350608320553] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Laparoscopy is now a reliable method for staging gastrointestinal cancer, orienting the therapy, and avoiding unnecessary laparotomy. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging concept with potential advantages for patient recovery. The first case of clinical diagnostic application of transvaginal NOTES for diagnostic cancer staging is presented. Informed consent and Institutional Commission approval were obtained for transvaginal clinical trials. On February 28, 2007, a patient with elective surgical indication for diagnostic cancer staging was submitted to transvaginal NOTES procedure, and intra- and postoperative parameters were documented. In a 50-year-old female patient presenting with ascitis, diffuse abdominal pain, and weight loss for 2 months, diagnosis of peritoneal carcinomatosis was suspected, which was also found when a CT scan was performed. Transvaginal NOTES was used for diagnostic staging of the patient, using a colonoscope introduced into the abdomen through a small incision in the vagina. Biopsies of liver, diaphragm, ovaries, and peritoneum were successfully performed. Operative time was 105 min, vaginal access and closure was obtained in 15 min. Abdominal inventory was reliable, and all 16 biopsies taken were positive for ovarian adenocarcinoma. The patient was dismissed 48 hours after the procedure without complications. Recent literature and experience of the study group suggest possibilities for preliminary clinical applications by transvaginal natural orifice surgery for diagnostic purposes.
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Affiliation(s)
- Ricardo Zorrón
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro,
| | - Monica Soldan
- Unit of Digestive Endoscopy, Department of Internal Medicine, University Federal Rio de Janeiro
| | - Marcos Filgueiras
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro
| | - Luis Carlos Maggioni
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro
| | - Luciana Pombo
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro
| | - Andre Lacerda Oliveira
- Department of Veterinary Surgery University Estadual Norte Fluminense-UENF, Campos de Goytacazes, Rio de Janeiro, Brazil
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McGee MF, Marks JM, Onders RP, Chak A, Rosen MJ, Williams CP, Jin J, Schomisch SJ, Ponsky JL. Infectious implications in the porcine model of natural orifice transluminal endoscopic surgery (NOTES) with PEG-tube closure: a quantitative bacteriologic study. Gastrointest Endosc 2008; 68:310-8. [PMID: 18407267 DOI: 10.1016/j.gie.2007.11.054] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 11/28/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Obtaining reliable closure of transvisceral defects currently limits natural orifice transluminal endoscopic surgery (NOTES). PEG tubes are potential means of managing NOTES gastrotomies. OBJECTIVE To determine the efficacy of PEG closure after NOTES. DESIGN An experimental animal study. SETTING A laboratory. INTERVENTIONS The pigs received gastric lavage with saline solution, chloramphenicol, or no lavage, and then underwent transgastric NOTES peritoneoscopy. Cultures were obtained by endoscopy during the surgery. A sterile foreign body was left in the peritoneal cavity. The gastrotomy was closed with a 20F PEG tube. The animals were observed for 14 days and underwent sterile laparotomy. Cultures of the foreign body and the peritoneal cavity were obtained. MAIN OUTCOME MEASUREMENTS Abscess rate, peritoneal quantitative cultures. RESULTS After 1 exclusion for anesthetic complications, 19 animals underwent NOTES; 18 (94.7%) survived the entire postoperative period. One animal died on postoperative day 2 after the PEG tube dislodged. At 14 days, 5 animals (27.8%) had intra-abdominal abscesses, 8 (44.4%) had positive peritoneal cultures, and 9 (50%) foreign bodies were contaminated on culture. Infectious complications were not altered by the type of gastric lavage or peritoneal bacterial inoculum introduced at the time of surgery. LIMITATION An animal model. CONCLUSIONS PEG closure of a NOTES gastrotomy is associated with subclinical intra-abdominal abscess formation and can result in death when the tube is dislodged during the early postoperative period. Preprocedural gastric lavage does not alter the intra-abdominal bacterial burden introduced at the time of surgery or subsequent infectious outcomes in the porcine model. These concerning findings necessitate additional studies to determine if porcine models are appropriate and applicable to human subjects in the NOTES setting.
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Affiliation(s)
- Michael F McGee
- Department of Surgery, Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
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Zhu JF, Hu H, Ma YZ, Xu MZ, Li F. Transumbilical endoscopic surgery: a preliminary clinical report. Surg Endosc 2008; 23:813-7. [PMID: 18649097 DOI: 10.1007/s00464-008-0086-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2008] [Revised: 06/13/2008] [Accepted: 06/23/2008] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There has been great interest in natural orifice transluminal endoscopic surgery (NOTES) in recent years. We report another new approach--transumbilical endoscopic surgery (TUES)--which we have performed in 40 cases for liver cysts (3), bleeding ascites (1), chronic appendicitis (10), and gallbladder diseases (26). METHODS Transumbilical endoscopic liver cyst fenestration, abdominal cavity exploration, appendectomy, and cholecystectomy were performed in a total of 40 patients. RESULTS All the operations were completed successfully except one case of intraoperative bleeding in TUES cholecystectomy which was converted to routine laparoscopic surgery. The operating times for TUES cholecystectomy, appendectomy, and liver cyst fenestration were 30-150 min,15-40 min, and 30-90 min, respectively. No postoperative bleeding or bile leakage occurred in this group of patients. CONCLUSIONS Transumbilical endoscopic surgery is feasible, and would be another option for scarless abdominal surgery. TUES cholecystectomy is technically challenging. Careful selection of patients is important in the initial period of this technique.
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Affiliation(s)
- Jiang Fan Zhu
- Department of General Surgery, East Hospital of Tongji University, 150 Ji Mo Road, 200120 Pudong, Shanghai, China.
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Madan AK, Tichansky DS, Khan KA. Natural Orifice Transluminal Endoscopic Gastric Bypass Performed in a Cadaver. Obes Surg 2008; 18:1192-9. [DOI: 10.1007/s11695-008-9553-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 04/30/2008] [Indexed: 01/11/2023]
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Transvesical endoscopic peritoneoscopy: intra-abdominal scarless surgery for urologic applications. Curr Urol Rep 2008; 9:50-4. [PMID: 18366974 DOI: 10.1007/s11934-008-0010-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
For many abdominal procedures, advantages such as minimal scarring, reduced pain, and faster recovery have made laparoscopy the favored approach over traditional open surgery. The most recent minimally invasive approach is natural orifice transluminal endoscopic surgery (NOTES), which limits morbidity because this surgery does not require incision. This article reviews the history, development, and current and future applications of NOTES in the field of urology.
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Ferencz A, Bahri H, Szántó Z, Roth E, Wéber G. [New generation of abdominal surgery: the Natural Orifice Transluminal Endoscopic Surgery]. Orv Hetil 2008; 149:1029-33. [PMID: 18508737 DOI: 10.1556/oh.2008.28369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Minimal invasive surgical techniques, namely laparoscopic procedures to the abdominal surgery have been introduced more than 20 years ago. In view of clinical results, the majority of these are considered as routinely performed procedure today. Natural Orifice Transluminal Endoscopic Surgery can be considered as a new generation of abdominal surgery. It means a method directed through natural orifices, and abdominal surgery operated by transluminal endoscopic techniques (transgastric, transcolonic, transvaginal) to reach diagnostic and therapeutic goals. Theoretically, this method allows the possibility to decrease invasiveness and postoperative pain, to prevent postoperative hernias and to improve cosmetic results. At present numerous researchers work worldwide to receive scientifically based answers to arising questions (surgical technique, indication, contraindication, complications, monitoring) and concerns in this area. The present paper gives an overview of the national and international literature on experimental results and clinical approaches in the field of this new surgical technique.
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Affiliation(s)
- Andrea Ferencz
- Pécsi Tudományegyetem, Altalános Orvostudományi Kar, Sebészeti Oktató és Kutató Intézet, Pécs.
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Cronin JA, Frecker MI, Mathew A. Design of a Compliant Endoscopic Suturing Instrument. J Med Device 2008. [DOI: 10.1115/1.2931551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This paper describes the initial design and optimization of a compliant endoscopic suturing instrument. The emerging field of Natural Orifice Transluminal Endoscopic Surgery (NOTES) requires innovative instruments to meet the size limitations inherent in this type of minimally invasive surgery; using compliant mechanisms is proposed as one method of meeting this requirement. The compliant design was modeled and optimized to maximize the distal opening and provide a puncture force of at least 4.6N, while being small enough to fit within a 3.3mm working channel. The design utilizes contact for stress relief and intertwining parts for added deflection. ANSYS® was used for finite element analysis including contact and nonlinear deformations. A prototype was fabricated from the optimized geometry and experimentally tested. The best geometry is predicted to have a distal opening of 14.6mm at the tips and supply a puncturing force of 4.83N. The force supplied at the tip was measured and was found to exceed the required 4.6N. The prototype successfully passed two complete sutures and qualitative results are provided. The results of the study will lead to further refinements and improvements in future designs.
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Affiliation(s)
- James A. Cronin
- Department of Mechanical and Nuclear Engineering, Pennsylvania State University, 326 Leonhard Building, University Park, PA 16802
| | - Mary I. Frecker
- Department of Mechanical and Nuclear Engineering, Pennsylvania State University, 326 Leonhard Building, University Park, PA 16802
| | - Abraham Mathew
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Department of Gastroenterology, Hershey, PA 17033
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Jiang Fan Zhu, Ying Zhang Ma, Jin Ling Yu, Hai Hu. Transumbilical endoscopic cholecystectomy with the trichannel trocar technique: a porcine feasibility study. Surg Innov 2008; 15:95-9. [PMID: 18480087 DOI: 10.1177/1553350608318453] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study is to verify the feasibility of another option: transumbilical endoscopic cholecystectomy by using the trichannel trocar technique. Eight domestic pigs were submitted to transumbilical endoscopic cholecystectomy by using the trichannel trocar technique. A fine grasper of 2 mm in diameter was inserted through a small skin incision on the right upper abdomen for grasping the gallbladders. The natural scar of the umbilicus was restored after extract of the specimen. All the gallbladders were removed successfully without severe bleeding during dissection, intraoperative, and postoperative complications. Postmortem examination revealed that the gallbladder fossa was clean, the clips on the cystic duct and artery were secure, and neither bile nor blood leakage was found at the operative field. The feasibility and safety of transumbilical endoscopic cholecystectomy are demonstrated by this study. It is possible to use this approach in patients with gallbladder diseases.
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Affiliation(s)
- Jiang Fan Zhu
- Department of General Surgery, East Hospital of Tong Ji University, Shanghai, China.
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Bernhardt J, Gerber B, Schober HC, Kähler G, Ludwig K. NOTES--case report of a unidirectional flexible appendectomy. Int J Colorectal Dis 2008; 23:547-50. [PMID: 18256848 DOI: 10.1007/s00384-007-0427-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) refers to a new surgical procedure using flexible endoscopes in the abdominal cavity. With this procedure, access is gained by way of organs which are reached through a natural, already-existing external orifice. The hoped-for advantages associated with this method include the reduction of post-operative wound pain, shorter convalescence, avoidance of wound infection and abdominal-wall hernias as well as the absence of scars. We performed a trans-vaginal appendectomy on a human subject. MATERIALS AND METHODS In experimental operations on animals, we first evaluated the trans-vaginal access site. After them, we started first operation in human. The procedure was carried out under preventive administration of antibiotics. We used a therapeutic single-canal gastroscope. The appendix was located after exploration of the abdomen. After preparation of the mesenteriolum, ligature of the appendix base was performed by means of endoloop, followed by transsection with scissors. Recovery of the specimen was achieved by pulling it out with the instrument. RESULTS On the evening of the day on which surgery had taken place, administration of nourishment was begun. After the procedure, the patient reported slight soreness in the muscles of the abdominal wall; she felt otherwise perfectly well. INTERPRETATION In the space of a year, the first operations have been performed on human subjects by a few select work groups. NOTES procedures are still in the initial stages of clinical development. Until they can be introduced into surgical daily routine, further improvements are required as to equipment, technology and operative procedure.
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Affiliation(s)
- Joern Bernhardt
- Department of Interdisciplinary Endoscopy, Medical Center Suedstadt Rostock, Rostock, Germany.
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Zorrón R, Filgueiras M, Maggioni LC, Pombo L, Lopes Carvalho G, Lacerda Oliveira A. NOTES. Transvaginal cholecystectomy: report of the first case. Surg Innov 2008; 14:279-83. [PMID: 18178917 DOI: 10.1177/1553350607311090] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Natural Orifice Translumenal Endoscopic Surgery is a new development area with potential advantages for patients. However, technical and ethical challenges involved in perforation and closure of a healthy organ, as seen in transgastric access, and lack of comprehension of physiopathology of these approaches haven't allowed clinical application. The present study, based on previous animal experiments, describes the first clinical application of transvaginal Natural Orifice Translumenal Endoscopic Surgery. On March 13, 2007, a 43-year-old female patient with symptomatic cholelithiasis with surgical indication was submitted to elective Natural Orifice Translumenal Endoscopic Surgery transvaginal cholecystectomy using a colonoscope, endoscopic graspers, and vaginal platform instruments. Operative time was 66 minutes, and vaginal access and closure were obtained in 15 minutes. The patient had good postoperative evolution and was dismissed within 48 hours without complications. Recent literature and experience of the present study group suggest possibilities for preliminary clinical applications by transvaginal natural orifice surgery. The access may offer earlier benefits in the literature than the transgastric route because of lack of danger of fistula and peritonitis. Further studies regarding instrument development and physiology of natural orifice surgery are ongoing, possibly bringing solutions for more advanced procedures.
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Affiliation(s)
- Ricardo Zorrón
- University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro, Brazil.
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Abstract
In Natural Orifice Transluminal Endoscopic Surgery (NOTES) a flexible endoscope is passed through a natural orifice of the body and intra-abdominal procedures can be performed through a transvisceral (transgastric, -colonic, -vaginal or -vesical) incision. Principally, this state-of-the-art technology decreases invasiveness and postoperative pain, prevents postoperative hernia formation and improves cosmetic results. However, numerous questions regarding the technique are unanswered yet. Further research is necessary to extend the armamentarium of minimally invasive surgery. This article reviews the current state of experimental results and clinical approaches of NOTES.
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Affiliation(s)
- György Wéber
- Pécsi Tudományegyetem, Altalános Orvostudományi Kar, Sebészeti Oktató és Kutató Intézet, 7624 Pécs.
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Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc 2007; 22:542-7. [PMID: 18027043 DOI: 10.1007/s00464-007-9646-5] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 08/30/2007] [Accepted: 09/22/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES) is an emerging concept in the recent literature that could lead to potential benefits in clinical applications. Restricted to animal experiments, however, human procedures have not yet been published. Because of the technical and ethical challenges involved in perforation and closure of a healthy organ-as is also seen in operating via the transgastric route-and because of the lack of understanding of the physiopathology and infection risk with these approaches, they have not been applied in the clinical setting. Thus the present study, based on previous animal experiments, describes preliminary clinical application in four cases of transvaginal NOTES cholecystectomy, and discusses safety, feasibility, and potential benefits of the method. METHODS Preliminary acute and survival animal experiments developed by the NOTES Research Group at our institution solved such technical problems for transvaginal NOTES as spatial orientation, insufflation, and instrumentation, making possible the introduction of NOTES as a clinical application. The trials were approved by ethics committee of our institution, and informed consent was obtained from all patients. Since 13 March 2007, four female patients with elective surgical indication for cholecystectomy have undergone transvaginal NOTES cholecystectomy. All intraoperative and postoperative parameters were documented. Vaginal access was achieved under direct vision with conventional instruments, and a 2-channel colonoscope was inserted into the abdominal cavity. After endoscopic insufflation to achieve pneumoperitoneum with CO(2), instruments were inserted through and alongside a colonoscope, allowing successful NOTES cholecystectomy in all patients, with vaginal extraction of the gallbladder. The vaginal wound was closed by direct vision using conventional instruments. RESULTS The procedure was successful in all patients, with operative time of 45-115 min. Patients experienced low need for postoperative analgesia. Free oral intake was permitted 2 h after the procedure. There were no postoperative complications, and patients were discharged, according to the study protocol, 48 h after the procedure. CONCLUSIONS Preliminary results showed the feasibility and safety of the transvaginal NOTES method in this small initial study population. The technique, developed in our institution, and not transgastric NOTES, may be the preferred approach to serve as the basis for clinical studies.
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Affiliation(s)
- R Zorron
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Av. Américas 13554 BL.1 AP.207 Barra da Tijuca, Rio de Janeiro, Brazil.
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Bittner JG, Marks JM, Dunkin BJ, Richards WO, Onders RP, Mellinger JD. Resident training in flexible gastrointestinal endoscopy: a review of current issues and options. JOURNAL OF SURGICAL EDUCATION 2007; 64:399-409. [PMID: 18063277 DOI: 10.1016/j.jsurg.2007.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Revised: 07/17/2007] [Accepted: 07/19/2007] [Indexed: 05/25/2023]
Affiliation(s)
- James G Bittner
- Department of Surgery, Medical College of Georgia School of Medicine, Augusta, Georgia 30912, USA
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Current World Literature. Curr Opin Obstet Gynecol 2007; 19:496-501. [PMID: 17885468 DOI: 10.1097/gco.0b013e3282f0ffad] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Perretta S, Sereno S, Forgione A, Dallemagne B, Coumaros D, Boosfeld C, Moll C, Marescaux J. A new method to close the gastrotomy by using a cardiac septal occluder: long-term survival study in a porcine model. Gastrointest Endosc 2007; 66:809-13. [PMID: 17905027 DOI: 10.1016/j.gie.2007.05.055] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Accepted: 05/31/2007] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Closure of the gastrotomy when performing transgastric procedures is one of the most challenging steps to overcome. Several methods of gastric closure have been described, but a simple and safe technique is still lacking. AIM To evaluate the technical feasibility and safety of a new method of endoscopic gastric closure using a nitinol septal occluder in a porcine survival model. DESIGN Endoscopic animal experimental study in a porcine survival model. MATERIALS AND METHODS In 6 male pigs under general anesthesia, a 1-cm full-thickness gastrotomy was performed on the anterior body of the stomach and closed with a nitinol septal occluder (Occlutech). Postoperative follow-up included endoscopy and laparoscopy at 1, 2, 4, and 6 weeks after the initial procedure and endoscopy alone at weeks 8, 10, and 12. RESULTS All of the gastrotomy closures with the septal occluder were successful. At follow-up endoscopy and laparoscopy there were no signs of adhesions, peritonitis, or perigastric abscess formation at the gastrotomy site. At 12 weeks, 5 of 6 animals were thriving, with appropriate weight gain. CONCLUSIONS Endoscopic gastrotomy closure with a septal occluder is technically feasible, safe, and effective in a survival porcine model.
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Affiliation(s)
- Silvana Perretta
- Institut de Recherche contre les Cancers de l'Appareil Digestif-European Institute of Telesurgery, University of Strasbourg, Strasbourg, France
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McGee MF, Marks JM, Onders RP, Chak A, Jin J, Williams CP, Schomisch SJ, Ponsky JL. Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator. Surg Endosc 2007; 22:214-20. [PMID: 17786515 DOI: 10.1007/s00464-007-9565-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Accepted: 06/05/2007] [Indexed: 12/21/2022]
Abstract
BACKGROUND The NDO Plicator is a device developed for endoscopic treatment of gastroesophageal reflux disease (GERD) by approximation of tissues together with a double-pledgeted U-stitch. It was theorized that this device may facilitate transgastric natural orifice translumenal endoscopic surgery (NOTES) because closure of the transgastric defect remains a key component for advancement of this new technology. METHODS A standardized 12-mm gastrotomy was created endoscopically in four pigs using a combination of needle-knife cautery and balloon dilation. As the endoscope was removed, a Savary soft-tipped wire was introduced into the stomach, and the NDO Plicator was subsequently advanced over the wire. Each defect was identified, and the device was positioned. If necessary, the Plicator's tissue grasper was used to hold the superior aspect of the gastrotomy and bring the opposed borders of the defect within the jaws of the device. The device was fired three times, leaving three pledgeted suture bundles to close the gastric defect. After closure, each animal was explored, and the integrity of the closure was assessed. The animals underwent in vivo contrast fluoroscopy and ex vivo burst pressure testing studies for assessment of leakage at the closure site. RESULTS The first animal was used to test feasibility, refine techniques, and develop a standard procedure. All of the next three animals studied showed complete sealing of the gastrotomy site without evidence of contrast extravasation on multiplanar fluoroscopic imaging. Each stomach was excised, submerged in water, and subjected to a pressurized air leak test. No leaks were noted until pressures exceeded 55 mmHg. CONCLUSION This study supports the use of the NDO Plicator for closure of standardized gastric defects in a porcine model. In addition to closing NOTES gastrotomies, the NDO Plicator may be a particularly useful tool for obtaining complete closure of gastric perforations and anastomotic leaks, and for performing stomal reduction after gastric bypass procedures. The mechanical properties of a closure are not the only factor determining whether a leak will develop. Tissue opposition, ischemia, and tension are important factors that are not easily or reliably measured. The physiologic relevance of gastric bursting pressure is not known. Therefore, corollary animal studies with longer-term evaluation are necessary before research proceeds to clinical trials.
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Affiliation(s)
- M F McGee
- Department of Surgery, Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Scott DJ, Tang SJ, Fernandez R, Bergs R, Goova MT, Zeltser I, Kehdy FJ, Cadeddu JA. Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments. Surg Endosc 2007; 21:2308-16. [PMID: 17704871 DOI: 10.1007/s00464-007-9498-z] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 06/19/2007] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Natural orifice translumenal endoscopic surgery (NOTES) is an evolving field and suitable instruments are lacking. The purpose of this study was to perform transvaginal cholecystectomies using instruments incorporated into a magnetic anchoring and guidance system (MAGS). METHODS Non-survival procedures were conducted in pigs (n = 4). Through a vaginotomy created under direct vision, a rigid access port was inserted into the peritoneal cavity and used to maintain a CO(2) pneumoperitoneum. MAGS instruments were deployed through the port and held in place on the peritoneal surface using magnetic coupling via an external handheld magnet which was optionally exchanged for an 18 ga percutaneous threaded needle anchor; instruments included a tissue retractor (a clip-fixated magnet or flexible graspers) and a cautery dissector. A gastroscope was used for visualization. RESULTS The first two procedures ended prematurely due to instrumentation shortcomings and inadvertent magnetic coupling between instruments; one case required a laparoscopic rescue. Three new forms of instrumentation were developed: (1) a longer access port (50 cm) which provided easier deployment of instruments and suitable reach, (2) a more robust cauterizer with a longer, more rigid, pneumatically deployed tip with better reach and sufficient torque to allow blunt dissection, and (3) a more versatile tissue retractor with bidirectional dual flexible graspers which provided excellent cephalad fundus retraction and inferiolateral infundibulum retraction. With these modifications, 100% of the cholecystectomy was completed in the third and fourth animals using only a NOTES/MAGS approach. Retrieval of the tissue retractor resulted in a rectal injury in the third animal but further procedural modifications resulted in a successful procedure in the fourth animal with no complications. CONCLUSIONS While still under development with more refinements needed, completely transvaginal cholecystectomy using MAGS instruments is feasible. By offering triangulation and rigidity, MAGS may facilitate a NOTES approach while alleviating shortcomings of a flexible platform.
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Affiliation(s)
- Daniel J Scott
- Southwestern Center for Minimally Invasive Surgery, Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9156, USA.
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Abstract
Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about the field. Such is the case of natural orifice transluminal endoscopic surgery (NOTES). NOTES has yet to prove its value in patients. However, having challenged one of the most fundamental and deeply entrenched dogmas in surgery and endoscopy, many of us feel that "we will never be the same again." In this article I will discuss the implications of this paradigm shift and suggest strategies for both gastroenterologists and surgeons that will allow us to test its full potential.
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Affiliation(s)
- Pankaj Jay Pasricha
- Center for Endoscopic Research, Training and Innovation (CERTAIN), University of Texas Medical Branch, 4.106 McCullough Building, 301 University Boulevard, Galveston, TX 77555-0764, USA.
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Hagenmüller F, Immenroth M, Berg T, Bally K, Rasche S. [The present and future status of "scarless" surgery]. Chirurg 2007; 78:525-30. [PMID: 17520231 DOI: 10.1007/s00104-007-1344-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The concept of scarless surgery aims at further minimization of diagnostic and therapeutic interventions. Based on the success of flexible gastroenterological endoscopy and laparoscopic surgery, it combines their advantageous approaches in a synergistic manner. Animal experiments have achieved encouraging results in respect to the feasibility of various types of interventions in the peritoneal and retroperitoneal cavity. Further studies and improvement of instruments will have to prove the practicality and superiority of this concept for medical outcome and efficiency compared to present standards of practice in the potential fields of application. The replacement of certain minimally invasive procedures with scarless intervention techniques seems reasonable, as do new fields of application. After further improvement of the methodology, adequate organization, infrastructure, and teaching structures will have to be developed. If they succeed, the concept of scarless surgery can expect a promising future.
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