Experimental trial of transvaginal cholecystectomy: an ex vivo analysis of the learning process for a novel single-port technique

Comparative analysis of vaginal natural orifice transluminal endoscopic surgery versus transumbilical laparoendoscopic single-site surgery in ovarian cystectomy

AIM

To objectively assess the safety, feasibility, advantages and disadvantages and health economics benefits of vaginal natural orifice transluminal endoscopic surgery (vNOTES) versus transumbilical laparoendoscopic single-site surgery (TU-LESS) in ovarian cystectomy.

METHODS

We retrospectively analyzed the data of all patients in our hospital who had undergone vNOTES and TU-LESS ovarian cystectomy due to 'unilateral ovarian cyst' from March 2019 to May 2020. Patients were classified into vNOTES group (86) and TU-LESS group (210) based on surgical paths. The patients' general characteristics and perioperative outcomes were compared.

RESULTS

All 296 patients completed surgery with no need to switch to conventional laparoscopy or laparotomy procedures. There were no complications of Grade III, IV, V in Clavien-Dindo classification. There were two patients in the vNOTES group and four patients in the TU-LESS group with complications of Grade I, all of whom were treated with antipyretic drugs for postoperative fever. One patient in the TU-LESS group presented the complication of Grade II and was treated with blood transfusion due to postoperative anemia. The two groups had similar general characteristics. Perioperative outcomes: The visual analogue scale (VAS) scores 24 h postoperation were significantly lower in the vNOTES group than in the TU-LESS group. The cosmetic scores were significantly higher in the vNOTES group than in the TU-LESS group. Postoperative stay and time of flatus after surgery were significantly shorter in the vNOTES group than in the TU-LESS group. There was not significant statistical differences between the two groups in operation time, estimated blood loss, Hb decrease at 48 h postoperation, maximum body temperature in 48 h after surgery and hospital costs.

CONCLUSION

It was proved to be safe and feasible in ovarian cystectomy by vNOTES. It worked better than TU-LESS in relieving postoperative pain, shortening postoperative stay and improving cosmetic effects and so on. As an emerging surgical path, large sample multicenter randomized controlled trials are required to further verify its safety and advantages.

Is the transvaginal route appropriate for intra-abdominal NOTES procedures? Experience and follow-up of 222 cases

BACKGROUND

Since 2007, natural orifice transluminal endoscopic surgery (NOTES) has been applied in humans. We performed this prospective study to evaluate the transvaginal route in terms of risks, complication rate, and long-term side effects such as dyspareunia.

METHODS

From June 2007 to September 2011, we performed 222 transvaginal hybrid NOTES procedures: 220 transvaginal cholecystectomies (TVC) and 2 transvaginal appendectomies (TVA). All patients were asked to present to our associated gynecologists within 1 week for an examination. After at least 3 months, the patients were interviewed using a standard questionnaire.

RESULTS

All operations could be successfully performed in this technique except two cases, which were converted to conventional laparoscopic cholecystectomy. The only intraoperative complication was the puncture of the urine bladder. We observed two postoperative complications: one biliary fistula 3 days after TVC, and one abscess in the Douglas pouch 3 weeks after TVC. The gynecological examinations revealed no abnormalities. The interview (median postoperative time, 6 months) with a follow-up rate of 93 % revealed no pain in the pelvis, dyspareunia, or sexual dysfunction after TVC.

CONCLUSIONS

The transvaginal route is appropriate for NOTES procedures; there is only a minor and acceptable rate of intra- and postoperative morbidity.

Education and training in NOTES: a systematic review

INTRODUCTION

Since the first published work on natural orifice translumenal endoscopic surgery (NOTES) a decade ago, progress has been made in the domain of education and training, although questions posed by the original White Paper remain. This article aims to review the current status of education and training in NOTES.

METHODS

A review of the literature was conducted to evaluate the following: (1) What are the current training methods/modalities used for NOTES; what is the level of evidence to support their use? (2) How has NOTES clinical training been quantified; what is the evidence relating to performance of different NOTES operators? (3) What clinical NOTES training programs have been established and what are the wider training needs?

RESULTS

A total of 25 studies were included: 11 nonanimal studies, 8 animal studies, and 6 descriptions of education programs. Several animal and simulator models demonstrated construct validity, but no study showed human predictive validity. Logarithmic learning curves in animal models demonstrate 10 to 15 cases achieving a proficiency level. Current trends are that gastroenterologists prefer it for diagnostic and basic procedures, whereas surgeons prefer it for complex therapeutic cases.

CONCLUSION

The development of a new specialty is intriguing but currently unviable. Training programs have been initiated, but information is limited; the common theme is surgeons receiving endoscopic training. Despite the research done, our knowledge of training and educating in NOTES procedures is limited, preventing a meta-analysis or formal review from being performed. Further research is needed to integrate NOTES into routine clinical procedure.

Anatomical measurements to optimize instrumentation for transvaginal surgery

BACKGROUND

Use of rigid instruments via transvaginal (TV) route has been proposed as a practical alternative to natural orifice translumenal endoscopic surgery (NOTES) using flexible devices. However, its safety has not been fully evaluated for each abdominal organ with different positional relationship to the vagina. The aim of this study is to obtain baseline anatomical data necessary for safer use of rigid TV instruments, by three-dimensional (3-D) radiologic measurements.

PATIENTS AND METHODS

A retrospective study was conducted on 51 consecutive female Japanese patients with aortic aneurysm who underwent whole-body multidetector computed tomography as preoperative evaluation. The gallbladder (GB), esophagogastric junction (EGJ), and spleen were located on 3-D images, and the following were obtained: (1) the distance from the vagina, (2) the transverse deviation from the midline, and (3) the sagittal deviation from the "vagina-promontory (V-P)" line.

RESULTS

The median distance from the vagina was 26.1 cm for GB, 30.6 cm for EGJ, and 31.1 cm for spleen. The transverse deviation from the midline was 17.7° for GB, 7.0° for EGJ, and 12.9° for spleen. The sagittal deviation from the V-P line was 7.6 degrees for GB, -7.0° for EGJ, and -10.3° for spleen. The percentage of "negative angle" cases, which means that the target is located "below" the V-P line, was only 9.8 % for GB versus 88 % for EGJ and spleen.

CONCLUSIONS

The intra-abdominal length of TV instruments should be more than 35 cm in Japanese population. GB is widely deviated from the midline and therefore can be safely approached even with rigid/straight instruments. Access to more midline and distant targets may suffer from interference by the sacral promontory, and be potentially dangerous in terms of risk of compression injury by rigid and straight instruments.

Transanal endoscopic microsurgery-based transanal access for colorectal surgery: experience on human cadavers

Transanal endoscopic microsurgery (TEM) was described in 1983 for local excision of rectal tumors. In the context of natural orifice translumenal endoscopic surgery, we have modified the original TEM system and developed a new set of instruments. These are more curved and, in addition, steerable. After extensive studies in an ex-vivo model, we developed a novel technique for transanal rectosigmoid resection and colorectal anastomosis. The technique comprises closure of the rectal lumen by purse-string suture, transection of the rectal wall distal to the closure, circumferential mobilization of rectum and mesorectal tissue in the anatomical plane from below upward, control of the inferior mesenteric vessel, removal of mobilized colorectum through the anus, and, finally, the colorectal anastomosis by either stapled or hand-sutured technique. This procedure was performed on three alcohol-glycerol preserved well-built human cadavers (M:F=2:1). The average operating time was 190 minutes. The average length of the resected specimen was 23 cm. There was no fecal contamination or injury to the resected specimen. Postprocedure laparotomy revealed adequate mesorectal resection and no inadvertent injury to other viscera. During dissection in the pelvis, as the resected rectum was pushed upward, an unobstructed "empty pelvis" situation was developed in the operating site, thus facilitating the mesorectal resection. Transanal access for colorectal surgery seems feasible. It provides a precise definition of the distal safety margin, good view of the pelvis for meticulous mesorectal resection, and reduces the abdominal wall trauma. These may enhance the outcome of colorectal resection. However, further clinical studies can only substantiate these findings.

A novel single-port technique for transanal rectosigmoid resection and colorectal anastomosis on an ex vivo experimental model

BACKGROUND

In the context of natural orifice translumenal endoscopic surgery (NOTES), we developed a new set of rigid instruments according to the principles of transanal endoscopic microsurgery (TEM).These instruments are long, curved, and steerable by rotating two wheels near its handle. Our success in transvaginal cholecystectomy in human with these instruments motivated us to explore the feasibility of rectosigmoid resection through the anus.

METHODS

The young bovine large bowel with attached organs is collected en bloc and reintegrated into an anatomically designed trainer to reproduce the human anatomy. The technique comprises the following: (1) closure of the rectal lumen by an endolumenal pursestring suture; (2) transection of the rectal wall 1 cm distal to the pursestring suture and continuation of the dissection toward the fascia and upward excising the mesorectal tissue; (3) inferior mesenteric artery is divided near its origin; (4) the colon is mobilized up to the splenic flexure; (5) the mobilized colon is brought down to the pelvis, ligated twice at the intended proximal resection site, and divided between the ligatures; (6) specimen is delivered transanally; and (7) intestinal continuity is restored by stapled or hand-sutured anastomosis.

RESULTS

Twelve rectosigmoid resections, 20 stapled, and 27 hand-sutured anastomoses were performed in two experimental setups. Mean operation time for the resection part was 78.6 min (standard deviation (SD)=9.9). The average specimen length was 37.2 cm. During dissection in the pelvis, as the specimen was pushed upward and toward abdomen, an "empty pelvis" view of the working field was achieved, facilitating dissection. The mean operation time for hand-sutured and stapled anastomoses were 47.7 (SD=6.9) and 43.3 (SD=7.1) min, respectively. Both groups had one anastomotic leak.

CONCLUSIONS

Transanal rectosigmoid resection is feasible with TEM technology. The unobstructed "empty pelvis" view is likely to enhance the quality of mesorectal dissection.

[Transvaginal cholecystectomy in animal model: first series in Hungary]

INTRODUCTION

The Natural Orifice Transluminal Endoscopic Surgery (NOTES) is the newest trend in minimally invasive surgery. Based on clinical experiences, transvaginal cholecystectomy causes less pain and operative stress, requires shorter hospitalization and allows patients to return quicker to normal activity.

MATERIALS AND METHODS

A transvaginal cholecystectomy was carried out using hybrid technique in animal model first time in Hungary. A 5 mm umbilical trocar was used for preparation of cystic artery and duct, clip application and gallbladder dissection. A transvaginally inserted 10 mm trocar was used for laparoscopic camera to follow the procedure. Gallbladder was fixed and secured with a special curved instrument inserted also transvaginally during the procedure. At the end of procedure the gallbladder was removed transvaginally.

RESULTS

Six transvaginal cholecystectomies was performed on pigs. The mean time of operations was 78 min (40-145 minutes). During the operations and the follow up period (3 months) no complications and mortality was detected.

CONCLUSIONS

According to our experiences both procedures can be safely carried out on animal model, but further refinement of devices is necessary.