Transvesical peritoneoscopy with rigid scope: feasibility study in human male cadaver

On the suitability of Thiel cadavers for natural orifice transluminal endoscopic surgery (NOTES): surgical training, feasibility studies, and anatomical education

BACKGROUND

Surgical training in virtual, animal and cadaver models is essential for minimally invasive surgery. Thiel cadavers are suitable for laparoscopy, but there are few data about the use of embalmed (Tutsch method) and slightly embalmed (Thiel method) cadavers in procedures of Natural Orifice Transluminal Endoscopic Surgery (NOTES), which are usually developed and learned on swine models and fresh frozen cadavers. The aim of this study was thus to assess the use of these cadavers for NOTES approaches.

METHODS

The following surgical procedures were evaluated: transanal total mesorectal excision (four cadavers: one Tutsch, two Thiel, one fresh frozen), transanal ileorectal bypass (five cadavers: one Tutsch, three Thiel, one fresh frozen), and transvaginal appendectomy (two Tutsch cadaver).

RESULTS

The Thiel method ensured tissue flexibility and consistency suitable for performing the above surgical procedures with good results and without complications, with only a small increase in rigidity with respect to fresh specimens. Cadavers embalmed with higher formalin concentrations (Tutsch method) were more difficult to use, due to high tissue rigidity and resistance of the abdominal wall to pneumoperitoneum, although NOTES accesses were possible.

CONCLUSIONS

Thiel cadavers are suitable for transanal/transrectal and transvaginal NOTES approaches, for training surgical residents/specialists and also for surgical research. In minimally invasive surgery (and particularly in NOTES), integration between cadaver (fresh frozen and/or Thiel) and animal models would represent the gold standard, allowing guaranteed knowledge of and respect for human surgical anatomy and correct management of surgery on living subjects. NOTES approaches to human cadavers may also be proposed for the anatomical education of medical students.

Hybrid transvaginal cholecystectomy, clinical results and patient-reported outcomes of 50 consecutive cases

OBJECTIVE

The aim of this study was to report the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC).

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has been developed as a minimal invasive alternative for conventional laparoscopic cholecystectomy. Although transvaginal NOTES procedures are becoming increasingly popular, data focussing on body image, cosmesis and sexual recovery are rare.

METHODS

Our clinic started to perform the TVC in the beginning of 2011. Female patients with symptomatic gallstone disease that were treated between January 2011 and April 2012 with TVC were entered in a prospective database. All patients received a survey postoperative with questions about recovery, cosmesis and body image.

RESULTS

Fifty consecutive patients were treated with a TVC. There were no major complications. Mean operative time was 61 min. In five patients (10 %), a conversion to another type of cholecystectomy was necessary. None of the sexually active women observed dyspareunia postoperative. The results for cosmesis and body image after the transvaginal approach were excellent.

CONCLUSIONS

TVC is a safe and feasible procedure when performed on selected patients. The transvaginal route seems to result in excellent cosmetic outcomes without gynaecologic complications after short-term follow up. Randomised trials are needed to specify the role of TVC in the treatment of patients with symptomatic gallstone disease and to detect differences in cosmetic outcomes.

Current progress on natural orifice transluminal endoscopic surgery (NOTES)

Natural orifice transluminal endoscopic surgery (NOTES) has received considerable interest in recent years as a novel surgical technique. Here, we aim to review the current progress on NOTES, particularly focusing on the advantages and complications related to NOTES, the recent advances of surgical approaches, new instruments for closure of the natural orifice incision, and the newly developed platform for NOTES. Finally, we make a prediction of the conceivable applications of NOTES on human subjects.

Transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney morcellation: a proof of concept study

Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Until now, the transvaginal approach has been the only method of removing larger specimens from the abdominal cavity using natural orifice transluminal endoscopic surgery. There has been no means of extracting larger specimens in men and the means are restricted even in women, particularly in young women. The present study shows that the difficulty of large specimen retrieval can be overcome, irrespective of the diameter of the chosen port, through natural orifices using morcellation.

OBJECTIVE

To show, in a porcine model, the feasibility of a complete transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney extraction after morcellation through the same port.

MATERIALS AND METHODS

Transvesical nephrectomy and morcellation were performed in six pigs at Minho University, Braga, Portugal after institutional review board approval. The transvesical port and the cystotomy were created under the guidance of a ureteroscope, while the remaining steps were done under the guidance of an operating telescope. Dissection of the renal vessels and kidney was performed using dissection grasping forceps and a vessel sealing system (LigaSure(™) ; Covidien, Mansfield, MA, USA) and morcellation was done using a Piranha(™) morcellator (Richard Wolf, Knittlingen, Germany).

RESULTS

There were no complications related to the creation of transvesical access. The image provided by the telescope was superior to that of the ureteroscope, especially underwater. Morcellation was quick and effective, with the support of a fixing needle through the abdominal wall, designed to fix the kidney, after laceration of a bowel loop occurred in the first experiment.  It was found that technical improvements are needed to ensure safety of NOTES morcellation.

CONCLUSIONS

Kidney morcellation after nephrectomy, using a natural orifice exclusively, is feasible.  Despite technical limitations, this proof of concept study can be regarded as a potential step towards the application of NOTES in urology.

Pure NOTES transvesical venous ligation: translational animal model of varicocelectomy

OBJECTIVE

To assess the feasibility of pure natural orifice transluminal endoscopic surgery (NOTES) transvesical venous ligation mimicking bilateral varicocelectomy in an animal model.

MATERIALS AND METHODS

Transvesical NOTES bilateral venous ligation was performed in 6 female pigs by considering lower epigastric vessels as a model for gonadal vessels. Under flexible cystoscopic guidance, a cystotomy was created on the anterior bladder. The flexible cystoscope was introduced through the over tube, and the lower epigastric vessels were visualized in retroflexion. Thulium laser was used to cut and coagulate the vessels. A bladder catheter was left in place for 4 days in all animals and they were sacrificed 15 days after the procedure.

RESULTS

The procedure was successfully carried out in all animals without intraoperative complications. Epigastric vessels were safely cut and coagulated using the thulium laser. Median time for the overall procedure, including establishment of the transvesical port, was 23 minutes (range 20-30). No complications were encountered during the postoperative follow-up period. Postmortem examination revealed complete coagulation and separation of vessels.

CONCLUSION

An animal model mimicking a NOTES transvesical bilateral varicocelectomy procedure is successfully shown in the present study. Despite being encouraging, these novel findings need to be interpreted with caution. Further research is warranted and development of purpose-built instrumentation is awaited to define potential urological applications of transvesical NOTES.

Disinfection of the Access Orifice in NOTES: Evaluation of the Evidence Base

Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.