Natural orifice translumenal endoscopic surgery (NOTES(®)): a technical review

Clinical efficacy and safety of transvaginal natural orifice transluminal endoscopic surgery for benign adnexal disease: a prospective trial

BACKGROUND

There is a scarcity of prospective clinical research evidence regarding the utilization of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) as a treatment option for ovarian cysts. The objective of this study was to assess the feasibility and safety of employing vNOTES for the management of ovarian cysts.

METHODS

Our study included women between the ages of 18 and 70 who intended to undergo surgical intervention for benign lesions. Stratified blocked randomization was employed to allocate participants into groups. The main objective was to assess whether the assigned group adhered to the recommended surgical technique for ovarian cystectomy or adnexectomy, without any deviation to alternative surgical methods.

RESULTS

A total of 196 patients were included in the study, with all surgeries in each group being conducted according to the assigned procedures. Among them, the ovarian cystectomy layer included 58 cases in the vNOTES group and 58 cases in the conventional laparoscopy (CL) groups. The adnexectomy layer included 40 cases in the vNOTES group and 40 cases in the CL group. Utilizing a sensitivity analysis, the two-sided 95% lower confidence limit was determined to be 5.5% for the disparity in proportions between the vNOTES groups and CL groups. These lower limits fell below the predetermined non-inferiority margin of 10%.

CONCLUSIONS

The study findings demonstrate that vNOTES was not inferior to CL in terms of adnexectomy or ovarian cystectomy. vNOTES can be considered a more minimally invasive surgical approach, as it results in reduced postoperative pain, faster recovery, and absence of visible incisions. Overall, vNOTES proves to be a safe, feasible, and less invasive treatment option.

TRIAL REGISTRATION

This study retrospectively registered with the China Clinical Trial Registry with the registration number ChiCTR2100052223(22-10-2021).

Transanal Mesenteric Resection in Hirschsprung's Disease Using ICG under Concept of NOTES Technique

Laparoscopic surgery has been applied for Hirschsprung's disease (HD). We herein report our approach to mesenteric processing for laparoscopic-assisted transanal endorectal pull-through (L-TERPT). Following mucosectomy and entering the abdominal cavity, a vessel sealing system is transanally inserted into the abdominal cavity for mesenteric processing based on concept of Natural Orifice Translumenal Endoscopic Surgery. Since the transanal axis is parallel to the dissected mesentery, it makes easier to operate in comparison to when the procedure is performed through the abdominal working port and can reduce the additional abdominal trocar wound. We also use indocyanine green (ICG) fluorescence navigation. Fluorescing the vessels with ICG allows intraoperative visualization of the blood flow in the retrieved intestine. With these innovative combined techniques, L-TERPT for HD can be safely performed, even in infants with small intraabdominal cavities.

Transvaginal Specimen Extraction After Laparoscopic Gastrectomy for Tumors

AIM

The aim was to evaluate the feasibility of transvaginal specimen extraction after laparoscopic gastrectomy for tumors.

METHOD

Inclusion criteria were females not planning to deliver a child and an accessible vaginal entry. Exclusion criteria were benign gastric pathologies and emergency cases.

RESULTS

There were 24 females with a mean age of 54.5±12.0. Subtotal, total, central, and vertical gastrectomies were implemented in 17, 4, 2, and 1 patients, respectively. There was no conversion to open or conventional laparoscopic surgery. Specimens were removed from the vagina in all cases successfully. Histopathologies were adenocarcinoma in 20, gastrointestinal stromal in 3, neuroendocrine tumors in 2 and high-grade dysplasia in the rest. Mean blood loss and duration of surgery were 122.5±163.4 (range: 10 to 800) ml. and 287.7±95.9 (range: 120 to 440) minutes, respectively. No patient required intraoperative blood transfusions. The median length of hospital stay was 7 days (range: 3 to 22). The mean tumor size was 7.8±6.5 (range: 0.5 to 24) cm. Fourteen of 24 cases were advanced gastric cancers. Mean dissected lymph node numbers in the patients with radical gastrectomy was 35.3±12.9 (range: 18 to 62). There were no early or late complications related to the specimen extraction and no wound-related problems were observed.

CONCLUSIONS

In the selected cases, transvaginal specimen extraction was feasible after laparoscopic gastric resections in patients with stomach tumors. As far as we know, this was the largest study on the transvaginal extraction of gastric tumors.

Managing Gallstone Disease in the Elderly

Geriatric patients tend to have subtle presentations of biliary disorders and, if untreated, can decompensate acutely. Each biliary disorder warrants formulation of an individualized treatment plan with a multidisciplinary approach. Acute cholecystitis, a common complication of gallstones, is initially managed by conservative measures and subsequently, among patients with optimal surgical risk, through laparoscopic or open cholecystectomy. High-risk patients undergo temporization, percutaneous or endoscopic, followed by definitive intervention. Acute cholecystitis with complications (ie, perforation, gangrene, or small bowel obstruction) warrants emergent cholecystectomy. Gallstone migration into the biliary system can cause choledocholithiasis, often complicated by biliary pancreatitis or cholangitis if not intervened. Therapy for choledocholithiasis is based on biliary clearance through endoscopic and, infrequently, surgical approaches.

Intra-abdominal pressure during endoscopic full-thickness resection comparing manual and automatic control insufflation: a block-randomized porcine study

BACKGROUND AND STUDY AIMS

An automatic carbon dioxide (CO2) insufflating system (SPACE) was developed to stabilize intra-lumenal pressure (ILP) during endoscopic interventions. This study investigated whether SPACE could improve the control and monitoring of extra-lumenal intra-abdominal pressure (IAP) after establishing a perforation during endoscopic full-thickness resection (EFTR) of the gastric wall in porcine models.

MATERIALS AND METHODS

After first establishing the optimal preset pressure for gastric EFTR in four pigs, we compared IAP dynamics during EFTR between manual insufflation and SPACE using a block-randomized study (n = 10). IAP was percutaneously monitored and plotted on a timeline graph every 5 s. The maximal IAP and the area under the IAP curve exceeding 10 mmHg (AUC≥10 mmHg) were compared between groups, with the agreement between IAP and endolumenally monitored ILP also analyzed for animals in the SPACE group.

RESULTS

In the first study, 8 mmHg was identified as the most preferable preset pressure after establishment of the perforation. In the randomized study, the mean maximal IAP in the SPACE group was significantly lower than that in the manual insufflation group (11.0 ± 2.0 mmHg vs. 17.0 ± 3.5 mmHg; P = 0.03). The mean AUC≥10 mmHg was also significantly smaller in the SPACE group. Bland-Altman analysis demonstrated agreement between IAP and ILP within a range of ± 1.0 mmHg.

CONCLUSIONS

SPACE could be used to control and safely monitor IAP during gastric EFTR by measuring ILP during perforation of the gastric wall.

Transanal Endoscopic Microsurgery: Endoscopy Assisted Treatment of Colorectal Anastomotic Stenosis

Transanal endoscopic microsurgery (TEM) is a type of natural orifice transluminal endoscopic surgery, developed for rectal tumors and used also to treat other rectal diseases. Anastomotic complications after colorectal surgery, including stenosis, represent a challenging problem. We present the case of a 36-year-old woman with a diagnosis of Hirschsprung disease that was submitted to a modified Duhamel operation. A postoperative barium enema showed a complete stricture of the anastomosis that was impossible to resolve by flexible endoscopic approach. Then an intraoperative endoscopic approach to facilitate the localization of preanastomotic colon (proximal colon from the anastomosis) was performed by a small colotomy and the colonic recanalization was obtained by the creation of a neo-anastomosis by TEM, under fluoroscopic-endoscopic control. The patient underwent a control barium enema showing regular retrograde transit of contrast medium without evidence of stenosis. In our experience, transanal approach by TEM-colonoscopy assisted is safe and feasible and represents a model of combined minimally invasive technique.

Adrenal natural orifice transluminal endoscopic surgery (NOTES): a step too far?

Surgical approach to adrenal gland has evolved from open to minimally invasive surgery. With the advent of technology, multiple techniques and approaches are available in a surgeon's armamentarium today to deal with adrenal nodules that require surgical intervention. Each approach has its own advantages and disadvantages. The era of minimal invasive surgery has fuelled our quest for better cosmesis, faster recovery, early return to work and reduced hospital stay. While minimal invasive method is the preferred approach for most benign adrenal masses less than 6 cm, its application for large adrenal lesions as well as adrenocortical carcinoma is still debatable. Single incision minimal invasive procedures further try to reduce the incisions and wound morbidity. With the aim to completely remove visible scars and possibly reduced morbidity, the concept of natural orifice transluminal endoscopic surgery (NOTES) has been proposed by some surgeons as well as interventional gastroenterologist. In NOTES, the peritoneal cavity is accessed through a hollow viscus to perform therapeutic as well as diagnostic procedures. While the theoretical advantages of scar less surgery and its advantages sound encouraging, the precise indications and its potential advantages for adrenal pathologies is yet to be defined. It should in no way, compromise our goal of safe patient surgery and outcomes.

A reliable detachable balloon that prevents abdominal cavity contamination during transrectal natural orifice transluminal endoscopic surgery

OBJECTIVE

To evaluate the efficacy and safety of a detachable endoluminal balloon in the prevention of abdominal cavity contamination during transrectal natural orifice transluminal endoscopic surgery (NOTES).

METHODS

The efficacy and safety of a detachable endoluminal balloon to maintain disinfection in the distal colon of the pigs were evaluated. The bacterial loads and colonic cleanliness were monitored. Additionally, the device was applied to another nine pigs that underwent a cholecystotomy by transrectal NOTES. Necropsy and pathological examination were performed after 28-day follow-up.

RESULTS

All animals exposed to the device and one of the seven pigs not exposed to the device scored three points on the bowel cleanliness scale (P < 0.001). After 30 min bacterial loads of the test (with balloon occlusion) and control (without balloon occlusion) groups showed a significant difference (0.8 × 10³  CFU/mL vs 186.8 × 10³  CFU/mL, P < 0.01). Cholecystotomy by transrectal NOTES with the device was successfully performed. The mean intraperitoneal procedure time was 102.9 ± 37.7 min. There were no procedure-related adverse events. During the follow-up, all animals presented normal behavior and appetite. No peritoneal infection or adhesion was detected at autopsy. Cholecystotomy and rectal incision were histologically healed and no histological abnormalities were detected in the colon related to balloon placement.

CONCLUSIONS

The detachable balloon provides a reliable solution for preventing peritoneal contamination during transluminal operations. The technique may assist in future transrectal NOTES.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Pregnancy and a Device Innovation from Our Institution

Natural orifice transluminal endoscopic surgery (NOTES) is a relatively new technique currently being studied around the world. Between June 2015 and June 2017, 12 patients diagnosed with ectopic pregnancy underwent transvaginal NOTES to remove their fallopian tubes. All 12 surgeries were completed successfully. The median age of patients was 33years (range, 28-42), and the median body mass index was 23.47 (range, 20.55-27.68). The median duration of amenorrhea was 53days (range, 41-60). The median serum β-human chorionic gonadotropin was 8887 U/mL (range, 392-25 695). The median ectopic mass longest diameter was 2.95 cm (range, 2.1-5.0). The median surgical time was 47.5 minutes (range, 40-70). The median hemoperitoneum was 52.5 mL (range, 20-300), and the median blood loss was 7.5 mL (range, 2-20). Our study has proven the feasibility and repeatability of transvaginal NOTES for less difficult ectopic pregnancies. The success of transvaginal NOTES lies in the choice of patients and the establishment of the transvaginal operating platform. We added a plastic ring between the inner and outer rings outside the wound retractor. The modified platform can lessen the technical difficulties of performing transvaginal NOTES and broaden its applicability to other procedures.

A case of total laparoscopic sigmoidectomy involving the use of needle forceps and transanal specimen extraction for sigmoid colon cancer

A 76-year-old male underwent endoscopic mucosal resection for a stage T1 tumour of the sigmoid colon. We performed laparoscopic sigmoidectomy through 5 ports using needlescopic instruments. The resected specimen was extracted from the abdominal cavity transanally. After attaching an anvil to the sigmoidal stump, the rectal stump was reclosed using an endoscopic linear stapler, and then, colorectal anastomosis was conducted using the double stapling technique. Performing transanal specimen extraction using needlescopic forceps improves aesthetic outcomes and reduces post-operative pain and the risk of abdominal incisional hernias. This method is an easy to introduce a form of reduced-port surgery because of its feasibility and conventional port arrangement. Hence, we consider that it is an option for minimally invasive surgery.

Gastrointestinal tract access for urological natural orifice transluminal endoscopic surgery

We conducted a literature review of natural orifice transluminal endoscopic surgery (NOTES), focusing on urologic procedures with gastrointestinal tract access, to update on the development of this novel surgical approach. As part of the methods, a comprehensive electronic literature search for NOTES was conducted using PubMed and Cochrane Library from March 2002 to February 2016 for papers reporting urologic procedures performed utilizing gastrointestinal tract access. A total of 11 peer-reviewed studies examining utility of gastrointestinal access for NOTES urologic procedures were noted, with the first report in 2007. The procedures reported in the studies were total/radical nephrectomy, partial nephrectomy, adrenalectomy, and prostatectomy. The transgastric approach was identified in five studies examining total/radical nephrectomy (n = 2), partial nephrectomy (n = 1), partial cystectomy (n = 1), and adrenalectomy (n = 1). Six studies evaluated transrectal approach for NOTES, describing total/radical nephrectomy (n = 3), partial nephrectomy (n = 1), robotic nephrectomy with adrenalectomy (n = 1) and prostatectomy (n = 1). Feasibility was reported in all studies. Most studies were preclinical and acute, and limited by concerns regarding restricted instrumentation and infection risk. We concluded that gastrointestinal access for urologic NOTES demonstrates promise as described by outlined feasibility studies in preclinical models. Nonetheless, clinical application awaits further advancements in surgical technology and concerns regarding infectious potential.

Feasibility prospective study of laparoscopic cholecystectomy with suprapubic approach

BACKGROUND

Since the publication of laparoscopic cholecystectomy (LC) using three ports instead of four, no significant evolution has impacted on our clinical practice in order to improve length of stay, postoperative pain, time of recovery and cosmetic results. Recently, a renewed interest has been observed with the suprapubic approach, called occult scar laparoscopic cholecystectomy (OSLC). The aim of this prospective multicentric study was to evaluate the feasibility of OSLC in 2 French centers.

METHODS

From March to September 2014, 60 patients were prospectively included in this study. The operation incisions consisted of an umbilical incision for camera; an incision in the right groin for maneuvers of exposition and a suprapubic incision for instrumental dissection and clipping. Outcome was by operative time, operative complications, hospital length of stay, analgesia required after surgery, and cosmetic outcomes. The Patient Satisfaction Scale and Visual Analog Score (VAS) also were used to evaluate the level of cosmetic result and postoperative pain.

RESULTS

No laparoscopy was converted to an open procedure, the mean operative time was 53±20min. No patient had intraoperative bile duct injury or significant bleeding. The mean length of stay was 1.70±0.76 days. Two patients (3%) experienced postoperative complication (1 intra-abdominal abscess treated by antibiotics and 1 subcutaneous seroma of the 11-mm port wound treated successfully by needle aspiration).

CONCLUSION

The technique proved to be safe and feasible with no specific complication and without specific instrument. It offers satisfactory postoperative pain level and good cosmetic results.

Single-Incision Multiport/Single Port Laparoscopic Abdominal Surgery (SILAP): A Prospective Multicenter Observational Quality Study

Background

Increasing experience with minimally invasive surgery and the development of new instruments has resulted in a tendency toward reducing the number of abdominal skin incisions. Retrospective and randomized prospective studies could show the feasibility of single-incision surgery without any increased risk to the patient. However, large prospective multicenter observational datasets do not currently exist.

Objective

This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. This study focuses on external validity, clinical relevance, and the patients’ perspective. Accordingly, the single-incision multiport/single port laparoscopic abdominal surgery (SILAP) study will supplement the existing evidence, which does not currently allow evidence-based surgical decision making.

Methods

The SILAP study is an international prospective multicenter observational quality study. Mortality, morbidity, complications during surgery, complications postoperatively, patient characteristics, and technical aspects will be monitored. We expect more than 100 surgical centers to participate with 5000 patients with abdominal single-incision surgery during the study period.

Results

Funding was obtained in 2012. Enrollment began on January 01, 2013, and will be completed on December 31, 2018. As of January 2016, 2119 patients have been included, 106 German centers are registered, and 27 centers are very active (>5 patients per year).

Conclusions

This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. An international enlargement and recruitment of centers outside of Germany is meaningful.

Trial Registration

German Clinical Trials Register: DRKS00004594; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004594 (Archived by WebCite at http://www.webcitation.org/6jK6ZVyUs)

Unlimited-Length Proctocolectomy Utilizing Sequential Intussusception and Pull-Through

Transanal, hybrid natural orifice translumenal endoscopic surgery (NOTES) and NOTES-assisted natural orifice specimen extraction techniques hold promise as leaders in the field of natural orifice surgery. We report the feasibility of a novel NOTES assisted technique for unlimited length, clean, endolumenal proctocolectomy in a porcine model. This technique is a modification of a transanal intussusception and pull-through procedure recently published by our group. Rectal mobilization was achieved laparoscopically; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached laparoscopically to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. To achieve an unlimited-length proctocolectomy, the IPT step was repeated several times prior to bowel resection. This was facilitated by removing the ligature applied in the first step of this procedure. Once sequential IPT established the desired length of bowel to be resected, a second ligature was placed around the rectum approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls. The anastomosis was achieved by deploying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. The minimally invasive nature of this evolving technique as well as its aseptic bowel manipulation has the potential to limit the complications associated with abdominal wall incision and surgical site infection.

Face and content validation of a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™)

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical paradigm, where peritoneal access is achieved through one of the natural orifices of the body. It is being reported as a safe and feasible surgical technique with significantly reduced external scarring. Virtual Translumenal Endoscopic Surgical Trainer (VTEST™) is the first virtual reality simulator for the NOTES. The VTEST™ simulator was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the VTEST™ simulator underwent face validation at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. This manuscript outlines the results of the subsequent evaluation study, performed in order to assess the face and content validity of the latest VTEST™ simulator.

METHODS

Twelve subjects participated in an institutional review board-approved study that took place at the 2014 NOSCAR summit. Six of the 12 subjects, who are experts with NOTES experience, were used for face and content validation. The subjects performed the hybrid transvaginal NOTES cholecystectomy procedure on VTEST™ that included identifying the Calot's triangle, clipping and cutting the cystic duct/artery, and detaching the gallbladder. The subjects then answered five-point Likert scale feedback questionnaires for face and content validity.

RESULTS

Overall, subjects rated 12/15 questions as 3.0 or greater (60 %), for face validity questions regarding the realism of the anatomical features, interface, and the tasks. Subjects also highly rated the usefulness of the simulator in learning the fundamental NOTES technical skills (3.50 ± 0.84). Content validity results indicate a high level of usefulness of the VTEST™ for training prior to operating room experience (4.17 ± 0.75).

An innovative procedure of laparoscope combined with endoscopy for gastrointestinal stromal tumor resection and cholecystectomy: A case report and literature review

The present study reports a novel approach to laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor (GIST) resection and cholecystectomy, and conducts a review of the associated literature. The novel surgical procedure was performed on one patient who was diagnosed with a GIST and cholecystic polypus. The GIST was resected using an insulation-tipped diathermic electrosurgical knife under the guide of an endoscope. Subsequently, a cholecystectomy was performed by inserting two more 5-mm trocars and instruments transumbilically, guided using an endoscope. The tumor and the gallbladder were exteriorized using a peroral approach and the incision lining of the stomach was sutured laparoscopically. The procedure was successfully performed and the patient experienced no discomfort during the 5-year follow-up. In conclusion, the present study demonstrates that laparoscopic and endoscopic cooperative surgery is feasible and would be an ideal choice for invisible abdominal scar surgery, in particular for multi-visceral resection.

Laparoscopic Gastrectomy and Transvaginal Specimen Extraction in a Morbidly Obese Patient with Gastric Cancer

Laparoscopic gastrectomy for cancer has some significant postoperative benefits over open surgery with similar oncologic outcomes. This procedure is more popular in the Far East countries where obesity is not a serious public health problem. In the Western countries, laparoscopic gastrectomy for cancer is not a common procedure, yet obesity is more common. Herein, we aimed to demonstrate the feasibility of laparoscopic gastrectomy for advanced gastric cancer in a morbidly obese patient. Additionally, we used natural orifice specimen extraction as an option to decrease wound-related complications, which are more prevalent in morbidly obese patients. In this case, we performed a fully laparoscopic subtotal gastrectomy with lymph node dissection and Roux-en-Y gastrojejunostomy with the specimen extracted through the vagina. To the best of our knowledge, this was the first report of a natural orifice surgery in a morbidly obese patient with gastric cancer.

A case of splenic metastasis of ovarian cancer treated with complete laparoscopic splenectomy and transvaginal specimen extraction

A 61-year-old woman was diagnosed with right inguinal lymph node and splenic metastasis of ovarian serous cystadenocarcinoma. We performed right inguinal lymph node dissection and total laparoscopic splenectomy in the supine position followed by transvaginal specimen extraction (TVSE). First, using three ports, we extracted the right inguinal lymph node. We repaired the posterior wall of the inguinal canal using a mesh plug. We added two ports and displaced the spleen from the retroperitoneum and lifted it using a snake retractor, disconnecting the hilum using an automatic suturing device. Next, the posterior wall of the vagina was intraperitoneally incised. And an Alexis® laparoscopic system was inserted into the vagina. The cap maintained aeroperitoneum, a collection bag was inserted in the abdominal cavity via the vagina, and the spleen was collected. When the spleen was removed from the body, partial fragmentation of the organ was required in the bag. Organ fragmentation was performed only within the bag, and we made sure not to tear the bag. The vaginal wound was laparoscopically sutured. The patient had no operative complications and was able to actively ambulate at the first day after surgery due to a slight postoperative pain. Total laparoscopic splenectomy with TVSE in the supine position may be a safe and feasible method for selected female patients. This technique enables minimally invasive surgery for female patients with splenic disease.

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.

Minimally invasive surgical technique integrating multiple procedures with large specimen extraction via inguinal hernia orifice

While laparoscopic surgery can be performed using small skin incisions, any resected specimen must still be able to fit through these opening. For procedures, such as cholecystectomies and appendectomies, this is not usually a problem; however, for large specimens such as bowel or large tumors, this becomes problematic. Currently, the standard technique is to attempt piecemeal removal of the specimen or enlarge one of the laparoscopic incisions, effectively creating a mini laparotomy. Creating a larger incision adds many of the drawbacks of open laparotomy and should be avoided whenever possible. In this article, we present a new technique of combining the repair of an inguinal hernia, umbilical hernia with a duodenal tumor resection in order to extract the specimen through the inguinal hernia orifice.

[INITIAL EXPERIENCE OF TRANSVAGINAL EXTRACTION OF THE KIDNEY FOLLOWING LAPAROSCOPIC NEPHRECTOMY IN OUR DEPARTMENT]

PURPOSE

We report the detailed technique and results of transvaginal extraction of the kidney following laparoscopic nephrectomy.

PATIENTS AND METHODS

From August 2013 onward, we planned to perform transvaginal extraction of the kidney following laparoscopic nephrectomy in a total of 6 female patients. Of the 6 patients, 5 underwent the procedure. After completion of the primary laparoscopic nephrectomy and entrapping the removed kidney, the patients were placed in the supine lithotomy position. A transverse posterior colpotomy was created transvaginally at the apex of the posterior fornix. An opening was made in the peritoneum bluntly with the fingers under laparoscopic view. After the drawstring of the entrapped specimen was delivered into the vagina, the specimen was extracted intact via the vagina. When the vaginal wall was too tight for a large specimen, the incision was extended on the affected side. After removal of the specimen, the peritoneum was sutured laparoscopically, and the posterior colpotomy incision was repaired transvaginally.

RESULTS

Transvaginal extraction was successful in 5 patients. The mean operative time for the vaginal extraction procedure was 59 minutes. Blood loss was minimal. The mean specimen weight was 447 g (range 271 to 655 g). No intraoperative complications occurred. Postoperatively, one case needed intermittent catheterization for a few days because of temporal dysfunction of the bladder.

CONCLUSIONS

Transvaginal extraction is an efficacious and minimally morbid technique for removing the intact kidney after laparoscopic nephrectomy.

Total laparoscopic subtotal gastrectomy with transvaginal specimen extraction is feasible in advanced gastric cancer

PURPOSE

Natural orifice specimen extraction (NOSE) is an ever-evolving advanced laparoscopic technique. NOSE minimizes surgical injury, involving a low risk of wound complications, fewer incisional hernias, faster recovery and less postoperative pain. Laparoscopic gastrectomy combined with NOSE is a procedure that can potentiate the advantages of both minimal invasive techniques. We aim to demonstrate the feasibility of laparoscopic subtotal gastrectomy with transvaginal specimen extraction in advanced gastric cancer.

CASE

A 72-year-old woman with a 2cm adenocarcinoma in gastric antrum was treated by laparoscopic subtotal gastrectomy and lymph node dissection. A totally laparoscopic Roux-en-Y gastrojejunostomy was constructed. Specimen was extracted through the posterior fornix of vagina without difficulty. Histopathology confirmed pT3pN0 tumor. After a 10-month follow-up the patient was asymptomatic and getting adjuvant chemoradiotherapy.

CONCLUSIONS

Transvaginal specimen extraction after laparoscopic gastric resection for advanced gastric cancer is a feasible procedure. It is offered to selected patients and of course only to female patients. Natural orifice surgery may provide faster recovery and decrease the wound related complications which may cause a delay on postoperative adjuvant chemo-radio therapies. We have presented, as far as we know, the first human case of a transvaginal extraction of an advanced gastric cancer after laparoscopic gastrectomy.

Emerging Techniques in Minimally Invasive Surgery. Pros and Cons

New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.

Endoscopic placement of self-expandable metallic stents for rectovaginal fistula after colorectal resection: a comparison with proximal diverting ileostomy alone

BACKGROUND

Self-expandable metal stents can be used to treat patients with rectovaginal fistula after colorectal resection for cancer.

METHODS

Fifteen patients with rectovaginal fistula, after colorectal resection for cancer, were treated with endoscopic placement of a self-expandable metal stent. In four patients, a diverting proximal stoma had been performed elsewhere. Mean age was 58 years. All patients had preoperative radiotherapy. In ten patients, the stent was placed as initial form of treatment. Four patients were referred after multiple failed operations. The control group consisted of ten patients who had rectovaginal fistula and underwent proximal diverting ileostomy and percutaneous drainage of the surrounding abscess

RESULTS

One patient was not able to tolerate the stent, which was removed. At a mean follow-up of 22 months, the rectovaginal fistula healed in 12 patients. In the remaining two patients, the fistula has reduced significantly in size to allow a successful flap transposition. The fistula healed only in five out of the ten patients who had only a proximal ileostomy.

CONCLUSIONS

Endoscopic placement of self-expandable metal stents represents a valid adjunctive to treat patients with rectovaginal fistula, after colorectal resection for cancer.

Natural orifice translumenal endoscopic surgery (NOTES): emerging trends and specifications for a virtual simulator

INTRODUCTION AND STUDY AIM

A virtual translumenal endoscopic surgical trainer (VTEST) is being developed to accelerate the development of natural orifice translumenal endoscopic surgery (NOTES) procedures and devices in a safe and risk-free environment. For a rapidly developing field such as NOTES, a needs analysis must be conducted regularly to discover emerging research trends and areas of potential high impact for a virtual simulator. This paper presents a survey-based study which follows a similar study conducted by this group in 2011 (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013).

METHODS

A 32-point questionnaire was distributed at the 2012 Natural Orifice Surgery Consortium for Assessment and Research annual meeting. These data were subsequently augmented by an identical online survey, targeted at the members of the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons, and analyzed.

RESULTS

Twenty-eight NOTES experts participated in the 2012 study. Cholecystectomy (CE) procedure remained the most commonly performed NOTES technique, with 18 positive responses (64%). In contrast to 2011, the popularity of the NOTES appendectomy (AE) was significantly lower, with only 2 (7%) instances (CE vs. AE, p < 0.001), while the number of peroral endoscopic myotomy (POEM, PE) cases had increased significantly, with 11 (39%) positive responses, respectively (PE vs. AE, p = 0.013). Strong preference toward hybrid rather than pure NOTES techniques (82 vs. 11%, p < 0.001) was also expressed. Other responses were similar to those in the 2011 study, with the VTEST™ utility in developing and testing new techniques and instruments ranked particularly high.

CONCLUSION

Based on the results of this study, a decision was made to focus exclusively on the transvaginal hybrid NOTES cholecystectomy procedure, including both rigid and flexible scope techniques. The importance of developing a virtual NOTES simulator was reaffirmed, with POEM identified as a promising candidate for future simulator development.

Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results

AIM

To treat patients with rectovaginal fistula after anterior resection for cancer using self-expanding metal stents.

METHOD

Ten patients of mean age of 56.3 years with rectovaginal fistula after colorectal resection for cancer were treated with endoscopic placement of a self-expanding metal stent. In three patients a diverting proximal stoma had been performed elsewhere. The rectal opening of the fistula was located from 3 to 10 cm from the anal verge (mean 6 cm). All patients had preoperative radiotherapy. In seven patients the stent was placed as the initial treatment while three referred patients had had multiple failed operations.

RESULTS

There were no complications after the procedure. At a mean follow-up of 24 months the rectovaginal fistula has healed without major faecal incontinence in eight patients. In the remaining two the fistula has reduced significantly in size to allow a successful flap transposition.

CONCLUSION

Endoscopic placement of a self-expanding metal stent is a valid adjunct to treat patients with rectovaginal fistula after colorectal resection for cancer.

Single-incision multiport laparoendoscopic surgery using a short-type flexible endoscope and its usefulness in cholecystectomy

INTRODUCTION

We previously demonstrated the advantages of a short-type flexible endoscope as a working scope in laparoscopic surgery through single-incision procedures in animal experiments. In this report, we examined the outcomes of laparoscopic surgery through a single incision using a flexible endoscope in a clinical setting. Specifically, we performed cholecystectomy using single-incision multiport laparoendoscopic (SIMPLE) surgery.

METHODS

Thirteen patients with cholecystolithiasis or gallbladder polyp underwent SIMPLE cholecystectomy using a newly developed short-type flexible endoscope with a working length of 60 cm. Twenty-seven patients underwent standard single-incision laparoscopic cholecystectomy using a 5-mm rigid laparoscope. We retrospectively compared the surgical outcomes between the two groups.

RESULTS

SIMPLE cholecystectomy using the short-type flexible endoscope was successfully carried out. No gallbladder perforation occurred, but perforation occurred in four cases in the standard laparoscopic cholecystectomy group; however, the difference was not statistically significant. Although no other surgical outcomes differed between the two groups, the flexible endoscope had several advantages over the standard laparoscope. The scope provided a flexible view of the operating field. The gallbladder dissection using the cutting device via the scope was easier and safer than that in standard single-incision laparoscopic cholecystectomy. The water-jet, suctioning, and self-cleaning lens functions of the scope served the surgery well.

CONCLUSIONS

SIMPLE cholecystectomy using a short-type flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but this endoscope with multiple functions may make the surgical procedures less stressful and safer.

A novel single-port laparoscopic operation for colorectal cancer with transanal specimen extraction: a comparative study

BACKGROUND

Extension of a single incision for the purpose of specimen extraction in single-port laparoscopic surgery (SPLS) can undermine the merits of SPLS, either by hurting cosmesis or by increasing wound morbidity.

METHODS

We retrospectively analyzed the clinical outcomes of patients undergoing SPLS sigmoidectomy, either with transanal specimen extraction (TASE, n = 15) or transumbilical specimen extraction (TUSE, n = 68), for colorectal cancer between March 2009 and March 2013. The inclusion criterion was a tumor diameter of ≤ 5 cm. The median follow-up was 93 months (range 13 - 149).

RESULTS

Most of intraoperative and postoperative variables were comparable between the two groups, except for lengthening of operation time in TASE (287 ± 87 min vs. 226 ± 78 min, P = 0.011). TUSE did not lengthen the duration of postoperative recovery, hospital stay, or pain, or increase the incidence of postoperative complications. Whereas TUSE showed 8.8% (6/68) of wound-related complications, TASE did not show wound-related complications during follow-up period (P = 0.586).

CONCLUSION

With the exception of a prolonged operation time, TASE showed equivalent surgical outcomes as TUSE in SPLS sigmoidectomy. Thus, the implement of TASE is expected to provide one way of reducing wound-related complications in SPLS in patients with a tumor diameter of ≤5 cm.

An integrated teaching method of gross anatomy and computed tomography radiology

It is essential for medical students to learn and comprehend human anatomy in three dimensions (3D). With this in mind, a new system was designed in order to integrate anatomical dissections with diagnostic computed tomography (CT) radiology. Cadavers were scanned by CT scanners, and students then consulted the postmortem CT images during cadaver dissection to gain a better understanding of 3D human anatomy and diagnostic radiology. Students used handheld digital imaging and communications in medicine viewers at the bench-side (OsiriX on iPod touch or iPad), which enabled "pixel-to-tissue" direct comparisons of CT images and cadavers. Students had lectures and workshops on diagnostic radiology, and they completed study assignments where they discussed findings in the anatomy laboratory compared with CT radiology findings. This teaching method for gross and radiological anatomy was used beginning in 2009, and it yielded strongly positive student perspectives and significant improvements in radiology skills in later clinical courses.

Comparison of immediate postoperative pain after transvaginal versus traditional laparoscopic cholecystectomy

BACKGROUND

Transvaginal cholecystectomy (TVC) is the most common natural orifice transluminal surgery (NOTES) performed in women, yet there is a paucity of data on intraoperative and immediate postoperative pain management. Previous studies have demonstrated that NOTES procedures are associated with less postoperative pain and faster recovery times. This study analyzes intraoperative and postoperative opioid use for TVC compared with traditional four-port laparoscopic cholecystectomies (LCs).

METHODS

This is a retrospective analysis of consecutive TVC and LC female patients between August 2009 and August 2012 in an academic institution. We compared demographics, intraoperative and postoperative opioid use and times in the operating room (OR) and in the post anesthesia care unit (PACU).

RESULTS

A total of 68 TVC and 67 LC patients were included in this study. The TVC and LC groups were similar in terms of age (both 41 years) and body mass index (29 and 31 kg/m2, respectively). The intraoperative preparation, surgical, and emergence times were significantly longer for the TVC than for the LC (p ≤ 0.01). Compared with the LC group, the intraoperative opioid requirement was significantly greater (TVC 27 mg vs. LC 25 mg; p = 0.003), but after adjusting for anesthesia time, the difference in OR opioid consumption became non-significant (p = 0.08). The PACU opioid requirement (TVC 2.5 vs. LC 5 mg; p = 0.04) was significantly lower for the TVC group, and a greater proportion of patients did not need any pain medications (TVC 38 % vs. LC 21 %; p = 0.04), compared with the LC group. The average PACU pain scores were not significantly different between the groups (p = 0.45).

CONCLUSION

TVC patients did not experience more pain than LC patients. Although the average pain scores of TVC patients did not differ from those of the LC patients, TVC patients did require less pain medication in the PACU.

Transvaginal cholecystectomy learning curve

BACKGROUND

There are few surgeons in the United States, within private practice and academic centers, currently performing transvaginal cholecystectomies (TVC). The lack of exposure to TVC during residency or fellowship training, coupled with a poorly defined learning curve, further limits interested surgeons who want to apply this technique to their practice. This study describes the learning curve encountered during the introduction of TVC to our academic facility.

METHODS

This study is an analysis of consecutive TVCs performed between August 14, 2009 and August 3, 2012 at an academic center. The TVC patients were divided into sequential quartiles (n = 15/16). The learning curve outcome was measured as the operative time of TVC patients and compared to the operative time of female laparoscopic cholecystectomy (LC) patients performed during the same time period.

RESULTS

Sixty-one patients underwent a TVC with a mean age of 38 ± 12 years and mean BMI was 29 ± 6 kg/m(2). Sixty-seven female patients who underwent a LC with average age 41 ± 15 years and average BMI 33 ± 12 kg/m(2). The average operative time of LC patients and TVC patients was 48 ± 20 and 60 ± 17 min, respectively. Significant improvement in TVC operative times was seen between the first (n = 15 TVCs) and second quartiles (p = 0.04) and stayed relatively constant for third quartile, during which there was no statistically significant difference between the mean LC operative time for the second and third TVC quartiles

CONCLUSIONS

The learning curve of a fellowship-trained surgeon introducing TVC to their surgical repertoire, as measured by improved operative times, can be achieved with approximately 15 cases.

Use of 3 mm percutaneous instruments with 5 mm end effectors during different laparoscopic procedures

BACKGROUND AND PURPOSE

With a recent focus on minimizing the visibility of scars, new techniques have been developed. Minilaparoscopy reemerged as an attractive option for surgery as it limits tissue trauma, reduces post-operative pain and improves cosmesis. This study was designed to describe our experience with percutaneous trocarless 3 mm instruments used in combination with standard 5 mm and 10 mm laparoscopic instruments in different general surgery procedures.

METHODS

We used the PSS (Percutaneous Surgical Set, Ethicon Endo surgery, Cincinnati, OH, USA) in different surgical procedures as accessory instruments in combination with standard 5 mm and 10 mm standard laparoscopic instruments.

MAIN FINDINGS

The use of percutaneous instruments was safe and feasible in all performed procedures. The surgical technique was not modified. The percutaneous instruments can assure a good grip and can be used for traction and counter-traction. No complications have been described. No pain at the site of insertion has been reported. The skin, muscle and peritoneal defects were smaller than with the 3 mm laparoscopic traditional instruments.

CONCLUSIONS

Percutaneous approach seems to be a good option in general surgery in terms of efficiency, offering better cosmetic results and good pain control.

Anesthetic management of transoral natural orifice transluminal endoscopic surgery: two cases report

Natural orifice transluminal endoscopic surgery (NOTES) is an evolving field of minimally invasive surgery. NOTES reaches the target organ by inserting the endoscope through a natural orifice (e.g. mouth, anus, urethra, vagina) and offers advantages of less postoperative pain and lower complication rate. Since its first description in 2004, NOTES has progressed from use on animal models to humans. We experienced anesthetic care of two patients who underwent transoral NOTES under general anesthesia.

Novel Totally Laparoscopic Endolumenal Rectal Resection With Transanal Natural Orifice Specimen Extraction (NOSE) Without Rectal Stump Opening: A Modification of Our Recently Published Clean Surgical Technique in a Porcine Model

Our group has recently described a novel technique for clean endolumenal bowel resection, in which abdominal and transanal approaches were used. In the current study, 2 modifications of this procedure were tested for feasibility in a porcine model. A laparoscopic approach to the peritoneal cavity was employed in rectal mobilization; this was followed by a transanal rectorectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. Once IPT was established, a second ligature was placed around the rectum approximating the proximal and distal resection margins. This was followed by a purse string suture through 2 bowel walls, encircling the shaft of the anvil just proximal to the ligatures. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls distal to the previously placed purse string suture and ligatures. The anastomosis was achieved by applying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. Although, this is a novel and evolving procedure, its minimally invasive nature, as well as aseptic bowel manipulation during endolumenal rectal resection, has the potential to limit the complications associated with abdominal wall incision and surgical site infection.

Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia

BACKGROUND

Peroral esophageal myotomy (POEM) is a new endoscopic operation for the treatment of achalasia. Here, we report 1-year physiologic and symptomatic outcomes following the procedure.

METHODS

POEM patients from a single-institution series who were more than 1 year removed from surgery were studied. Eckardt and GerdQ scores were obtained to assess symptoms. High-resolution manometry (HRM), timed barium esophagram (TBE), and upper endoscopy were preformed preoperatively and at 1-year follow-up. 24-h pH monitoring was also performed at 1 year follow-up.

RESULTS

The study population was comprised of 41 patients who were more than 1 year post-POEM. One (2%) major complication, a contained leak at the EGJ requiring re-operation, and 7 (17%) minor complications occurred. Mean length of stay was 1.4 days. At mean 15-month follow-up, Eckardt scores improved from pre-POEM 7 ± 2 to post-POEM 1 ± 2, (scale 0-12, p < .001), and 92% of patients achieved treatment success (Eckardt score <4). Two of the three treatment failures in the series occurred in the initial three patients. 15% of patients had post-POEM symptoms suggestive of gastroesophageal reflux (GerdQ >7). On follow-up HRM, esophagogastric junction integrated relaxation pressure was decreased significantly (pre-POEM 28 ± 12 mmHg vs. post-POEM 11 ± 4 mmHg, p < .001), and 47% of patients studied had partial recovery of peristalsis. On follow-up TBE, barium column heights were decreased compared with preoperatively. Postoperative upper endoscopy revealed esophagitis in 59% of patients (11 LA Grade A, 2 LA Grade D). However, of the 13 24-h pH monitoring studies performed, only four (31%) demonstrated pathologic esophageal acid exposure.

CONCLUSIONS

In this series, POEM resulted in greater than 90% symptomatic treatment success at mean 15-month follow-up. Rates of iatrogenic gastroesophageal reflux, as measured both by symptoms and 24-h pH monitoring, appeared to be on par with recent studies of patients undergoing laparoscopic Heller myotomy and pneumatic dilation.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

BACKGROUND

NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.

METHODS

Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.

RESULTS

At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.

CONCLUSION

As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods-combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

Complications of transvaginal natural orifice transluminal endoscopic surgery: a series of 102 patients

OBJECTIVE

To review the complications encountered in our facility and in previously published studies of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) to date.

BACKGROUND

TV NOTES is currently observed with critical eyes from the surgical community, despite encouraging data to suggest improved short-term recovery and pain.

METHODS

All TV NOTES procedures performed in female patients between 18 and 65 years of age were included. The median follow-up was 90 days. The TV appendectomies and ventral hernia repairs were pure NOTES, through a SILS port in the vagina, whereas TV cholecystectomies were hybrid procedures with the addition of a 5-mm port in the umbilicus.

RESULTS

A total of 102 TV NOTES procedures, including 72 TV cholecystectomies, 24 TV appendectomies, and 6 TV ventral hernia repairs, were performed. The average age was 37 years old and body mass index was 29 kg/m. Three major and 7 minor complications occurred. The first major complication was a rectal injury during a TV access port insertion. The second major complication was an omental vessel bleed after a TV cholecystectomy. The third complication was an intra-abdominal abscess after a TV appendectomy. Seven minor complications were urinary retention (4), transient brachial plexus injury, dislodgement of an intrauterine device, and vaginal granulation tissue.

CONCLUSIONS

As techniques in TV surgery are adopted, inevitably, complications may occur due to the inherent learning curve. Laparoscopic instruments, although adaptable to TV approaches, have yet to be optimized. A high index of suspicion is necessary to identify complications and optimize outcomes for patients.

Quality and safety of minimally invasive surgery: past, present, and future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

A prospective, randomized, controlled, trial comparing occult-scar incision laparoscopic cholecystectomy and classic three-port laparoscopic cholecystectomy

BACKGROUND

This study was designed to evaluate the outcome of laparoscopic cholecystectomy by comparing a new technique using occult-scar incision for laparoscopic cholecystectomy (OSLC) with classic three-port laparoscopic cholecystectomy (CLC). In the occult-scar incision, we moved the subcostal and subxiphoid trocar insertion sites to the suprapubic area so that operative scars were hidden in the pubic hairs and below umbilicus.

METHODS

Between July 2009 and 2012, patients undergoing laparoscopic cholecystectomy were randomized to the OSLC or CLC approach after obtaining informed consent. Outcome was measured by operative time, operative complications, hospital length of stay, cost, analgesia required after surgery, and cosmetic outcomes. The patient satisfaction score (PSS) and visual analog score (VAS) also were used to evaluated the level of cosmetic result and postoperative pain.

RESULTS

A total of 75 patients were randomized into CLC (n = 35) and OSLC (n = 40) groups. No patient was converted to an open procedure in either the CLC or OSLC group. No operative complications were reported within 30 days in either group. The PSS of 7 and 30 days after surgery were both significantly higher in the OSLC group than in the CLC group (5.8 ± 1.5 vs. 8.0 ± 1.1, P = 0.03; 6.5 ± 1.2 vs. 9.2 ± 0.8, P = 0.02). The VAS for pain was significantly lower in the OSLC group on postoperative day 3 compared with the CLC group (2.6 ± 1.2 vs. 6.3 ± 0.9, P = 0.01). There was no significant difference in operative time, hospital stay, and cost between the two groups.

CONCLUSIONS

The OSLC is a safe and feasible alternative compared with CLC in experienced hands, and it is superior for outcomes regarding pain control and cosmesis.

Prolonged capnoperitoneum does not cause postoperative ileus in pigs: safety of prolonged capnoperitoneum

INTRODUCTION

Operative time is an accepted risk factor for the development of postoperative ileus (POI). Innovative surgical procedures such as robotic surgery and natural orifice transluminal endoscopic surgery (NOTES) will be associated with longer operative times. Although intraabdominal manipulation is a major factor for POI the impact of prolonged capnoperitoneum on postoperative gastrointestinal transit time (GIT-TT) has rarely been studied.

MATERIAL AND METHODS

IRB approved survival pilot study to assess postoperative GIT-TT using fecal collection and chromium-oxide (Cr2O3) labeling in pigs. Twelve female pigs were randomly assigned to three groups of four animals each. Group A received eight hours anesthesia and pressure-controlled high flow capnoperitoneum (15 mmHg), group B eight hours of anesthesia only and group C no intervention. No intraoperative manipulation. The pilot study was terminated after eight days.

RESULTS

None of the animals developed POI. In Group A one animal died after eight hours of general anesthesia. No differences in postoperative fecal output, Cr2O3 excretion rate or weight gain were found.

CONCLUSION

This study is the first to investigate eight hours of capnoperitoneum in a survival model. GIT-TT is not affected by prolonged capnoperitoneum in pigs. No POI occurred with prolonged capnoperitoneum. Prolonged capnoperitoneum is safe regarding postoperative gastrointestinal function in innovative surgical procedures.