Consumer demand for surgical innovation: a systematic review of public perception of NOTES

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

Introduction

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

Materials and Methods

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

Results

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

Conclusion

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

Robotic-Assisted Transrectal Cholecystectomy in a Porcine Model

Background. With increasing experience and technological advancement in surgical instruments, surgeons have explored the feasibility of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). These techniques aim to further reduce surgical trauma, but are not popular due to their inherent pitfalls including clashing of instruments, lack of counter traction, lengthy operating time, and so on. A novel surgical robotic system was designed to overcome the limitations of the existing technologies. Animal trials were conducted to demonstrate its feasibility in performing robotic-assisted transrectal cholecystectomy in a porcine model. Method. The Novel surgical robotic system is a high dexterity, single access port surgical robotic system that enables surgeons to carry out single-port surgical procedure or NOTES. The proposed system’s main features include the ability to perform intraabdominal and pelvic surgeries via natural orifices like the vagina or rectum. The system is equipped with multiple miniaturized (16 mm diameter) internally motorized robotic arms, each with a minimum of 7 degrees of freedom, a dual in vivo camera system, a cannula, and an external swivel system. Results. Robotic-assisted transrectal cholecystectomy was successfully performed in 3 adult male pigs. The estimated blood loss was <10 mL in all 3 cases. There were no intraoperative complications. The system provided good dexterity and clear vision. Conclusions. The trial demonstrated that the system can provide the surgeon a stable platform with adequate spacing for the transrectal insertion of robotic arms, 3-dimensional vision, and enhanced dexterity in performing NOTES cholecystectomy.

[NOTES in visceral surgery : Current status]

The idea to use natural orifices as an access route for operations in the body has inspired many clinicians and researchers worldwide. Some of these expected a continuation of the development from open surgery to laparoscopic surgery finally to a less invasive modality. Others hoped for economic benefits for endoscopists to take over previous surgical patients into gastroenterological departments. The first experimental studies demonstrated that the initial expectations could not be implemented in a short period of time. The available endoscopes could not be proved for advanced procedures. Key problems like sterility, infection control, tissue manipulation, safety of access closure, and specimen retrieval manifested to be too large for routine clinical use. However, the attraction of the natural orifice transluminal endoscopic surgery (NOTES) philosophy has resulted in a reduction of the number and diameters of trocars in laparoscopic surgery. Hybrid NOTES as a combination of classical laparoscopic access with natural orifice instrumentations (mostly transvaginal) have become clinical reality in many hospitals. This development fits into the long-term trend towards less invasive surgery and more effective interventional methods in endolumenal endoscopy.

The Evolving Role of Minimally Invasive Surgery in Pediatric and Adolescent Urologic Oncology

OBJECTIVE

This review aims at evaluating the current status of minimally invasive surgery at the difficult crossroad between the attractiveness of innovation faced against the solid outcomes offered by the current gold standard, specifically concerning pediatric and adolescent urologic oncology conditions.

METHODS

This is a critical review of the literature and current paradigms on the use of minimally invasive surgery for pediatric and adolescent urologic oncology cancers. Focus is mainly on the use of laparoscopy for the treatment of Wilms' tumors but other neoplasms are also discussed.

RESULTS

We draw parallels with other similar pathologies, respecting critical lessons from international cooperative study groups. We discuss various aspects of the pros and cons of minimally invasive surgery in this patient population and make a case for the development of dedicated pediatric surgeons for urologic cancer.

CONCLUSION

Herein we draft a proposal suggesting a way forward with the adoption of reasonable paradigm shifts founded on carefully conducted studies for the introduction of minimally invasive surgery in the care of pediatric and adolescent urologic cancer.

Development of a puff- and suction-type pressure stimulator for human tactile studies

In this study, we developed a tactile stimulator capable of administering either puff- or suction-type stimuli. The system is composed of three parts: a control unit, an air-handling unit, and a stimulation unit. The control unit controls the type, intensity, and time of stimulation. The air-handling unit delivers the stimulation power quantitatively to the stimulation unit, as commanded by the control unit. The stimulation unit stably administers either type of pressure to the skin, without any change of the tactor. Although the design of the stimulator is simple, it allows for five levels of control of the stimulation intensity (2-6 psi) and 0.1-s steps of control of the stimulation time, as we confirmed by tests. Preliminary electroencephalographic and event-related potential (ERP) studies of our system in humans confirmed the presence of N100 and P300 waves at standard electrode position C3, which are related to perception and cognition, respectively, in the somatosensory area of the brain. In addition, different stimulation types (puff and suction) and intensities (2 and 6 psi) were reflected in different peak-to-peak amplitudes and slopes of the mean ERP signal. The system developed in this study is expected to contribute to human tactile studies by providing the ability to administer puff- or suction-type stimuli interchangeably.

[Minimally invasive surgery and robotic surgery: surgery 4.0?]

Surgery can only maintain its role in a highly competitive environment if results are continuously improved, accompanied by further reduction of the interventional trauma for patients and with justifiable costs. Significant impulse to achieve this goal was expected from minimally invasive surgery and, in particular, robotic surgery; however, a real breakthrough has not yet been achieved. Accordingly, the new strategic approach of cognitive surgery is required to optimize the provision of surgical treatment. A full scale integration of all modules utilized in the operating room (OR) into a comprehensive network and the development of systems with technical cognition are needed to upgrade the current technical environment passively controlled by the surgeon into an active collaborative support system (surgery 4.0). Only then can the true potential of minimally invasive surgery and robotic surgery be exploited.

Towards autonomous motion control in minimally invasive robotic surgery

INTRODUCTION

While autonomous surgical robotic systems exist primarily at the research level, recently these systems have made a strong push into clinical settings. The autonomous or semi-autonomous control of surgical robotic platforms may offer significant improvements to a diverse field of surgical procedures, allowing for high precision, intelligent manipulation of these systems and opening the door to advanced minimally invasive surgical procedures not currently possible.

AREAS COVERED

This review highlights those experimental systems currently under development with a focus on in vivo modeling and control strategies designed specifically for the complex and dynamic surgical environment. Expert review: Novel methods for state estimation, system modeling and disturbance rejection, as applied to these devices, continues to improve the performance of these important surgical tools. Procedures such as Natural Orifice Transluminal Endoscopic Surgery and Laparo-Endoscopic Single Site surgery, as well as more conventional procedures such as Colonoscopy, serve to benefit tremendously from the development of these automated robotic systems, enabling surgeons to minimize tissue damage and shorten procedure times while avoiding the consequences of laparotomy.

Women’s Perception of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Objective. Over the past 8 years, natural orifice transluminal endoscopic surgery (NOTES) has developed from preclinical to routine clinical practice. However, there are still concerns regarding the transvaginal approach. In our survey, we were interested in females with a professional medical background, thus having at least a basic medical understanding, which might discriminate between objective and subjective concerns. Material and Methods. A questionnaire with 14 items was distributed among 1895 female physicians and nursing and administration staff of the University Medical Center Hamburg-Eppendorf. In addition, a qualitative literature review was performed. Data analysis was carried out using statistical package R version 2.15.0. Results. The questionnaire was answered anonymously by 553 employees (29%). Fifty-seven percent were nurses, 18.6% belonged to administration, and 17% were physicians. A total of 63.1% of our respondents would choose the transvaginal NOTES technique for an assumed ovariectomy, while only 30.4% would choose this access for cholecystectomy. Doubts regarding transvaginal NOTES were related to sexual dysfunction (44.8%), its experimental nature (43.8%), future pregnancies (36.8%), and ethical reasons (30.3%). The literature review showed that women’s perception of the transvaginal access is documented very heterogeneously and therefore difficult to compare. Conclusions. Despite the good reported results of NOTES and the medical background of the surveyed female employees, our study and the literature review clearly shows that there are  fears regarding the transvaginal access, which might be a result of limited information. More accurate explanation of the available methods by the attending surgeon can lead to a better choice of the patient’s preferred method.