Natural Orifice Translumenal Endoscopic Surgery

A Comparative Study Between Single-Incision Laparoscopic Appendicectomy Using Conventional Instruments and Glove-Port (SILACIG) and Conventional Multiport Laparoscopic Appendicectomy (CMLA)

Introduction

Appendicectomy is the most common surgical procedure. Conventional laparoscopic appendicectomy being time-tested, attempts were made to make it less invasive. Single-incision laparoscopic appendicectomy is the most recent trend. The present study is conducted with the aim to compare surgical outcomes between single-incision laparoscopic appendicectomy using conventional instruments and glove-port (SILACIG) with conventional multiport laparoscopic appendicectomy (CMLA).

Materials and methods

A total of 80 patients with appendicitis were recruited and underwent SILACIG (n=40) and CMLA (n=40). They were monitored for operative time, time of oral intake, pain on the second postoperative day, day of discharge, return to work, and scar size after two months.

Results

There was no significant difference between SILACIG and CMLA in terms of the time of oral intake, day of discharge, and return to work. Operative time was significantly more in the SILACIG group as compared to CMLA. Pain on the second postoperative day was less than CMLA, and the size of the operative scar was significantly smaller than 2 cm in the SILACIG group as compared to the CMLA group.

Conclusion

SILACIG is a feasible, safe, and cost-effective technique. It is comparable with CMLA in terms of preoperative diagnosis, postoperative oral intake, hospitalization period, and return to work. It shows less pain on the second postoperative day and cosmetic benefit but requires more operative time than CMLA. 

Natural Orifice Transluminal Endoscopic Surgery-assisted Vaginal Hysterectomy versus Total Laparoscopic Hysterectomy: A Single-center Retrospective Study Using Propensity Score Analysis

Objectives

The aim of this study is to evaluate the safety and efficacy of natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy (NOTES-AVH) compared with total laparoscopic hysterectomy (TLH).

Materials and Methods

The population was a cohort of women who underwent NOTES-AVH and TLH for a nonprolapsed uterus and benign gynecological disease between October 2015 and December 2017 at Rajavithi Hospital, Thailand. Study outcomes included operative time, the requirement of blood transfusion, perioperative complications, and postoperative pain. Factors applied for propensity score matching included age, body mass index, parity, underlying disease, previous abdominal surgery, preoperative diagnosis, presence of endometriosis, and uterine weight. Mean difference (MD) and risk ratio with 95% confidence interval (CI) were calculated to represent relative measures of the comparison.

Results

Among the 50 pairs, there were no differences in operative time (MD 15.9 min; 95% CI - 9.3-41.1), intraoperative complications (relative risk [RR] 0.33; 95% CI 0.04-3.10) or requirement of blood transfusion (RR 1.50; 95% CI 0.26-8.60) between the NOTES-AVH and TLH groups. NOTES-AVH was associated with lower intensity of postoperative pain (MD - 1.5 at 6-h; 95% CI - 0.8-2.2 and MD - 1.0 at 24-h; 95% CI - 0.4--1.6) and shorter length of stay (MD - 0.3 day; 95% CI - 0.1-0.7 day).

Conclusion

NOTES-AVH was safe and feasible for an alternative approach for hysterectomy. This technique was superior to TLH in that no abdominal incision was required, and postoperative pain was less intense.

Lessons Learned After 101 Cases of Single-Site Magnetic-Assisted Cholecystectomy in Children

BACKGROUND / PURPOSE

The aim of this report is to present our experience with a magnetic-assisted single-site cholecystectomy technique ("magnachole") in pediatric patients.

METHODS

We performed a retrospective chart review of all patients who underwent magnachole between 2009 and 2019. We evaluated patients' demographics, diagnosis, operative time, complications, conversion rate and length of stay. Additionally, simple lineal regression analysis was conducted to determine if the surgeon's experience, the patient's age at surgery, the patient's gender or the patient's body weight affected operative time.

RESULTS

A total of 101 patients were operated during the analyzed period. The mean age at surgery was 12.6 (range 4 to 19) years, and the mean body weight was 53.7 (range 13.5 to 123) kg. The most frequent indication (91%) was symptomatic cholelithiasis. Mean operative time was 85 (range 45 to 240) min. The mean operative time decreased by 22.7 min (p < 0.001, 95% [CI] 10.35 to 35.13) when we compared the first 51 cases to the last 50 cases. Simple lineal regression showed a reduction of 2.6 min in operative time per year. Age at surgery, gender, and weight did not influence operative time. There were no intraoperative complications. Only 1 case required an additional port to complete the operation. There were no conversions to open cholecystectomy. Median length of stay was 26 h (range 10 to 168).

CONCLUSION

The magnachole technique is safe and effective, and has become our preferred surgical approach for children who need a cholecystectomy. As expected, the operative time decreased as surgeons gain experience with the technique. The technique is feasible regardless of the patient's body habitus.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Canine ovariectomy by hybrid or total natural orifice transluminal endoscopic surgery: technical feasibility study and pain assessment

OBJECTIVE

To compare technical feasibility, surgical time, surgical complications, and postoperative pain in ovariectomy (OVE) by hybrid and total natural orifice transluminal endoscopic surgery (NOTES).

STUDY DESIGN

Prospective randomized clinical trial.

ANIMALS

Sixteen healthy and sexually intact bitches.

METHODS

Dogs were randomly assigned to the hybrid NOTES group (HNG; n = 8) and the total NOTES group (TNG; n = 8) to compare surgical time, pain scores and complications. Pain was assessed by using the visual analog scale (VAS) and the Melbourne pain scale (MPS).

RESULTS

Surgical time did not differ between the experimental groups (HNG = 46.3 ± 18.5 minutes, TNG = 54.6 ± 31.1 minutes). Exteriorization of the ovaries through the vaginal wound was the major difficulty. Complications were minor in both groups and occurred intraoperatively only in the HNG, and in both groups post operatively. No dogs required rescue analgesia in the intraoperative or postoperative period. There were no differences in VAS or MPS scores between the groups for any surgical times except for the VAS assessment at 72 hours after extubation (HNG = 1.1 ± 0.3, TNG = 0.7 ± 0.4, P = .0221).

CONCLUSION

Both NOTES techniques were comparable for canine OVE, with no requirement for additional analgesia in the postoperative periods. It was not possible to determine whether there was a clear advantage of one technique rather than the other.

CLINICAL SIGNIFICANCE

The minimally invasive techniques proposed for laparoscopic OVE are feasible for dogs with low pain scores and low rates of complications for both groups.

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.

Intra-abdominal bacterial contamination in TAMIS total mesorectal excision for rectal carcinoma: a prospective study

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) is currently gaining a lot of attention. NOTES is expected to further reduce surgical trauma and improve patient care due to eliminating abdominal incisions. The interest in transrectal NOTES has grown slowly, because of concerns of bacterial contamination due to transection of the rectum at the start of the procedure. However, different studies already demonstrated that transanal TME (TaTME) can be performed without major complications. This prospective study focuses on the presence and clinical significance of peritoneal bacterial contamination after TaTME for rectal cancer.

METHODS

Three bacterial cultures were taken at standardized locations from the pelvic area after completion of the TaTME procedure and before closure of the incisional wounds. The cultures were evaluated for bacterial count and species identification. Furthermore, C-reactive protein and white blood cell count were measured perioperatively, and postoperative complications were recorded.

RESULTS

Twenty-three consecutive patients were included between July 2013 and December 2014. Thirty-nine percent (9/23) of the cultures showed gastrointestinal flora. Four of these patients (44 %) developed presacral abscesses. The remaining 61 % (14/23) of the cultures were negative. None of these patients developed infectious complications.

CONCLUSION

Transanal TME procedures are associated with positive cultures in more than one-third of the patients. In these patients, postoperative locoregional infectious complications are more common.

Ovariossalpingo-histerectomia em cadelas: comparação da dor e análises cardiorrespiratória, pressórica e hemogasométrica nas abordagens convencional, por NOTES híbrida e NOTES total

A cirurgia endoscópica por orifícios naturais (NOTES) é um novo conceito de abordagem videocirúrgica, que surge como alternativa à cirurgia convencional, eliminando incisões abdominais e as possíveis complicações relacionadas a ela. A proposta deste artigo foi comparar técnicas de ovariossalpingo-histerectomia (OSH) em cadelas, buscando determinar o procedimento que oferece menores alterações hemodinâmicas e menos estímulos dolorosos trans e pós-operatório. Para tanto, foram utilizadas 21 cadelas alocadas em três grupos. No primeiro, os pacientes foram submetidos à OSH por celiotomia (GC), no segundo por meio da técnica de NOTES híbrida (GNH) e no terceiro (GNT), utilizando-se a técnica de NOTES total. O tempo cirúrgico do GNH foi significativamente maior que nos demais grupos. Em ambos os grupos de cirurgia NOTES, verificou-se diminuição das pressões arteriais médias e diastólicas no transoperatório. Apenas o grupo GNH desenvolveu acidose severa no transoperatório. Levando-se em consideração as avaliações da dor, apenas o grupo convencional necessitou de analgesia resgate transcirúrgica. No pós-operatório, observou-se que os cães do GC apresentaram índices mais elevados na escala visual analógica e na escala de Melbourne que os animais dos demais grupos, sendo necessária analgesia resgate em 100% deles. Em contraste, no GNT nenhum dos cães requereram complementação analgésica pós-operatória. Conclui-se que a técnica de OSH por NOTES total apresenta parâmetros cardiorrespiratórios e hemogasométricos semelhantes à técnica convencional e mais estáveis que a técnica de NOTES híbrida, bem como resulta em menor dor trans e pós-operatória que a técnica convencional.

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.

[Peroral endoscopic full and partial-thickness myotomy. A viability study in an animal model]

BACKGROUND

Peroral endoscopic myotomy has recently been developed and performed on patients with good results.

AIMS

To evaluate the technical feasibility of peroral endoscopic full-thickness and partial thickness myotomy in a porcine model.

MATERIAL AND METHODS

Eighteen criollo pigs were randomly assigned to 2 groups: group A (partial-thickness myotomy) and group B (full-thickness myotomy). The mucosal defect proximal to the myotomy site was left open. On the seventh postoperative day the pig was euthanized and follow-up surgical exploration was performed. The duration of each procedure, postoperative progression of the animal, complications, and anatomopathologic findings were registered.

RESULTS

The procedure was viable in all the pigs. The mean surgery duration was 81±35.3min (group A 51.11±11.12, group B 111±22.61; P<.05). The main complication during myotomy was subcutaneous emphysema (16%). The histopathologic study of the group A surgical specimens reported complete circular myotomy in all cases, and complete circular and longitudinal myotomy was reported in 100% of the group B sample.

CONCLUSIONS

The endoscopic myotomy technique is feasible. Endoscopic partial-thickness myotomy was associated with shorter surgery duration and better results during the intraoperative period and the 7-day follow-up.

A comparison of transumbilical single-port laparoscopic appendectomy and conventional three-port laparoscopic appendectomy: from the diagnosis to the hospital cost

Purpose

Recently many cases of appendectomy have been conducted by single-incision laparoscopic technique. The aim of this study is to figure out the benefits of transumbilical single-port laparoscopic appendectomy (TULA) compared with conventional three-port laparoscopic appendectomy (CTLA).

Methods

From 2010 to 2012, 89 patients who were diagnosed as acute appendicitis and then underwent laparoscopic appendectomy a single surgeon were enrolled in this study and with their medical records were reviewed retrospectively. Cases of complicated appendicitis confirmed on imaging tools and patients over 3 points on the American Society of Anesthesia score were excluded.

Results

Among the total of 89 patients, there were 51 patients in the TULA group and 38 patients in the CTLA group. The visual analogue scale (VAS) of postoperative day (POD) #1 was higher in the TULA group than in the CTLA group (P = 0.048). The operative time and other variables had no statistical significances (P > 0.05).

Conclusion

Despite the insufficiency of instruments and the difficulty of handling, TULA was not worse in operative time, VAS after POD #2, and the total operative cost than CTLA. And, if there are no disadvantages of TULA, TULA may be suitable in substituting three-port laparoscopic surgery and could be considered as one field of natural orifice transluminal endoscopic surgery with the improvement and development of the instruments and revised studies.

A review of minimally invasive single-port/incision laparoscopic appendectomy

INTRODUCTION

Single-port/incision laparoscopic appendectomy (SPILA) is a modern advancement toward stealth surgery, using a single point of entry. Despite the paucity of clinical data, it is increasingly being used to minimize scarring and, potentially, pain associated with the multiple entry points. We aimed to summarize and present available data on this new approach.

METHODOLOGY

All available databases until December 2010 including the Cochrane Controlled Trials Register, MEDLINE, and EMBASE were searched and cross-referenced for studies describing single-incision laparoscopic appendectomy. Case and experimental reports, series with fewer than 5 patients, and non-English articles were excluded. Outcome measures were operative time, postoperative hospital stay, pain scores, complications, conversion, and mortality, stratified according to type of SPILA approach. SPSS version 18.0.0 software was used for data collection.

RESULTS

Database query yielded 79 articles; 45 were included (1 randomized controlled trial, 44 case series). Total cases were 2806, with mean patient age for studies ranging from 7.0 to 37.5 years. No mortality was reported. The overall complication rate was 4.13%. The overall weighted mean operating time was 41.3 minutes (range, 15.0-95.9 minutes). The weighted mean hospital stay was 2.79 days (range, 1.0-6.6 days).

CONCLUSIONS

Although the incidence of complications with SPILA remains low and operating times between new and traditional approaches are comparable in case-based literature, adequately powered randomized trials are required to assess its effectiveness. Occurrence of long-term complication types remains unexplored.

Endolumenal rectal resection and transanal natural orifice specimen extraction (NOSE) without rectal stump opening: a novel, clean surgical technique in a porcine model

Minimally invasive surgery has been continuously evolving over the past 20 years. The use of natural orifice specimen extraction (NOSE) is one of the most recent contributions to minimally invasive methods. The anus has been widely used in NOSE procedures. However, an open rectal stump carries the highest risk of contamination compared with other translumenal approaches to the peritoneal cavity. In this study, the feasibility of a novel NOSE method was tested in a porcine model. This technique combined abdominal and transanal approaches. The abdominal approach was used in rectal mobilization; 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 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. The specimen was resected and extracted by making a full-thickness incision through 2 bowel walls distal to the previously placed ligatures. Anastomosis was achieved by applying the stapler. The technique was found to be feasible. A substantial length of bowel was resected in all experiments. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. Although more investigation is warranted, this procedure has the potential to limit surgical site infections by using aseptic bowel manipulation during colorectal resection and transanal specimen extraction.

The lateral decubitus position improves transoral endoscopic access to the posterior aspects of the thorax

BACKGROUND

The success of natural orifice transluminal endoscopic surgery (NOTES) depends on an adequate exploration of surgical regions. Currently, limited data are available regarding the optimal position for the NOTES approach for thoracic surgery. This study therefore aimed to evaluate the effectiveness of transoral thoracic exploration in a canine model placed in a lateral decubitus position.

METHODS

A total of 14 dogs were used in this study. Transoral thoracoscopy was performed using a custom-made metal tube via an incision over the vestibular incision with the animal in a supine position. After thoracic exploration, the animal was placed in a lateral decubitus position. The thoracic intervention (surgical lung biopsy, pericardial window creation, and dorsal sympathectomy) was performed by passing a flexible bronchoscope through the lumen of a metal tube.

RESULTS

The mean operative time for this procedure was 70 min (range 45-100 min). For 12 dogs, all procedures were completed without major complications. However, for one dog, the exploration of the thoracic cavity was incorrect (the right lower lobe had been misinterpreted as the left lower lobe). Another dog had minor bleeding because of an intercostal artery injury that occurred during sympathectomy.

CONCLUSION

The posterior aspect of the thoracic cavity can be exposed via a transoral approach with the animal in a lateral decubitus position. This approach may be considered as an adjuvant to the supine approach, in which exploration of the posterior thoracic cavity is restricted.

Single-incision laparoscopic appendectomy: prospective case series at a single centre in Singapore

PURPOSE

Laparoscopic appendectomy is widely accepted as a standard of care for acute appendicitis. Aim of our study is to assess the safety and feasibility of single-incision laparoscopic appendectomy (SILA) in our hospital setting.

METHODS

From March to August 2010, 30 patients (21 male, 9 female) with mean age 30.4 years (range, 17 to 64 y) with clinical diagnosis of acute appendicitis underwent SILA.

RESULTS

The procedure was successful in 28 of 30 patients. Mean operative time was 80.4 minutes (range, 31 to 136 min). There was no mortality or major postoperative complication. The median hospital stay was 1.9 days (range, 1 to 5 d). The mean visual analogue scale score at the time of discharge was 2.2 (range, 1 to 4).

CONCLUSIONS

In our early experience, SILA is safe and feasible, with acceptable operative time, short learning curve, and good cosmetic result.

Laparo-endoscopic single-site radical prostatectomy: Feasibility and technique

Background

As laparoscopy becomes a standard approach in many urological procedures, researchers strive to make minimally invasive surgery less invasive. Our objective was to apply recent innovations in equipment and surgical approaches to develop the technique and perform laparo-endoscopic single site radical prostatectomy (LESS-RP).

Methods

The technique for LESS-RP was derived by combining existing techniques of standard laparoscopic RP and developing techniques of urological LESS. This incorporated newly available low-profile trocars, flexible instruments and a flexible-tip laparoscope. The procedure was performed through a single 3-cm transverse infra-umbilical incision. LESS-RP was completed successfully via a single operative site without auxiliary needles or trocars. Perioperative variables and postoperative outcomes were recorded and measured.

Results

The operative time was 424 min and the hospital stay was 10 days because of a vesicourethral leak and ileus. The anastomotic leak resolved and the urethral catheter was removed at 4 weeks after surgery. The final pathology showed negative margins and Gleason 3 + 4 pT2c prostatic adenocarcinoma.

Conclusions

LESS-RP is feasible by replicating laparoscopic RP techniques and incorporating the LESS technique with the advent of flexible-tip laparoscopes and flexible instruments. After a learning curve has been overcome, this should be further tested prospectively to compare oncological and functional outcomes with laparoscopic and robotic-assisted RP.

A prospective, randomized assessment of a spatial orientation device in natural orifice transluminal endoscopic surgery

BACKGROUND

One of the challenges in natural orifice transluminal endoscopic surgery (NOTES) is spatial orientation. The Queen's NOTES group has devised a novel method of orientation by using a magnetic device that passes within an endoscope channel allowing for 3-dimensional imaging of the shape and orientation of the endoscope.

OBJECTIVE

To assess the feasibility and utility of a novel orientation device.

DESIGN

Randomized, controlled trial.

SETTING

Animal research laboratory study on four 25-kg pigs.

INTERVENTION

The device was tested by 6 endoscopists and 6 laparoscopic surgeons. Starting at the gastrotomy, the time to identify 4 targets was recorded. Participants were required to identify and touch the gallbladder, the fallopian tube, a clip on the abdominal wall, and the liver edge. Use of the orientation device was randomized for each session.

MAIN OUTCOME MEASUREMENTS

Time to identify targets with and without the device. Secondary analysis assessed differences between medical specialties and level of training.

RESULTS

The mean time to identify all 4 targets with the device was 75.08 ± 42.68 seconds versus 100.20 ± 60.70 seconds without the device (P <.001). The mean time to identify all 4 targets on the first attempt was 102.29 ± 61.36 seconds versus 72.99 ± 40.19 seconds on the second attempt (P <.001). No differences based on specialty or level of training were identified.

LIMITATIONS

Small sample size and simplicity of tasks.

CONCLUSION

Regardless of randomization order, both groups were faster with the device. These encouraging results warrant further study using more complex scenarios.

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients

OBJECTIVES

Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases.

METHODS

Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented.

RESULTS

Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients.

CONCLUSIONS

Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

The future of endoscopy

Extraordinary developments have occurred in the field of endoscopy over the past 40 years. The era that began with the fiberoptic endoscope (fiberscope) has now moved to the videoscope and, more recently, to the capsule endoscope. Videoendoscopy will remain the major form of endoscopy for the next 5-10 years but, thereafter, diagnostic procedures including colonoscopy will increasingly be performed by capsule endoscopy. This change will be largely driven by patient preference rather than superior results from capsule studies. Image analysis of capsule studies will be accelerated by software that highlights abnormal areas and, by 2025, capsule studies will be 'read' by computer. For the next decade, more complex therapeutic procedures will be performed by a new group of therapeutic endoscopists using advanced videoscopes. Several new therapeutic procedures will emerge but natural orifice transluminal approaches will need to compete with advances in laparoscopic techniques. It is also likely that health administrators faced with escalating medical costs will demand that new and more expensive procedures not only facilitate patient care but result in superior health outcomes.

Single-incision laparoscopic appendectomy for acute appendicitis: a preliminary experience

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) is a major conceptual change in the field of modern surgery. However, corresponding technological refinements are not yet available to fill the gap separating the current laparoscopy from the NOTES of the future. Meanwhile, "hybrid" NOTES techniques, including single-port procedures, have been increasingly reported. This report describes a technique of single-incision laparoscopic appendectomy (SILA) for selected patients with acute appendicitis.

METHODS

Patients with noncomplicated acute appendicitis, excluding those with abscess, perforation, peritonitis, previous surgery, or obesity, underwent SILA. The procedure was performed using a single 15-mm-diameter umbilical incision with two 5-mm-diameter port sites.

RESULTS

The study enrolled 36 women and 19 men with a mean age of 28 years (range, 18-78 years). The procedure was achieved for 41 patients (74.5%). The mean operative time was 39 min (range, 14-111 min). There was no mortality. The postoperative complication rate was 5.4% (3 complications in 3 patients), and the median hospital stay was 39 h (range, 8-240 h).

CONCLUSION

The SILA technique is safe and feasible for selected patients with noncomplicated acute appendicitis. Compared with other transumbilical techniques of appendectomy, SILA has the advantages of feasibility without endoscopic skills and an acceptable operative time. Technical refinements and accomplished learning probably will enable its wider use for more patients with acute appendicitis.

Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy

INTRODUCTION

There have been attempts to minimize the invasiveness of laparoscopic cholecystectomy by reducing the size and/or the number of the operating ports and instruments. These attempts create technical challenges related principally to retraction and triangulation necessary to expose the surgical field for a safe surgery. A new technique based on retraction and triangulation with magnetic instruments for single port laparoscopic surgery is presented.

METHODS

Between March 2007 and December 2008, 40 laparoscopic cholecystectomies were performed with single-port laparoscopic surgery with the assistance of magnetic forceps (IMANLAP project). The surgical technique is described, and the intraoperative and postoperative course of the patients is assessed.

RESULTS

There were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. Depending on the patient's anatomy, a 1-mm needle was added in some cases. There were no interactions observed between the magnetic devices and the anesthetic monitoring and the rest of the devices of the operation room.

CONCLUSIONS

This new procedure is feasible and safe. The main goal is control of the magnetic field, allowing enough controlled strength for retraction and sufficient triangulation for adequate exposure of the surgical field. This allows for the use of a single port through which an optic device with a working channel can perform the operation with safety. Finally, the procedure can be performed in a manner similar to the traditional laparoscopic cholecystectomy, and it also appears to be simple to learn.

Totally NOTES (T-NOTES) transvaginal cholecystectomy using two endoscopes: preliminary report

BACKGROUND

Clinical applications of transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) are still limited in the literature, mostly case reports performed by hybrid procedures with laparoscopic assistance. Avoiding complications from incisions is the main goal for natural orifice surgery. This study reports on a technique developed at our institution that uses two endoscopes inserted into the vagina to perform a Totally NOTES (T-NOTES) transvaginal cholecystectomy, and describes preliminary results.

METHODS

IRB approval was obtained at the institution for transvaginal NOTES clinical trials, and informed consent was obtained. The technique of T-NOTES transvaginal cholecystectomy was clinically applied in four female patients with symptomatic cholelithiasis, and data were prospectively documented. Transvaginal NOTES access was obtained by direct vaginal incision, and two endoscopes were simultaneously introduced in the abdominal cavity. Dissection was accomplished with available endoscopic instruments. Ligation of cystic duct and artery was performed using endoscopic clips. Vaginal closure was achieved using the direct-vision sutured technique.

RESULTS

The technique was successfully performed in the four patients. Insufflation and spatial orientation was of good quality. Mean operative time was 210 min. There were no complications during the 30-day follow-up. Postoperative course was uneventful, and patients were released from the hospital on the first postoperative day.

CONCLUSION

Tranvaginal T-NOTES using two endoscopes provides a feasible method for natural orifice cholecystectomy using available technology. Large-series studies are needed to evaluate the results with respect to safety of the approach.