Critical analysis of hot topics in NOTES

Robotic platforms in gynaecological surgery: past, present, and future

Background

More than two decades ago, the advent of robotic laparoscopic surgery marked a significant milestone, featuring the introduction of the AESOP robotic endoscope control system and the ZEUS robotic surgery system. The latter, equipped with distinct arms for the laparoscope and surgical instruments, was designed to accommodate remote connections, enabling the practice of remote telesurgery as early as 2001. Subsequent technological progress has given rise to a range of options in today's market, encompassing multi-port and single-port systems, both rigid and flexible, across various price points, with further growth anticipated.

Objective

This article serves as an indispensable guide for gynaecological surgeons with an interest in embracing robotic surgery.

Materials and methods

Drawing insights from the experience of the Strasbourg training centre for minimally invasive surgery (IRCAD), this article offers a comprehensive overview of existing robotic platforms in the market, as well as those in development.

Results

Robotic surgical systems not only streamline established operative methods but also broaden the scope of procedures, including intra- and transluminal surgeries. As integral components of the digital surgery ecosystem, these robotic systems actively contribute to the increasing integration and adoption of advanced technologies, such as artificial intelligence-based data analysis and support systems.

Conclusion

Robotic surgery is increasingly being adopted in clinical practice. With the growing number of systems available on the marketplace, the primary challenge lies in identifying the optimal platform for each specific procedure and patient. The seamless integration of robotic systems with artificial intelligence, image-guided surgery, and telesurgery presents undeniable advantages, enhancing the precision and effectiveness of surgical interventions.

What is new?

This article provides a guide to the robotic platforms available on the market and those in development for gynaecologists interested in robotic surgery.

Advancing flexible endoscopy to natural orifice transluminal endoscopic surgery

PURPOSE OF REVIEW

This review is an update on the recent advancements and clinical applications of flexible endoscopy in the context of natural orifice translumenal endoscopic surgery (NOTES). We focus on recent developments in gastrointestinal luminal and transluminal NOTES.

RECENT FINDINGS

NOTES has evolved from a hybrid approach utilizing a laparoscopic assistant to pure NOTES without laparoscopic assistance. Current experimental and clinical studies focus on the implementation of new minimally invasive approaches as well as on the training in the use of these procedures. In recent years, flexible endoscopic-NOTES and endoluminal surgery have increasingly reported favorable results in preclinical and experimental settings using flexible endoscopic cholecystectomy, cholecystolithotomy, and appendectomy. Additionally, flexible endoscopic lymphadenectomy and thyroidectomy are among the new interventions that are opening new frontiers for endoscopists to explore.

SUMMARY

Flexible endoscopy has paved way to new frontiers for endoscopists and surgeons. As the armamentarium of interventional endoscopy increases and the ability of endoscopists to perform advanced interventions safely fosters an inevitable step forward that will involve the integration of new technology with innovative thinking.

International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video)

BACKGROUND

Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs).

OBJECTIVE

To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia.

DESIGN

Retrospective study.

SETTING

International, multicenter, academic institutions.

PATIENTS

All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included.

INTERVENTIONS

POEM.

MAIN OUTCOME MEASUREMENTS

Eckardt score and adverse events.

RESULTS

A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases.

LIMITATIONS

Retrospective design and selection bias.

CONCLUSION

POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients.

Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port?

Laparoscopic surgery for colorectal disease is an evolving, dynamic subject undergoing constant adaptation. Hence there are significant ongoing advances in technique and technology as has been seen with the emergence of single port and Natural Orifice Transluminal Endoscopic operations with already considerable ramifications for many aspects of minimal access surgery. Most recently single port technologies and expertise have synergized with Transanal Endoscopic (TEM/TEO) experience to allow their convergence out of their respective niches so that pelvic surgery can be laparoendoscopically performed from both its abdominal and perineal aspects. Distinct from wound-related benefits, such capacity for high resolution and multi-dimensional imaging relates significant benefit to the operating team and patient. This state of the art review demonstrates the crucial perspective that advanced practices and performance capabilities are intrinsically complimentary rather than competitive. All surgeons need therefore to participate in adapting their practice styles to allow technical step-advance across the discipline.

Cardiorespiratory impact of transesophageal endoscopic mediastinoscopy compared with cervical mediastinoscopy: a randomized experimental study

BACKGROUND

Transesophageal natural-orifice transluminal endoscopic surgery (NOTES) mediastinoscopy has been described as a feasible, less-invasive alternative to video-assisted mediastinoscopy (VAM). We aimed to investigate hemodynamic and respiratory effects during transesophageal NOTES mediastinoscopy compared with VAM.

PATIENTS AND METHODS

This was a short-survival experiment in 20 female pigs randomized to NOTES (n = 10) or VAM (n = 10) mediastinoscopy. In the NOTES group, an endoscopist accessed the mediastinum through a 5-cm submucosal tunnel in the esophageal wall, and CO2 was used to create the pneumomediastinum. Conventional VAM was carried out by thoracic surgeons. A 30-minute systematic exploration of the mediastinum was then performed, including invasive monitoring for hemodynamic and respiratory data. Blood samples were drawn for gas analyses.

RESULTS

All experiments except 2 in the NOTES group (one because of technical difficulties, the other because of thoracic lymphatic duct lesion) were completed as planned, and animals survived 24 hours. Also, 3 animals in the NOTES group presented a tension pneumothorax that was immediately recognized and percutaneously drained. VAM and NOTES animals showed similar pulmonary and systemic hemodynamic behavior during mediastinoscopy. Pulmonary gas exchange pattern was mildly impaired during the NOTES procedure, showing lower partial arterial oxygen pressure associated with higher airway pressures (more important in animals that presented with pneumothorax).

CONCLUSIONS

NOTES mediastinoscopy induces minimal deleterious respiratory effects and hemodynamic changes similar to conventional cervical VAM and could be feasible when performed under strict hemodynamic and respiratory surveillance. Notably, serious complications caused by the injury of pleura are more frequent in NOTES, which mandates an improvement in technique and suitable equipment.

Novel technique of auto-tunneling during peroral endoscopic myotomy (with video)

BACKGROUND

Peroral endoscopic myotomy (POEM) was developed to reduce lower esophageal sphincter pressure in patients with achalasia. POEM is technically challenging and time consuming. The creation of an esophageal submucosal tunnel is a major and integral part of the procedure. Dissection of the submucosal fibers is a lengthy task.

OBJECTIVE

To present our initial experience with the use of a novel gel with dissecting properties for facilitating submucosal tunneling during POEM.

SETTING

Johns Hopkins Hospital.

INTERVENTION

POEM.

RESULTS

The gastroscope was successfully introduced into the submucosal space in all pigs. The gel in the submucosal space was easily suctioned through the working channel of the gastroscope and did not interfere with endoscopic visualization. The esophageal submucosal tunnel was noted to be already formed upon entry into the submucosal space in all 5 pigs. Esophageal submucosal dissection was not required in any case. "Auto-tunneling" by the dissecting gel stopped at the level of the lower esophageal sphincter. Further tunneling into the gastric cardia was needed in all pigs. The average procedure (including myotomy) time was 28 minutes.

LIMITATIONS

Animal experiments.

CONCLUSION

Gel consistently resulted in efficient auto-tunneling without any complications. This gel has the potential to revolutionize POEM and endoscopic submucosal dissection if its safety and efficacy are replicated in other animal studies and subsequently in human trials.

Mid-gut stents

PURPOSE OF REVIEW

Gastrointestinal stents offer a feasible, safe, cost effective, and minimally invasive method for reestablishing luminal patency. Previous clinical reports and systematic reviews have demonstrated the role of enteral stents in both the upper and lower gastrointestinal tract. Over the last two decades, the rapid development of deep enteroscopy in concert with the evolution of various stent devices/deployment mechanisms has enabled placement of enteral stents in the mid-gut; hence this has been increasingly reported. The present article focuses on stenting in the mid-gut, a relatively novel term, referring to the small bowel between the ampulla and the ileocecal valve.

RECENT FINDINGS

Mid-gut stenting is technically more difficult than stenting in the upper and lower gastrointestinal tract, and therefore requires particular expertise, restricting its widespread utility. In total, 86 reported cases involving mid-gut stent deployment, by either endoscopic approaches (80.2%) or percutaneous approaches (19.8%), have been published. Although limited, these results have demonstrated that mid-gut stenting is reliable, effective, and a minimally invasive method for palliating malignant obstruction, as well as sealing leaks and fistulae.

SUMMARY

This article reviews the current status of mid-gut stenting, including endoscopic technique. The article also speculates about the potential for future advances within this field.

A technical review of flexible endoscopic multitasking platforms

BACKGROUND

Further development of advanced therapeutic endoscopic techniques and natural orifice translumenal endoscopic surgery (NOTES) requires a powerful flexible endoscopic multitasking platform.

METHODS

Medline search was performed to identify literature relating to flexible endoscopic multitasking platform from year 2004-2011 using keywords: Flexible endoscopic multitasking platform, NOTES, Instrumentation, Endoscopic robotic surgery, and specific names of various endoscopic multitasking platforms. Key articles from articles references were reviewed.

RESULTS

Flexible multitasking platforms can be classified as either mechanical or robotic. Purely mechanical systems include the dual channel endoscope (DCE) (Olympus), R-Scope (Olympus), the EndoSamurai (Olympus), the ANUBIScope (Karl-Storz), Incisionless Operating Platform (IOP) (USGI), and DDES system (Boston Scientific). Robotic systems include the MASTER system (Nanyang University, Singapore) and the Viacath (Hansen Medical). The DCE, the R-Scope, the EndoSamurai and the ANUBIScope have integrated visual function and instrument manipulation function. The IOP and DDES systems rely on the conventional flexible endoscope for visualization, and instrument manipulation is integrated through the use of a flexible, often lockable, multichannel access device. The advantage of the access device concept is that it allows optics and instrument dissociation. Due to the anatomical constrains of the pharynx, systems are designed to have a diameter of less than 20 mm. All systems are controlled by traction cable system actuated either by hand or by robotic machinery. In a flexible system, this method of actuation inevitably leads to significant hysteresis. This problem will be accentuated with a long endoscope such as that required in performing colonic procedures. Systems often require multiple operators. To date, the DCE, the R-Scope, the IOP, and the Viacath system have data published relating to their application in human.

CONCLUSION

Alternative forms of instrument actuation, camera control and master console ergonomics should be explored to improve instrument precision, sphere of action, size and minimize assistance required.