Early results of novel robotic surgery-assisted low anterior resection for rectal cancer and transvaginal specimen extraction by using Da Vinci XI: initial clinical experience

OBJECTIVE

The aim of this study is to evaluate the early results of robotic surgery-assisted low anterior resection for rectal cancer and transvaginal specimen extraction, regarding the operative time, operative and early postoperative complications, hospital stay, and pathological reports in a series of 10 patients.

METHODS

From November 2016 to October 2019, case series study on patients diagnosed with RC was included in this study. All robotic-assisted low anterior resection of the rectum, vaginal removal of the specimen, colorectal anastomosis, and loop ileostomies were performed using the Da Vinci XI system.

RESULTS

The mean age of patient was 64.8 (58-72) years. Low anterior resection was performed to seven patients, and very low anterior resection was performed to three patients. Total mesorectal excision of the rectum, transvaginal specimen extraction, transanal anastomoses, and protective ileostomy were performed in all 10 patients. The mean operative time was 275±30.50 min, and estimated blood loss was 50±10.50 mL. No patient required conversion to conventional surgery. Negative circumferential resection, proximal, and distal margins were accomplished negative. Mean number of lymph nodes harvested was 20±5.5. According to the pathological reports, all were adenocarcinoma. T1 stage was 80.0%, and T2 stage was 20.0%. Lymph node metastasis accounted for 80.0%.

CONCLUSIONS

To our literature search, this is the first study reporting the early outcomes of the novel robotic surgery-assisted low anterior resection for rectal cancer and transvaginal specimen extraction by using the Da Vinci Xi system. It can be performed safely and successfully in selected patients by providing an excellent cosmetic body image, which may be important for women.

Transvaginal laparoscopic salpingo-oophorectomy: an oncological risk-reducing procedure

Aim:

Since the first natural orifice transluminal endoscopic surgery procedure, renewed interest has arisen in further developing and advancing minimal access surgery. We introduce a natural orifice endoscopic approach for a bilateral salpingo-oophorectomy.

Patients & methods:

Using the vagina as a natural orifice, we performed a transvaginal laparoscopic salpingo-oophorectomy to remove bilateral adnexa in patients with a strong family history of ovarian and/or breast cancer and those positive for BRCA1/2 mutation.

Results:

Total 36 women underwent transvaginal laparoscopic salpingo-oophorectomy. Conversion to routine laparoscopy was required in eight patients to complete the operation. No peri-operative complications were noted.

Conclusion:

We describe a novel approach in gynecological surgery. Our technique proved to be safe and efficient with the advantage of avoiding any abdominal scars.

This article describes a novel, keyhole surgical approach to remove tubes and ovaries in a female patient. The approach is known as a ‘natural orifice endoscopic approach’ and involves using the vagina as a natural orifice. Both tubes and ovaries were removed in patients with a strong family history of ovarian and/or breast cancer and those positive for BRCA1/2 genetic mutation. Two ports are inserted into the vagina to access the abdomen with both specimens subsequently retrieved vaginally. Total 36 women underwent the procedure with no complications. The technique proved to be safe and efficient with the advantage of avoiding any abdominal scars compared with routine keyhole surgery.

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).

Electrocautery device does not provide adequate pulmonary vessel sealing in transumbilical anatomic pulmonary lobectomy

INTRODUCTION

Safe pulmonary vessel sealing device plays a crucial role in anatomic lung resection. In 2014, we reported high rates of massive bleeding complications during transumbilical lobectomy in a canine model due to difficulty in managing the pulmonary vessel with an endostapler. In this animal survival series, we aimed to evaluate the outcome of pulmonary vessel sealing with an electrocautery device to simplify the transumbilical thoracic surgery.

METHODS

Under general anesthesia, a 3-cm longitudinal incision was made over the umbilicus. Under video guidance, a bronchoscope was inserted through the incision for exploration. The diaphragmatic wound was created with an electrocautery knife and used as the entrance into the thoracic cavity. Using the transumbilical technique, anatomic lobectomy was performed with electrosurgical devices and endoscopic vascular staplers in 15 canines.

RESULTS

Transumbilical endoscopic anatomic lobectomy was successfully completed in 12 of the 15 animals. Intraoperative bleeding developed in three animals during pulmonary hilum dissection, where one animal was killed due to hemodynamic instability and the other two animals required thoracotomy to complete the operation. There were five delayed bleeding and surgical mortality cases caused by inadequate vessel sealing by electrosurgical devices. Postmortem examination confirmed correct transumbilical lobectomy in the twelve animals that survived the operations.

CONCLUSION

Transumbilical anatomic lobectomy is technically feasible in a canine model; however, the electrosurgical devices were not effective in sealing the pulmonary vessel in the current canine model.

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.

Transvaginal laparoscopic appendectomy simultaneously with vaginal hysterectomy: initial experience of 10 cases

Background

Natural orifice transluminal endoscopic surgery (NOTES) involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform surgical interventions. The vagina is the most widely used approach to NOTES. We report the utilization of the vaginal opening at the time of vaginal hysterectomy as a natural orifice for laparoscopic appendectomy.

Material/Methods

We reviewed cases of 10 patients with chronic appendicitis who underwent transvaginal laparoscopic appendectomy simultaneously with vaginal hysterectomy. A laparoscopic approach was established after removal of the uterus, and the appendix was removed transvaginally. Among the 10 cases, 5 were conducted under gasless laparoscopy by using a simple abdominal wall-lifting instrument.

Results

All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 21 minutes to 34 minutes. All patients were discharged less than 4 days after surgery, without external scars.

Conclusions

Transvaginal appendectomy with rigid laparoscopic instruments following vaginal hysterectomy appears to be a feasible and safe modification of established techniques, with acceptable outcomes.

Feasibility of transumbilical anatomic pulmonary lobectomy in a canine model

PURPOSE

Transthoracic thoracoscopic lobectomy is the preferred method of surgical treatment for early lung cancer. Current methods require a transthoracic approach and are associated with chronic postoperative pain in up to 25% of patients. Single-port transumbilical uniport surgery may offer advantages over multiport surgery with less postoperative pain and better cosmetic results. The aim of this study was to evaluate the feasibility of a transumbilical anatomic lobectomy of the lung (TUAL) in a canine model.

METHODS

TUAL was performed in 12 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. Variables evaluated for surgical outcomes were operating time, operative complications, body rectal temperature, respiratory rate, white blood cell count, and arterial blood gases.

RESULTS

TUAL was successfully completed in ten animals. There were six bleeding complications related to surgery. In four animals, an avulsion of pulmonary vessel causes intraoperative bleeding, requiring simultaneous pulmonary artery and bronchus resections. In one animal, slipping of endoclip after vessel clipping caused perioperative bleeding. The other animal encountered bleeding complication during dissection of inferior pulmonary vein. Both animals required conventional thoracotomy to complete the surgery.

CONCLUSIONS

TUAL in the canine model is feasible but associated with significant morbidity. With further development and refinement of instruments, comparative studies between the novel transumbilical lobectomy and the current video-assisted transthoracic lobectomy will clarify the role of transumbilical lobectomy in thoracic surgery.

Acute inflammatory response to transgastric natural orifice transluminal endoscopic surgery peritoneoscopy: an experimental study in swine

OBJECTIVE

To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy.

METHODS

This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1β, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h.

RESULTS

All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1β, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups.

CONCLUSIONS

Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric peritoneal access by natural orifice transluminal endoscopic surgery is similar in intensity to the response that occurs after laparoscopy.

Present and future advanced laparoscopic surgery

Modern laparoscopy, starting with Kurt Semm's insufflators and the first successful appendectomies, has only been around for approximately 30 years. Since those early successes, the technology has grown from the inception of basic laparoscopy to endoscopic surgery through natural orifices, and it continues to evolve by leaps and bounds with computer-assisted surgery and improved robotics in surgery. Without question, laparoscopy has revolutionized the way we perform standard surgery, especially relative to the techniques that had been used for hundreds of years. Despite the development of multiple novel technologies since the 1980s, very little has changed with regard to basic conceptualizations and practice of laparoscopy. In this review article, we will describe the highlights of recent advanced laparoscopic surgery procedures, their potential applications within the field of surgery, and how these advances may impact and improve future quality and patient outcomes.

Feasibility of Transumbilical Surgical Lung Biopsy and Pericardial Window Creation

Background. To date there are no practical platforms for performing natural orifice transluminal endoscopic surgery in the thoracic cavity. This study evaluates the feasibility of transumbilical thoracosopy for lung biopsy and pericardial window creation. Methods. Eleven dogs (6 in the nonsurvival group and 5 in the survival group) were used for this study. A homemade metallic tube was advanced into the abdominal cavity via a 12-mm umbilical incision. The metallic tube was advanced into the thoracic cavity through a subxyphoid diaphragmatic incision under video guidance. Access to the thoracic cavity was achieved by a flexible bronchoscope via the metallic tube. Surgical lung biopsy and pericardial window creation were performed using an electrocautery loop and needle knife. The animals were euthanized 20 minutes after the surgery was complete (nonsurvival group) or 14 days postsurgery (survival group) for necropsy evaluation. Results. Eight pericardial window creations and 21 of 22 preplanned lung biopsies were completed in a median time of 72.18 minutes (range 50-105 minutes). One dog in the nonsurvival group died after tension pneumothorax due to postprocedure massive air leaks. In the survival group, the postoperative period was uneventful in all 5 dogs. Autopsies revealed no signs of vital organ injury and complete healing of the diaphragmatic incision occurred in all animals. Conclusions. The study demonstrated that transumbilical thoracoscopic surgical lung biopsy and pericardial window creation is feasible. The safety and efficacy of the transumbilical approach need to be verified by a more detailed survival study.

Colorectal natural orifice transluminal endoscopic surgery (NOTES) and transvaginal/transrectal specimen extraction

Advancements in minimally invasive surgery have both revolutionized laparoscopy and set the stage for the advancement of endoscopic surgery to the forefront of modern medicine. Natural orifice transluminal endoscopic surgery (NOTES) has now become a subject of great interest to surgeons worldwide who wish to reduce the morbidity associated with abdominal operations. However, the application of NOTES to colorectal surgery has thus far been limited due to the complex dissection, anastomosis and specimen extraction typically required when operating on the large bowel. For this reason, laparoscopic-assisted natural orifice surgery has been the means by which most surgeons have begun to incorporate natural orifice surgery into their established practices. Transanal endoscopic surgery, transvaginal-assisted laparoscopy and transrectal specimen extraction are all emerging techniques that may be currently employed, in a hybrid manner, with traditionally accepted laparoscopic operations in order to transition toward less invasive surgery and even pure NOTES. To this end, the vagina appears to be the most practical and widely used site of specimen extraction and adjunct access site for laparoscopic hybrid operations. An accompanying video demonstrates the authors' preferred technique for transvaginal and transrectal specimen extraction.

Transoral endoscopic surgery versus conventional thoracoscopic surgery for thoracic intervention: safety and efficacy in a canine survival model

PURPOSE

Transoral endoscopic surgery has been shown to be feasible and safe in both humans and animal models. The purpose of this study was to evaluate the safety and efficacy of transoral and conventional thoracoscopy for thoracic exploration, surgical lung biopsy, and pericardial window creation.

METHODS

The animals (n = 20) were randomly assigned to the transoral endoscopic approach group (n = 10) or conventional thoracoscopic approach group (n = 10). Transoral thoracoscopy was performed with a flexible bronchoscope via an incision over the vestibulum oris. In conventional thoracoscopy, access to the thoracic cavity was obtained through a thoracic incision. Surgical outcomes (body weight, operating time, operative complications, and time to resumption of normal diet), physiologic parameters (respiratory rate, body temperature), inflammatory parameters [white blood cell (WBC) counts and C-reactive protein (CRP)], and pulmonary parameters (arterial blood gases) were compared for both procedures.

RESULTS

The surgical lung biopsy and pericardial window creation were successfully performed in all animals except one animal in the transoral group. There was no significant difference in operating times between the groups. The increase in WBC in the transoral thoracoscopy group was significantly smaller on postoperative day 1 than in the conventional thoracoscopy group (p = 0.0029). The transoral group had an earlier return to preoperative body temperature (p = 0.041) and respiratory rate (p = 0.045) on day 7. With respect to pulmonary parameters, there was no significant difference in blood pH, pCO2, or PaCO2 between the transoral and transthoracic groups. All animals survived without complications 14 days after surgery.

CONCLUSIONS

This study demonstrated that the transoral approach was comparable to conventional thoracoscopic surgery for lung biopsy and pericardial window creation in terms of safety and efficacy.

Comparison of hemodynamic and inflammatory changes between transoral and transthoracic thoracoscopic surgery

BACKGROUND

Natural orifice transluminal endoscopy has been developed for abdominal surgical procedures. The aim of this study was to compare the surgical outcome between a novel transoral approach and a standard transthoracic approach for the thoracic cavity in a canine model.

METHODS

Twenty-eight dogs were assigned to transoral (n = 14) or standard thoracoscopy (n = 14). Each group underwent thoracic exploration, pre-determined surgical lung biopsy, and pericardial window creation. Blood draws were obtained before surgery and at postoperative days 1, 3, 7, and 14. Operative time, complications, laboratory parameters, hemodynamic parameters, and inflammatory parameters were compared between the two procedures. The animals were monitored for two weeks and necropsy were performed for surgical outcome evaluation.

RESULTS

The thoracic procedures were successfully performed in all of the dogs, with the exception of one animal in the transoral group. There were no serious acute or delayed complications related to surgery. There was no difference between the two surgical groups for each of the hemodynamic parameters that were evaluated. Regarding the immunological impact of the surgeries, transoral thoracoscopy was associated with significant elevations in interleukin 6 and c-reactive protein levels on postoperative days 1 and 3, respectively, when compared with the standard thoracoscopy. All dogs recovered well, without signs of mediastinitis or thoracic infection. Necropsy revealed absence of infection, no injury to vital organs, and confirmed the success of the novel procedure.

CONCLUSIONS

This study suggests that both techniques were comparable with respect to procedure success rate, hemodynamic impact, and inflammatory changes. Furthermore, there was no difference in the incidence of postoperative discomfort between groups.

Needs analysis for developing a virtual-reality NOTES simulator

INTRODUCTION AND STUDY AIM: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical technique that requires a cautious adoption approach to ensure patient safety. High-fidelity virtual-reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing the virtual transluminal endoscopic surgery trainer (VTEST) for this purpose. The objective of this study is to conduct a structured needs analysis to identify the design parameters for such a virtual-reality-based simulator for NOTES.

METHODS

A 30-point questionnaire was distributed at the 2011 National Orifice Surgery Consortium for Assessment and Research meeting to obtain responses from experts. Ordinal logistic regression and the Wilcoxon rank-sum test were used for analysis.

RESULTS

A total of 22 NOTES experts participated in the study. Cholecystectomy (CE, 68 %) followed by appendectomy (AE, 63 %) (CE vs AE, p = 0.0521) was selected as the first choice for simulation. Flexible (FL, 47 %) and hybrid (HY, 47 %) approaches were equally favorable compared with rigid (RI, 6 %) with p < 0.001 for both FL versus RI and HY versus RI. The transvaginal approach was preferred 3 to 1 to the transgastric. Most participants preferred two-channel (2C) scopes (65 %) compared with single (1C) or three (3C) or more channels with p < 0.001 for both 2C versus 1C and 2C versus 3C. The importance of force feedback and the utility of a virtual NOTES simulator in training and testing new tools for NOTES were rated very high by the participants.

CONCLUSION

Our study reinforces the importance of developing a virtual NOTES simulator and clearly presents expert preferences. The results of this analysis will direct our initial development of the VTEST platform.

Single-port endo-laparoscopic surgery (SPES) for totally extraperitoneal inguinal hernia: a critical appraisal of the chopstick repair

PURPOSE

Developments in minimal access surgery brought a new concept: single-port endolaparoscopic surgery (SPES). The aim of our study is to verify the safety and feasibility of SPES TEP hernia repair and report our initial clinical outcome.

METHODS

We prospectively collected data of all patients who underwent SPES TEP repair from May 2009 to December 2010. Data regarding patient demographics, type, size and location of hernia, port devices used, type of mesh and fixation, operative time, complications, length of stay and cosmetic results were collected and analyzed.

RESULTS

A total of 47 patients (36 M, 11 F) underwent 70 SPES TEP hernia repairs; median age was 53 years (range 22-80). 60 % had indirect hernia, 27.5 % direct, 8.5 % pantaloon, 2 % femoral and 2 % recurrent hernias. Mean hernia size was 1.91 ± 0.67 cm. Port devices used include 33 Triport, 12 SILS and 2 SSL. We used anatomical mesh in 20; flat polypropylene in 10 and titanium-coated polypropylene mesh in 17 patients. Fixation of mesh was achieved in 18 patients with absorbable tacks, 8 with titanium tacks, 1 with fibrin glue, and no tack in 20 with anatomical mesh. No conversions occurred and small seroma was reported in 3 (6.3 %) patients. Mean operative time was 96.48 min (range: 50-150). Average hospital stay was 11.8 h (range: 9-26). Median follow-up was 11 months (range 6-18), and no recurrence was noted. 82.6 % patients were very satisfied, and 17.4 % were satisfied with the procedure.

CONCLUSION

SPES TEP repair is a safe and feasible technique with good patient satisfaction.

Surgery via natural orifices in human beings: yesterday, today, tomorrow

BACKGROUND

We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated.

METHODS

Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated.

RESULTS

The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable.

CONCLUSIONS

NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.

Perirectal NOTES access: "down-to-up" total mesorectal excision for rectal cancer

OBJECTIVES

Clinical natural orifice surgery has been applied for abdominal surgery in recent years, mostly by vaginal and oral access. The study describes preliminary successful human applications of transcolonic natural orifice transluminal endoscopic surgery (NOTES), using a new transrectal total mesorectal excision procedure for rectal cancer.

METHODS

Institutional review board approval was obtained for the study. In 2 patients with rectal adenocarcinoma, total mesorectal resection and rectosigmoidectomy with lymphadenectomy was performed using a low NOTES transcolonic access. "Down-to-up" mesorectal dissection was achieved either using a flexible scope or a transrectal single port device. The specimens were extracted transanally, and transorificial low anastomosis was performed.

RESULTS

Operative time was 350 and 360 minutes, respectively; no complications occurred and patients were discharged after 6 days.

CONCLUSION

Successful human reports on transcolonic NOTES suggest potential applications. The treatment of colorectal diseases through transorificial single port or flexible perirectal NOTES access are promising new approaches besides current methods to improve patient care.

Development of a feasible transrectal natural orifice transluminal endoscopic surgery (NOTES®) approach in a cadaveric appendectomy model: anterior is better

BACKGROUND

The transrectal natural orifice transluminal endoscopic surgery (NOTES) approach is a potentially promising alternative to transgastric or transvaginal approaches for intraperitoneal procedures. However, whether the optimal transrectal approach for intraperitoneal surgery is anterior or posterior remains unknown. To evaluate this, a prospective comparison of anterior and posterior transrectal NOTES approaches in a cadaveric appendectomy model was performed.

METHODS

Operations were performed on human cadavers using a transanal endoscopic microsurgery (TEM) scope to assist with access and closure. Posterior access was achieved by tunneling cephalad through the retrorectal space into the peritoneal cavity. Anterior transrectal access was established through the rectal wall just above the peritoneal reflection. A dual-channel flexible endoscope was used to perform appendectomies. Rectotomies were closed using sutures or staples. Operative time, degree of laparoscopic assistance, complications, and leak-testing results were recorded.

RESULTS

This study investigated 10 cadavers with access and closure attempted using both anterior (n = 10) and posterior (n = 5) approaches, whereas appendectomies were performed using either an anterior (n = 8) or a posterior (n = 2) approach. The anterior approach required less time than the posterior approach for peritoneal access (4 ± 1 vs. 61 ± 14 min; p < 0.001), specimen extraction (2 ± 1 vs. 5 ± 1 min; p < 0.01), and the total operation (99 ± 35 vs. 176 ± 26 min; p = 0.02). A "pure" NOTES dissection was possible with the anterior approach using rigid transanal instruments for assistance. Dissection time, closure time, and the incidence of complications were similar between the two approaches. Leak testing of closures showed significant variability for all closure types.

CONCLUSION

Transrectal NOTES appendectomy is feasible in a cadaveric model using an anterior transrectal approach. This approach is technically easier, results in shorter operative times, and allows for a "pure" NOTES dissection compared with a posterior transrectal approach. Leak pressure testing of NOTES closures is unreliable in the cadaveric model.