Rapid Communication: Transvaginal Single-Port NOTES Nephrectomy: Initial Laboratory Experience

Hysterectomy and bilateral adnexectomy using transvaginal natural orifice transluminal endoscopic surgery: The role of multichannel abdominal PORT and vaginal support ring

BACKGROUND

Although transvaginal natural orifice transluminal endoscopic surgery (NOTES) is gaining importance, knowledge on transvaginal NOTES procedures in gynecologic practice is limited.

OBJECTIVE

We aimed at evaluating the feasibility and safety of performing hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) via transvaginal NOTES using a self-developed multichannel abdominal port and vaginal support ring.

STUDY DESIGN

A prospective, single-center, cohort pilot study was conducted from May to December 2017 in patients with benign uterine diseases or endometrial atypical hyperplasia or cervical intraepithelial neoplasia (n = 30) scheduled for laparoscopic hysterectomy. The procedure was performed using a self-developed five-channel port and a vaginal support ring.

RESULTS

Hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) in all 30 cases (mean age: 51.43 ± 4.60 years and body mass index: 23.42 ± 1.45 kg/m² ) were successfully performed completely under transvaginal NOTES. Mean operation time was 95.90 ± 14.60 minutes and mean blood loss during the procedure was 52.50 ± 19.20 mL. Average weight of specimen was 79.97 ± 35.48 g. Only one complication of bladder injury was noted and was rectified accordingly. Visual Analog Score (VAS) at first day after operation was 2.70 ± 0.72. After follow-up for 4.50 ± 1.85 months, all the patients' vaginal stump healed well without scar formation.

CONCLUSION

Our study showed that use of multichannel abdominal port could make laparoscopic instruments easier to fix and operate wherein the vaginal support ring reduces the leakage of carbon dioxide pneumoperitoneum. There was no scar on the abdomen and VAS was much lower. This study also demonstrated cosmetic benefits and rapid postoperative recovery.

Compact teleoperated laparoendoscopic single-site robotic surgical system: Kinematics, control, and operation

BACKGROUND

To date a variety of teleoperated surgical robotic systems have been developed to improve a surgeon's ability to perform demanding single-port procedures. However typical large systems are bulky, expensive, and afford limited angular motion, while smaller designs suffer complications arising from limited motion range, speed, and force generation. This work was to develop and validate a simple, compact, low cost single site teleoperated laparoendoscopic surgical robotic system, with demonstrated capability to carry out basic surgical procedures.

METHODS

This system builds upon previous work done at the University of Hawaii at Manoa and includes instrument and endoscope manipulators as well as compact articulated instruments designed to overcome single incision geometry complications. A robotic endoscope holder was used for the base, with an added support frame for teleoperated manipulators and instruments fabricated mostly from 3D printed parts. Kinematics and control methods were formulated for the novel manipulator configuration.

RESULTS

Trajectory following results from an optical motion tracker and sample task performance results are presented.

CONCLUSIONS

Results indicate that the system has successfully met the goal of basic surgical functionality while minimizing physical size, complexity, and cost.

Pure retroperitoneal natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy using standard laparoscopic instruments: a safety and feasibility study in a porcine model

Background

Among the different organs used for NOTES (natural orifice translumenal endoscopic surgery) technique, the transvaginal approach may be the optimal choice because of a simple and secure closure of colpotomy site. Pure and hybrid NOTES transvaginal operations were routinely performed via transperitoneal access. In this study, we investigate the safety and feasibility of pure retroperitoneal natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy using conventional laparoscopic techniques in a porcine model.

Methods

Six female pigs, weighing an average of 30 kg, were used in this study. Under general anesthesia, pure retroperitoneal NOTES transvaginal nephrectomy was conducted using standard laparoscopic instruments. Posterolateral colpotomy was performed, and the incision was enlarged laterally using blunt dissection and pneumatic dilation. A single-port device was inserted to construct the operative channel. The retroperitoneal space was created using sharp and blunt dissection under endoscopic guidance up to the level of the kidney. Dissection and removal of the kidney were performed according to standard surgical procedure, and the colpotomy site was closed using interrupted sutures. The survival and complications were observed 1 week postoperatively.

Results

Our results showed that two cases failed because of peritoneal rupture. One case was successful, but required the assistance of an extra 5 mm laparoscopic trocar inserted in the flank. Three cases of pure retroperitoneal NOTES transvaginal nephrectomy were completed, and survived 1 week after the operation. In these three cases, no intra- or postoperative complications were observed.

Conclusions

All findings confirmed the safety and feasibility of the retroperitoneal pure retroperitoneal NOTES transvaginal nephrectomy using standard laparoscopic instruments, which suggested the possibility of clinical application in human beings in the future.

Advances in laparoscopic urologic surgery techniques

The last two decades witnessed the inception and exponential implementation of key technological advancements in laparoscopic urology. While some of these technologies thrived and became part of daily practice, others are still hindered by major challenges. This review was conducted through a comprehensive literature search in order to highlight some of the most promising technologies in laparoscopic visualization, augmented reality, and insufflation. Additionally, this review will provide an update regarding the current status of single-site and natural orifice surgery in urology.

Impact of cosmetic result on selection of surgical treatment in patients with localized prostate cancer

Objectives:

To analyze the effect of cosmetic outcome as an isolated variable in patients undergoing surgical treatment based on the incision used in the 3 variants of radical prostatectomy: open (infraumbilical incision and Pfannestiel incision) and laparoscopic, or robotic (6 ports) surgery.

Patients and methods:

612 male patients 40 to 70 years of age with a negative history of prostate disease were invited to participate. Each patient was evaluated by questionnaire accompanied by a set of 6 photographs showing the cosmetic appearance of the 3 approaches, with and without undergarments.

Participants ranked the approaches according to preference, on the basis of cosmesis. We also recorded demographic variables: age, body mass index, marital status, education level, and physical activity.

Results:

Of the 577 patients who completed the questionnaries, the 6-port minimally invasive approach represents the option preferred by 52% of the participants, followed by the Pfannestiel incision (46%), and the infraumbilical incision (11%), respectively. The univariate and multivariate analyses did not show statistically significant differences when comparing the approach preferred by the patients and the sub-analyses for demographic variables, except for patients who exercised who preferred the Pfannestiel incision (58%) instead of minimally invasive approach (42%) with statistically significant differences.

Conclusion:

The minimally invasive approach was the approach of choice for the majority of patients in the treatment of prostate cancer. The Pfannestiel incision represents an acceptable alternative. More research and investment may be necesary to improve cosmetic outcomes.

Percutaneous Externally Assembled Laparoscopic Instruments: Creation of a New Surgical Paradigm

OBJECTIVES

Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) produce excellent cosmetic outcomes, but are technically challenging. The objective of this study was to test the functionality and feasibility of a novel minimally invasive surgical paradigm, which maintains triangulation but uses special externally assembled instruments to minimize the postoperative cosmetic impact.

METHODS

Percutaneous Externally Assembled Laparoscopic (PEAL) instruments have specialized 2.96-mm shafts with interchangeable 5-mm working tips that are assembled externally. First, 5-mm laparoscopic, PEAL, and 2-mm needlescopic instruments were tested to determine piercing force on fresh human cadaver organs. In a bench-top study, 20 subjects assembled and used PEAL instruments in five different skills tests that were also compared with the same tasks using conventional laparoscopic instruments. Finally, PEAL instrument functionality was tested in a four-porcine nephrectomy feasibility study.

RESULTS

PEAL (2.80 lbF) and 5-mm laparoscopic instruments (2.28 lbF) had a significantly higher mean organ piercing perforation force compared with needlescopic instruments (1.39 lbF, p < 0.05). Average assembly time of PEAL instruments was 31.08 seconds (range: 19.83-43.85). There were no significant differences in the amount of time needed for completion of the bench-top tasks between laparoscopic and PEAL instruments (p > 0.05 for all tasks). Four-porcine PEAL nephrectomies were completed with no complications and minimal blood loss (mean 7.5 mL). Mean operative time was 98.25 minutes (range 79-116).

CONCLUSION

PEAL tools are easily assembled, have similar safety and efficacy compared with standard laparoscopic tools, and are less likely to injure organs compared with needlescopic instruments. They function well during laparoscopic nephrectomy and may decrease the invasiveness of conventional laparoscopic instrumentation.

Roles of NOTES and LESS in management of small renal masses

INTRODUCTION

Over the last 2 decades, open surgery has been largely displaced by laparoscopic surgery for the treatment of renal masses. Recently, minimally invasive surgical techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES), have been developed for such purpose.

METHODS

In the present literature review, the current status of treatment for small renal masses was investigated. The advantages and disadvantages of LESS and NOTES are presented to confirm the feasibility and reproducibility of these techniques.

RESULTS

LESS significantly reduces pain and offers excellent cosmetic outcomes with comparable oncological and perioperative results, and NOTES offers the potential for surgery by various approach without any transcutaneous abdominal incision in management of small renal masses.

CONCLUSION

When the technical limitations are overcome, clinical application of LESS and NOTES is expected to increase. Further prospective and comparative studies are needed to clarify the application of these new techniques.

[Natural orifice transluminal endoscopic surgery in urology: feasability of a transrectal, flexible retroperitoneoscopy in a porcine model]

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) in urology is becoming more and more interesting due to technical innovations. One of those innovations is the HybridKnife®, a multifunctional sonde that combines high-frequency electrosurgery and water jet surgery. The aim of this study was to establish a transrectal, flexible endoscopic retroperitoneoscopy in a porcine model by means of the HybridKnife® for further development of a transrectal retroperitoneal NOTES lymphadenectomy (NOTES-RLA).

MATERIAL AND METHODS

Five female pigs (25-30 kg body mass) were anesthetized and placed in a supine position. The rectal mucosa was opened 3-5 cm cranially of the linea dentata. After submucosal tunneling, the retrorectal space was opened. We performed a flexible endoscopic retroperitoneoscopy by means of a double-channel gastroscope 13.806 PKS (Karl Storz-Endoskope, Tuttlingen, Germany) and the HybridKnife® I-type (ERBE Elektromedizin, Tübingen, Germany).

RESULTS

Transrectal access was safe and feasible without any difficulties. Using the HybridKnife® water jet technology, the retroperitoneal space could be distended which enabled safe access to the iliacal vessels, the bifurcation of the aorta/vena cava, and the pre- and paraaortal/-caval space up to the renal vessels. The water jet did not lacerate or injure blood vessels, nerves, or lymph vessels in any of the surgical procedures.

CONCLUSIONS

By means of the HybridKnife®, transrectal access into the retrorectal space is safe and easily feasible. The water jet technology combined with electrosurgery prevented injuries of blood vessels, nerves, and lymph vessels and enabled transrectal flexible endoscopic retroperitoneoscopy as a precondition for further establishment of a transrectal NOTES-RLA.

Future perspective of gastric cancer endotherapy

Endoscopic resection of early gastric cancer (EGC) has proven safety and efficacy, and is the established standard of care in Japan. In the past decade, it is increasingly established worldwide. The endoscopic submucosal dissection (ESD) is superior to endoscopic mucosal resection (EMR) technique as it is designed to provide adequate staging and long-term curative therapy-based on the en bloc R0 specimen irrespective of the size and/or location of the tumor coupled with the reliable pathological specimen. However, ESD is still requiring skilled and experienced endoscopist to perform because of complex procedures, higher complication and causing long-time consuming. The learning and application of these relatively complex endoscopic techniques for EGC has been shown across the world. Thus, a standardized ESD training system is urgently needed to disseminate safe and effective ESD technique to practices with limited ESD experience. In recent years, several innovations providing solutions to easier and safer performance of ESD have emerged. Those increase control of surgical effectors manipulating the target tissue, and enhance performance in complex surgical tasks. Very recently, the use of the laparoscopic and endoscopic cooperative surgery (LECS) procedure is indicated for EGC that would be difficult to treat with ESD. As an ultimate gastric cancer endotherapy with a reasonable surgical time, LECS might be promising method at this stage. The indications for LECS for EGC could be expanded in the future, which could result in increasingly successful gastric cancer treatment.

A state of the art review and categorization of multi-branched instruments for NOTES and SILS

BACKGROUND

Since the advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and single incision laparoscopic surgery (SILS), a variety of multitasking platforms have been under development with the objective to allow for bimanual surgical tasks to be performed. These instruments show large differences in construction, enabled degrees of freedom (DOF), and control aspects.

METHODS

Through a literature review, the absence of an in-depth analysis and structural comparison of these instruments in the literature is addressed. All the designed and prototyped multitasking platforms are identified and categorized with respect to their actively controlled DOF in their shafts and branches. Additionally, a graphical overview of patents, bench test experiments, and animal and/or human trials performed with each instrument is provided.

RESULTS

The large range of instruments, various actuation strategies, and different direct and indirect control methods implemented in the instruments show that an optimal instrument configuration has not been found yet. Moreover, several questions remain unanswered with respect to which DOF are essential for bimanual tasks and which control methods are best suited for the control of these DOF.

CONCLUSIONS

Considering the complexity of the currently prototyped and tested instruments, future NOTES and SILS instrument development will potentially necessitate a reduction of the available DOF to minimize the control complexity, thereby allowing for single surgeon bimanual task execution.

Minimally invasive surgical instruments with an accessory channel capable of integrating fibre-optic cable for optical biopsy: A review of the state of the art

This review article provides a comprehensive overview and classification of minimally invasive surgical instruments with an accessory channel incorporating fibreoptics or another auxiliary device for various purposes. More specifically, this review was performed with the focus on the newly emerging field of optical biopsy, its objective being to discuss primarily the instruments capable of carrying out the optical biopsy and subsequent tissue resection. Instruments housing the fibreoptics for other uses, as well as instruments with an accessory channel capable of housing the fibreoptics instead of their original auxiliary device after relevant design modifications, supplement the review. The entire Espacenet and Scopus databases were searched, yielding numerous patents and articles on conceptual and existing instruments satisfying the criteria. The instruments were categorised based on the function the fibreoptics or the auxiliary device serves. On the basis of their geometrical placement with respect to the tissue resector or manipulator, the subcategories were further defined. This subdivision was used to identify the feasibility of performing the optical biopsy and the tissue resection in an accurate and successive fashion. In general, the existing concepts or instruments are regarded as limited with regard to such a functionality, either due to the placement of their accessory channel with or without the fibreoptics or due to the operational restrictions of their tissue manipulators. A novel opto-mechanical biopsy harvester, currently under development at Delft University of Technology, is suggested as a promising alternative, ensuring a fast and accurate succession of the optical and the mechanical biopsies of a flat superficial tissue.

Single-access laparoscopic rectal cancer surgery using the glove technique

INTRODUCTION

Single-access laparoscopic surgery has been widely adopted in many kinds of surgery including laparoscopic cholecystectomy and laparoscopic colectomy. Performing single-access rectal surgery, however, has technical drawbacks such as instrument collision and endostaple application issues. The glove technique is likely to mitigate these problems.

METHODS

Fourteen patients with anal canal to mid-rectum cancers were recruited and underwent single-access laparoscopic surgery via the glove technique. An incision was made at the paraumbilicus to insert a wound protector with surgical gloves. The operation was medial to lateral and inferior mesenteric artery and inferior mesenteric vein were identified and controlled. Total mesorectal excision was performed while keeping traction and countertraction down to the pelvic floor.

RESULTS

Average operative time was 251.66 min (range, 180-300 min). Hospital stay ranged from 5 to 8 days (median, 7 days). No serious early postoperative surgical problems related to complications were observed. The pathologic results showed good mesorectal capsule grading. The mean lymph node harvest was 14 nodes (range, 7-26 nodes), and the mean wound length was 5 cm (range, 4-6 cm).

CONCLUSIONS

In rectal surgery, the glove technique for single-access laparoscopic surgery is feasible and is comparable to commercial single-port techniques in terms of oncologic results.

LESS and NOTES instrumentation: future

PURPOSE OF REVIEW

Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are novel techniques with potential to minimize the morbidity of surgery. Challenging ergonomics, instrument clashing, and the lack of true triangluation still remain great concerns.

RECENT FINDINGS

New technological developments in instrument design have been created to enhance clinical applicability of these techniques. Further technological advancements including the incorporation of novel robotic surgical platforms (R-LESS) exploit the ergonomic benefits in an attempt to further advance LESS surgery. Promising devices include magnetic anchoring and guidance systems that have the potential to allow external manoeuvring of intracorporeal instruments while facilitating triangulation and reducing clashing. As well, the benefit of miniature in-vivo robots that can be placed endoscopically intra-abdominally and controlled wirelessly will allow internal manipulation of tissue from internal repositionable platforms.

SUMMARY

It remains to be seen whether LESS or NOTES will prove their clinical benefit over standard laparoscopic or robotic procedures. In this chapter, we review the current LESS and NOTES technology, and focus on new innovations and research in the field.

Reduction in Renal Specimen After Laparoscopic Radical Nephrectomy: A Histopathologic Analysis

Abstract Background and Purpose: There is no consensus on the most appropriate way to extract the kidney after laparoscopy. A previous study evaluated the reduction in total kidney volume and incision size (40%) after perfusion with a 5% hypertonic solution in a porcine model. The purpose of the current study was to compare the histopathologic renal tumor diagnosis before and after this perfusion. Furthermore, fluid drained from the renal vein was analyzed for the presence of neoplastic cells. Materials and Methods: After radical nephrectomy, specimens of 21 cases of renal tumors were studied. A small piece of the tumor was removed and fixed in formaldehyde. After that, 500 mL of a 5% NaCL solution was infused through the renal artery. The first 10 mL drained from the vein was collected and sent for cytologic study. The specimens and the fragment were analyzed. The parameters studied were histologic subtypes, Fuhrman grade, necrosis, and microvascular invasion. Results: Clear-cell renal carcinoma was found in 81% of the cases. Two cases of chromophobic renal carcinoma, one case of papillary tumor, and one case of oncocytoma were found. There were no differences in histologic subtypes, Fuhrman grade, necrosis, and microvascular invasion before and after perfusion in most of the cases. All cytologic analysis of drained liquid from the renal vein was negative for neoplastic cells. Conclusions: Renal perfusion with 5% NaCL solution after laparoscopic radical nephrectomy did not interfere with the histopathologic and cytologic characteristics of the kidney. In addition, all samples from the liquid drained from the renal vein were negative for neoplastic cells. These findings suggest that renal shrinkage with hypertonic saline after laparoscopic radical nephrectomy is feasible and might be useful for patients with kidney cancer. Validation of our results as well as their impact on clinical outcomes is warranted.

Urological applications of natural orifice transluminal endoscopic surgery (NOTES)

Improvements in surgical techniques, and particularly the development and widespread clinical introduction of laparoscopy in the past two decades, have revolutionized the management of urological disease. Natural orifice transluminal endoscopic surgery (NOTES) holds promise in further advancing treatment outcomes in urology. This novel minimally invasive surgical approach can negate the requirement for skin incisions and, therefore, could potentially improve morbidity, convalescence, and cosmesis. After considerable preclinical development, the feasibility of 'hybrid' NOTES-involving concurrent laparoscopy-and 'pure' NOTES nephrectomy and prostatectomy procedures has now been successfully demonstrated in patients with urological conditions, whereas proof-of-concept studies of NOTES partial cystectomy have been performed in animal models. Whether such procedures offer therapeutic and safety benefits compared with traditional laparoscopic techniques remains unknown; indeed, concerns remain over the potential perioperative and postoperative adverse events associated with NOTES, such as incomplete closure of the entry-point incision, infection, and haemorrhage. In particular, however, the requirement for the development of specific rationally designed NOTES instrumentation as well as specially trained, highly skilled personnel to perform the surgery continues to restrict the utility of NOTES. Thus, considerable effort is now needed to shift the focus of research to refining NOTES methodologies to enable translation of these promising proof-of-principle studies into the clinic.

Hybrid transvaginal nephrectomy: development of our technique

OBJECTIVE

To evaluate the development of natural orifice transluminal endoscopic surgery (NOTES) transvaginal nephrectomy and present the initial experience.

METHODS

Thirty-eight female patients were submitted to hybrid NOTES transvaginal nephrectomy for tumor (n=23) and nonfunctioning renal unit (n=15) in 2 academic medical centers. Patients underwent surgery from July 2010 to June 2012 and none of them were candidates for partial nephrectomy (clinical stage T1b or higher). The procedure was performed by the use of multi-instrument ports or flexible cannulas inserted through umbilical and vaginal incisions. A 30° lens extra-long camera and combinations of conventional laparoscopic and prebent instruments were used. Specially designed extra-long, prebent straight instruments were found to be particularly useful for transvaginal manipulations. Prospective data regarding patient demographics, intraoperative and postoperative course of the patients, and pathology results were collected.

RESULTS

Average tumor diameter was 6 cm (range, 4.9-7.5 cm). Average operative time was 114.1 minutes (range, 90-190 minutes). Estimated blood loss ranged between 50 and 150 mL (average, 80 mL). Intraoperatively, 2 bladder perforations occurred and were treated by suturing. Postoperatively, 2 patients suffered from fever of unknown origin and 2 patients required transfusions due to bleeding. Average hospital stay was 3.3 days (range, 3-5 days). Positive surgical margins were not detected.

CONCLUSION

Hybrid NOTES transvaginal nephrectomy is a feasible and safe alternative to standard laparoscopic nephrectomy in selected patients. Difficulties arising from limitations in current instrumentation have been addressed by the use of specially designed instruments. Further clinical studies are required to ascertain this approaches' place among nephrectomy techniques.

Gastric ESD: current status and future directions of devices and training

Endoscopic mucosal resection (EMR) of early gastric cancer, which has been proved to be safe and effective and is the established standard of care in Japan, has become increasingly established worldwide in the past decade. Endoscopic submucosal dissection (ESD) is superior to EMR, as it is designed to provide precise pathologic staging and long-term curative therapy based on an en bloc R0 specimen irrespective of the size and/or location of the tumor. However, ESD requires highly skilled and experienced endoscopists. The introduction of ESD to the Western world necessitates collaborations between Eastern and Western endoscopists, pathologists, and surgeons.

Feasibility of transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in the cadaveric model

OBJECTIVE

To examine feasibility of transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in human cadavers in the evolution of this technique, as transrectal hybrid NOTES nephrectomy has been demonstrated in the porcine model.

METHODS

Four hybrid transrectal NOTES nephrectomies were performed on 4 cadavers (3 female/1 male, 2 right/2 left). Pneumoperitoneum was created by periumbilical 12-mm trocar, through which a laparoscope was advanced to obtain intra-abdominal visualization. A 4-cm horizontal incision was made 2-cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A peritoneal window was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen entrapment bag was deployed transrectally for specimen extraction, followed by transrectal incision closure.

RESULTS

Transrectal NOTES nephrectomy was successfully performed in all cases, with intact specimen extraction. Median weight was 77 kg (range 74-85 kg); median body mass index (BMI) was 30.1 kg/m(2) (range 25.6-31.2 kg/m(2)). Mean operative time was 175 minutes (range 150-210 minutes). Median transrectal access time was 36 minutes (range 24-47 minutes). Median dimensions of removed kidneys were length 11.2 cm (range 10-12 cm), width 5 cm (range 4.5-6 cm), and thickness 3.8 cm (range 3-4.5 cm).

CONCLUSION

Transrectal hybrid NOTES nephrectomy in the cadaver model is feasible with intact specimen extraction and acceptable operative times. Preclinical survival studies are requisite to assess sterility and complications. This approach may be an alternative to transvaginal access.

Gastric surgery and notes

Rather than being an end point in and of itself, NOTES offers an approach that encompasses the potential use of a natural orifice in conjunction with flexible instruments as a less invasive and more cosmetically appealing method of performing certain surgical procedures. Gastric surgery through natural orifices is one of the cutting-edge procedures in the evolving field of NOTES. The potential indications for NOTES involve a wide spectrum of upper gastrointestinal diseases, including achalasia, reflux disease, submucosal tumors, cancer, and morbid obesity. Although NOTES is becoming more widely used, most studies still involve only small numbers of patients, and the design of larger series and comparative trials to evaluate the early indications and results of NOTES is needed.

Endoscopic submucosal dissection--current success and future directions

More than 10 years have passed since endoscopic submucosal dissection (ESD) was first developed in Japan. ESD enables en bloc complete resection of superficial gastrointestinal neoplasms regardless of the size and location of the lesions. With improvements in techniques and devices, excellent therapeutic results have been achieved despite the inherent technical difficulties of this procedure. ESD aiming for curative treatment can be performed for gastrointestinal neoplasms without risk of lymph node metastasis. Accurate histopathologic examination of the resected specimen is required to determine the risk of lymph node metastasis, for which en bloc resection is beneficial. Owing to the high success rate of en bloc complete resection and accurate histopathologic examination, tumour recurrence rates after ESD are reported to be very low in Japan. Excellent results of ESD in a large number of cases have also been reported from other Asian countries such as South Korea, Taiwan and China. Although scepticism exists among Western clinicians regarding the application of ESD, it is developing slowly and reports indicate promising results in some European countries. With further development of technologies, such as endoscopic robotics, ESD could become the worldwide treatment of choice for early gastrointestinal neoplasms.

[Onset of a training program for single-port laparoscopic urology]

OBJECTIVES

To describe the onset of a single port laparoendoscopic program to carry out oncology surgery in a Urology Service. We present the initial experience in the laboratory and in the Animal Facility with rigid precurved instruments and KeyPort reusable access element (Richard Wolf).

MATERIAL AND METHODS

Two surgeons experienced in laparoscopic surgery and with the help of four assistants performed a training program based on predetermined tasks performed in simulation boxes (pelvitrainer) and porcine model following the requirements of the Regional Community of Madrid to handle experimental animals.

RESULTS

The participants in this program were initially divided into pairs made up of an experienced surgery and assistant for the predetermined multiple tasks in simulator box in order to become familiarized with the instruments. After, 20 animal sessions were conducted in which the following were performed: (retroperitoneal or pelvic) lymph node dissections (n = 20), nephrectomies (n = 40), cystorrhaphy with suture (n = 20) and uterine-vesical anastomosis (n = 20). Times needed to perform the exercises and the principal errors perceived during the performance of each one of the tasks were recorded. The tasks, of growing complexity, were performed with the instruments described in increasingly less time and with less difficulty. An accessory trocar of 3.5 mm was required to perform the in vivo sutures.

CONCLUSIONS

The KeyPort approach has potential application in different urological applications. Standardized training allows the acquirement of skills and makes the successful implementation possible of a laparoendoscopic surgery program in humans.

Laparoendoscopic single site in pelvic surgery

Laparoendoscopic single site (LESS) has recently gained momentum as feasible techniques for minimal access surgery. Our aim is to describe the current status of laparoendoscopic single site (LESS) in pelvic surgery. A comprehensive revision of the literature in LESS pelvic surgery was performed. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-01 to 30-11-11. References outside the search period were obtained selected manuscript΄s bibliography. Search terms included: pelvic anatomy, less in gynecology, single port colectomy, urological less, single port, single site, NOTES, LESS and single incision. 314 manuscripts were initially identified. Out of these, 46 manuscripts were selected based in their pelvic anatomy or surgical content; including experimental experience, clinical series and literature reviews. LESS drastically limit the surgeon's ability to perform in the operative field and the latter becomes hardened by the lack of space in anatomical location like the pelvis. Potential advantages of LESS are gained with the understanding that the surgical procedure is more technically challenging. Pelvic surgical procedures related to colorectal surgery, gynecology and urology have been performed with LESS technique and information available is mostly represented by case reports and short case series. Comparative series remain few. LESS pelvic surgery remain in its very beginning and due to the very specific anatomical conditions further development of LESS surgery in the mentioned area can be clearly be facilitated by using robotic technology. Standardization ad reproducibility of techniques are mandatory to further develop LESS in the surgical arena..

Transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney morcellation: a proof of concept study

Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Until now, the transvaginal approach has been the only method of removing larger specimens from the abdominal cavity using natural orifice transluminal endoscopic surgery. There has been no means of extracting larger specimens in men and the means are restricted even in women, particularly in young women. The present study shows that the difficulty of large specimen retrieval can be overcome, irrespective of the diameter of the chosen port, through natural orifices using morcellation.

OBJECTIVE

To show, in a porcine model, the feasibility of a complete transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney extraction after morcellation through the same port.

MATERIALS AND METHODS

Transvesical nephrectomy and morcellation were performed in six pigs at Minho University, Braga, Portugal after institutional review board approval. The transvesical port and the cystotomy were created under the guidance of a ureteroscope, while the remaining steps were done under the guidance of an operating telescope. Dissection of the renal vessels and kidney was performed using dissection grasping forceps and a vessel sealing system (LigaSure(™) ; Covidien, Mansfield, MA, USA) and morcellation was done using a Piranha(™) morcellator (Richard Wolf, Knittlingen, Germany).

RESULTS

There were no complications related to the creation of transvesical access. The image provided by the telescope was superior to that of the ureteroscope, especially underwater. Morcellation was quick and effective, with the support of a fixing needle through the abdominal wall, designed to fix the kidney, after laceration of a bowel loop occurred in the first experiment.  It was found that technical improvements are needed to ensure safety of NOTES morcellation.

CONCLUSIONS

Kidney morcellation after nephrectomy, using a natural orifice exclusively, is feasible.  Despite technical limitations, this proof of concept study can be regarded as a potential step towards the application of NOTES in urology.

Transvaginal NOTES-assisted laparoscopic nephrectomy: a survival study in a sheep model

BACKGROUND

This study aims to evaluate the feasibility and usefulness of an ovine model in order to perform natural orifice translumenal endoscopic surgery (NOTES) approach and laparoscopic nephrectomy for research and training purposes.

METHODS

Ten healthy female sheep were used to perform transvaginal NOTES-assisted right laparoscopic nephrectomy using a flexible 12-mm gastroscope through a vaginal access and two additional 5- and 10-mm trocars placed in the abdomen. The renal artery, the renal vein, and the ureter were dissected, and ligation was accomplished by using laparoscopic clips. The right kidney was retrieved transvaginally after enlarging the vaginal trocar incision. All data related with the surgical procedure, perioperative, and postoperative outcomes were recorded. The animals were monitored after surgery for a 30-day period with daily clinical follow-up.

RESULTS

We established a useful animal model of transvaginal NOTES-assisted laparoscopic nephrectomy, performing the transvaginal approach and the abdomen exploration with no complications in any animals. The renal artery, the renal vein, and the ureter were identified, clipped, and transected combining the 5-mm laparoscopic access and the endoscopic vision in the whole group. Mean operative time was 86 ± 14.49 min, estimated blood loss was less than 20 ml in all cases, and there was no bleeding or laceration of adjacent organs. The animals recovered successfully in all cases postoperatively. After 1 month, exploratory laparotomy did not show alterations in abdominal cavity, and the vaginotomy incision healed completely in every animal.

CONCLUSIONS

This experiment shows that transvaginal NOTES-assisted laparoscopic nephrectomy in ovine model is feasible and reproducible while offering an innovative possibility to help surgeons with this recent technology in the treatment of renal cancer. Well-managed experimental studies need to be carried out to determine the safety and efficacy of NOTES in the treatment of renal cancer.

Single access laparoscopic nephrectomy

Laparoscopic nephrectomy has assumed a central role in the management of benign and malignant kidney diseases. While laparoscopy is less morbid than open surgery, it still requires several incisions each at least 1-2 cm in length. Each incision carries morbidity risks of bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis. An alternative to conventional laparoscopy is single access or keyhole surgery, which utilizes magnetic anchoring and guidance system (MAGS) technology or articulating laparoscopic instruments. These technical innovations obviate the need to externally space trocars for triangulation, thus allowing for the creation of a small, solitary portal of entry into the abdomen. Laboratory and early clinical series demonstrate feasibility as well as safe and successful completion of keyhole nephrectomy. Future work is necessary to improve existing instrumentation, increase clinical experience, assess benefits of this surgical approach, and explore other potential applications for this technique.

Instrumentation for natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery

OBJECTIVE

To describe the evolution of instrumentation and technology for natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) as applied to urologic procedures.

MATERIALS AND METHODS

We performed a search of published reports on PubMed and MEDLINE for the search terms NOTES, single-port, single-incision, single-site, natural orifice + surgery, SPA, LESS, incisionless, and scarless from 1990-2009. Studies relevant to this urologic symposium were chosen for detailed review.

RESULTS

Multiple case reports, case series, and review articles relevant to NOTES and LESS utilized for urologic surgery dating from 1991 to 2009 were identified. We were subsequently able to chronicle the technological advances in instrumentation utilized for NOTES, including transvaginal nephrectomy, transvesical NOTES, combination or hybrid NOTES, and robotic-assisted NOTES or R-NOTES. For LESS, we detailed the development of various access ports and operating platforms to facilitate performing urologic procedures through a single-port access site.

CONCLUSIONS

Significant progress has been made in developing new, multi-lumenal access ports and articulating or curved instruments to aid in triangulation necessary for certain urologic procedures. Magnetic anchoring guidance systems (MAGS) have further enhanced the approach to LESS, with the potential for future application to NOTES. NOTES and LESS have future implications for the armamentarium of urologic surgeons, although much more research is necessary to further improve instrumentation and overcome the learning curve necessary for new technology.

Single-port access laparoscopic surgery for rectal cancer: initial experience with 10 cases

BACKGROUND

Single-port access laparoscopic surgery is emerging as a method to improve the morbidity and cosmetic benefits of conventional laparoscopic surgery and minimize the surgical trauma. However, the feasibility of this procedure in rectal surgery has not yet been determined.

OBJECTIVE

This study aimed to evaluate our initial experience using single-port access in laparoscopic rectal surgery.

DESIGN

This investigation was designed as a prospective clinical study.

SETTINGS

The study took place in a university hospital.

PATIENTS

Ten patients with nonmetastatic rectal cancer underwent rectal resections.

MAIN OUTCOME MEASURES

The main outcome measures are perioperative data including intraoperative and postoperative complications, pathological outcome, length of stay, and short-term follow-up.

RESULTS

The median age of the patients was 67 (range, 49-83) and the median body mass index was 23.5 kg/m (range, 20-25 kg/m). Six patients had previously had abdominal surgery. The operations were 6 low anterior resections (4 receiving diverting ileostomy), 2 anterior resections, 1 Hartmann procedure, and 1 abdominoperineal resection. The median operative time was 229 minutes (range, 185-318), and blood loss ranged from 0 to 100 mL. In 2 cases, it was necessary to add an extra 5-mm port to deal with intraoperative complications. The median hospital stay was 7 days (range, 4-14). There were no anastomotic leaks and no mortality. All of the resection margins were clear, and the circumferential resection margin was a median of 11 mm (range, 2.5-25). The median number of lymph nodes examined was 14 (range, 3-20).

LIMITATIONS

This study's limitations include the lack of registration of postoperative pain, immunological parameters, and long-term clinical and oncological outcome. The small sample size makes it difficult to ascertain complication and conversion rates.

CONCLUSIONS

Single-port access laparoscopic surgery for rectal cancer can be performed safely in slim patients with a small tumor. This technique can be an alternative option for selected patients in the hands of skilled laparoscopic surgeons. Prospective comparative studies are needed to determine the role for this technique approach in the future.

Current status of natural orifice trans-endoscopic surgery (NOTES) and laparoendoscopic single site surgery (LESS) in urologic surgery

Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) represent novel approaches in urological surgery. To perform a review of the literature in order describe the current status of LESS and NOTES in Urology. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-02 to 15-05-09. Search terms included single port, single site, NOTES, LESS and single incision. A total of 412 manuscripts were initially identified. Out of these, 64 manuscripts were selected based in their urological content. The manuscript features subheadings for experimental and clinical studies, as NOTES-LESS is a new surgical technique and its future evolution will probably rely in initial verified feasibility. A subheading for reviews presents information regarding common language and consensus for the techniques. The issue of complications published in clinical series and the future needs of NOTES-LESS, are also presented.

A prospective randomized comparison of traditional laparoendoscopic single-site surgery with needlescopic-assisted laparoscopic nephrectomy in the porcine model

BACKGROUND AND PURPOSE

Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model.

MATERIALS AND METHODS

Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed.

RESULTS

Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696).

CONCLUSIONS

The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.

Transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in a porcine model

OBJECTIVE

To examine feasibility of transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy in the porcine model. NOTES uses ports of entry to the peritoneal cavity instead of abdominal wall incisions, thereby eliminating visible scar and also potentially reducing postoperative pain.

METHODS

After obtaining Institutional Animal Care and Use Committee approval, 3 female pigs (45 kg) underwent transrectal hybrid NOTES nephrectomy (2 right, 1 left). Pneumoperitoneum was created by a periumbilically-inserted 12-mm trocar, through which a laparoscope was advanced to obtain intraabdominal visualization. A horizontal incision was made 2 cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A window in the peritoneum was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen extraction bag was deployed transrectally and the specimen was delivered intact, followed by transrectal incision closure.

RESULTS

Transrectal hybrid NOTES nephrectomy was successfully performed in all cases. Mean operative time was 180 minutes (30 minutes for rectal access). Estimated blood loss was 50 mL. On necropsy, no intraabdominal injuries were noted.

CONCLUSIONS

In this initial report on feasibility of transrectal hybrid NOTES nephrectomy, we were able to perform the procedures with minimal blood loss and extract intact specimen. Survival studies are prerequisite to assess sterility and short- and long-term complications. This approach may be useful as an alternative to transvaginal access.

Single-incision laparoscopic surgery (SILS) in complex colorectal surgery: a technique offering potential and not just cosmesis

AIM

Single-incision (or port) laparoscopic surgery (SILS) has recently emerged as a method to improve morbidity and cosmetic benefit of conventional laparoscopic surgery. The literature contains two reports of SILS right hemicolectomy, and we report our experience of this technique.

METHOD

Seven consecutive, unselected patients underwent SILS retrocaecal appendicectomy, right hemicolectomy, extended right hemicolectomy, colectomy with ileorectal anastomosis, proctocolectomy, anterior resection and restorative proctocolectomy/ileoanal pouch using a single Triport (Olympus Keymed, Southend, UK), conventional instrumentation and nerve block analgesia. Three had undergone previous surgery, two had cancer and two were immunosuppressed.

RESULTS

Umbilical, right- and left-iliac fossa SILS was feasible using conventional instruments. Operative time ranged between 23 and 195 min (median 48 min). Four patients tolerated normal diet within 6 h (12-16 h for the remainder). Only one patient required postoperative enteral morphine (10 mg × 4). Discharge occurred between 8 and 90 h (median 16 h) of surgery. A secondary haemorrhage from the ileorectal anastomosis was managed conservatively.

CONCLUSION

SILS colorectal resection is feasible and safe when performed by an experienced laparoscopic surgeon and theatre team. It may have advantages over conventional laparoscopic surgery in terms of reduced pain, lower cost, faster recovery and cosmesis.

Natural Orifice Translumenal Endoscopic Surgery (NOTES) in urology

The concept of endoscopic surgery performed through natural orifices - Natural Orifice Translumenal Endoscopic Surgery (NOTES) - represents one of the most exciting ideas recently introduced in surgery. The use of natural orifice as a transluminal access to the peritoneal cavity has been shown to be effective and reproducible. After the introduction of the transgastric access (2004), the adaptation of the well-known transvaginal access, looking for ideal and more suitable entrance has led to the development of the transcolonic and transvescical ports. To date, the NOTES technique showed its full potential in experimental models, so as to allow the completion of most of the standard procedures performed in laparoscopic technique and thus opening the door to a new era, considered as "3rd generation surgery". However, only few experiences have been translated to humans and this concept is still at an early stage of experimental development. Many efforts are still needed to establish the standardization and validation of the techniques, the verification of safety and effectiveness. ?This article intends to photograph the actual role of NOTES, reviewing its history, analyzing the potential benefits and drawbacks, browsing and comparing the different transluminal routes, describing the equipment and platforms currently available, and finally to point out the state of the art of NOTES in the urological field.

A specialized course of basic skills training for single-port laparoscopic surgery

BACKGROUND

Single-port laparoscopy (SPL) requires specialized skills; however, there are currently no specialized training courses for SPL. The aim of this study is to present an effective specialized training course of basic skills for SPL.

METHODS

We designed a specialized training course for single-port laparoscopic basic skills. The study included 10 male urology residents. The trainees practiced the traditional training course for laparoscopy basic skills for 5 days. Basic skills were assessed on day 6 and a self-efficacy confidence index was measured. On day 7, all trainees performed a traditional laparoscopic nephrectomy and single-port laparoscopic nephrectomy. The participants were then randomized into 2 groups: 5 trainees performed the specialized training course and the other 5 trainees continued to practice the traditional training course. Both groups were trained for 5 days. After completion, the trainees were tested on completing a porcine single-port laparoscopic nephrectomy. Operative performance was measured by 2 experts who were blinded to which training the student had received, using an altered global rating. In addition, participants completed a general self-efficacy instrument after performing surgeries.

RESULTS

The overall operative performance score for single-port laparoscopic surgery was significantly better in the specialized training group. A significant difference in confidence index was seen between the traditional laparoscopy training and specialized single-port training groups (18.40 ± 2.70 vs 29.4 ± 3.51, respectively; P = .001.). Four relative instrument locations which avoided the problem of crowding were also noted in the specialized training group.

CONCLUSION

The specialized training course is effective for developing SPL skills.

Robotic natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery: current status

PURPOSE OF REVIEW

To analyse the evidence supporting current and future application of robotic technology in natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS).

RECENT FINDINGS

Early clinical experience with the application of currently available da Vinci robotic system to LESS has been encouraging, as some of the constraints encountered during conventional LESS can be overcome. Robotic devices that are currently being developed for NOTES and LESS focus on improving either tissue manipulation capabilities for externally actuated robotic and flexible endoscopy systems or visualization for robots that are inserted completely into the peritoneal cavity.

SUMMARY

Robotic technology is rapidly evolving and is expected to drive several aspects of minimally invasive surgery forward in the near future with the ultimate goal of minimizing complications and improving outcomes.

A history and evolution of laparoscopic nephrectomy: perspectives from the past and future directions in the surgical management of renal tumors

June 25, 2010 marks the twentieth anniversary of the first clinical laparoscopic nephrectomy. Since the advent of this procedure a paradigm shift toward minimally invasive options for urological surgery has been witnessed, resulting in rapid technological innovations and improved patient outcomes. A history of the minimally invasive surgical management of renal masses is presented with a focus on laparoscopic nephrectomy.

Natural orifice translumenal endoscopic surgery: radical prostatectomy in the canine model

PURPOSE

The goal of this study is to demonstrate the feasibility of transurethral radical prostatectomy in the canine model. We describe the surgical procedure for natural orifice translumenal endoscopic surgery-radical prostatectomy (NOTES-RP).

MATERIALS AND METHODS

NOTES-RP was performed on six nonsurvival male canines. The 100 watt holmium:yttrium-aluminum-garne laser, 550 μm end-firing fiber, 28F laser resectoscope, 7F stabilizing catheter, and continuous irrigation were used to radically resect the prostate. A Vest vesicourethral anastomosis was performed using a laparoscopic suture device that was delivered through the nephroscope. In the initial cases, the prostate was removed manually; for the last two cases, the prostate was removed endoscopically with a tissue morcellator.

RESULTS

NOTES-RP was successfully executed in all canines. Visualization was not obscured by bleeding. Dissection times ranged from 40 to 120 minutes. Fluid absorption was problematic in cases lasting more than 1 hour, because of the intraperitoneal location of the canine prostate and bladder.

CONCLUSIONS

The feasibility and technique of NOTES-RP was successfully demonstrated in the living canine model.

[Transumbilical single-incision laparoscopic ureterolithotomy]

INTRODUCTION

laparoendoscopic single-site surgery (LESS) using transumbilical access and conventional laparoscopic instruments is a very attractive alternative to perform ureterolithotomy for ureteral stone with failed endourological management.

MATERIAL AND METHOD

a 29-year-old woman presented with chronic right lumbar pain and a 1.2 cm impacted calculus localized at transition of abdominal to pelvic ureter. Semi-rigid ureteroscopy had failed to fragment the stone and shockwave lithotripsy was not available. Double-J ureteral catheter had been inserted preoperatively. We performed a transumbilical single-incision laparoscopic ureterolithotomy. Three conventional trocars were inserted in a single semi-circular umbilical incision. Right colon was detached and the ureter was identified. Calculus was extracted and the ureteral incision was closed with intracorporal sutures.

RESULTS

ureterolithotomy was successfully completed, with all the operative steps performed transumbically. Operative time was 180 minutes. No single-port device or articulating and bent instruments were utilized. Estimated blood loss was less than 50 mL. No intraoperative, access-related and postoperative complications took place. The duration of hospitalization was 24 hours and scarless appearance was observed on postoperative day 15.

CONCLUSION

transumbilical single-incision laparoscopic ureterolithotomy is feasible and safe. This approach offers an inherent cosmetic advantage and few postoperative discomfort. Additional experience and continued investigation are warranted.

New trends in minimally invasive urological surgery

PURPOSE

The perceived benefits of minimally-invasive surgery include less postoperative pain, shorter hospitalization, reduced morbidity and better cosmesis while maintaining diagnostic accuracy and therapeutic outcome. We review the new trends in minimally-invasive urological surgery.

MATERIALS AND METHODS

We reviewed the English language literature using the National Library of Medicine database to identify the latest technological advances in minimally-invasive surgery with particular reference to urology.

RESULTS

Amongst other advances, studies incorporating needlescopic surgery, laparoendoscopic single-site surgery , magnetic anchoring and guidance systems, natural orifice transluminal endoscopic surgery and flexible robots were considered of interest. The results from initial animal and human studies are also outlined.

CONCLUSION

Minimally-invasive surgery continues to evolve to meet the demands of the operators and patients. Many novel technologies are still in the testing phase, whilst others have entered clinical practice. Further evaluation is required to confirm the safety and efficacy of these techniques and validate the published reports.

Training for laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery

A combination of refinements in laparoscopic instrumentation and increasing surgical experience has driven innovation in the area of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). By combining working ports and the extraction incision into one site, LESS allows access to the peritoneum with fewer incisions and less scarring than the traditional multiport laparoscopic technique. Reduced incisional morbidity and improved cosmesis have sparked a growing interest in the utilization of these techniques to perform urological surgery. Mastering of the technique requires training and repetition to develop the muscle memory required to perform these challenging procedures. Although there has been an explosion of literature published about initial experiences with LESS and NOTES, little has been written about training and implementation of this approach. Here, we describe our institutional experience and the essential elements of a LESS and NOTES training curriculum and offer some insight into establishing a successful programme.

LESSons in minimally invasive urology

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. LaparoEndoscopic Single Site (LESS) surgery potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. Technological developments in instrumentation, access and optics devices are overcoming some of the challenges that are raised when operating through a single site. Further advances in the technique have included the incorporation of robotics (R-LESS), which exploit the ergonomic benefits of ex vivo robotic platforms in an attempt to further improve the implementation of LESS procedures. In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of tissue from internal repositionable platforms. The use of magnetic anchoring and guidance systems (MAGS) might allow the external manoeuvring of intra-corporeal instruments to reduce clashing and facilitate triangulation. However, the final promise in minimally invasive surgery is natural orifice transluminal endoscopic surgery (NOTES), with its scarless technique. It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical utility over standard laparoscopic methods.

Needloscopy-assisted transvaginal cholecystectomy

The reasons for hybrid surgery are various: endoscopic peritoneoscopy under laparoscopic visualization provides a safe way to improve pure natural orifice endoscopic surgery with less abdominal incision. Herein we are presenting a hybrid technique composed of advantages of needloscopy and natural orifice transluminal endoscopic surgery (NOTES). Two women with symptomatic cholelithiasis have undergone successful needloscopy-assisted transvaginal cholecystectomies. Main principle of this approach is the ability of performing cholecystectomy procedure same as in standard laparoscopic cholecystectomy. In contrast, we get benefit of less abdominal trauma due to transvaginal endoscopic exposure, clipping maneuver, and removal of gallbladder. We believe that, trend of more minimal invasive surgery which created the idea of NOTES, gets benefit from hybrid techniques as an interval step toward NOTES when waiting for the ideal equipment and sufficient experience.

New trends in minimally invasive urological surgery: what is beyond the robot?

PURPOSE

To review the minimal-invasive development of surgical technique in urology focusing on nomenclature, history and outcomes of Laparo-Endoscopic Single-site Surgery (LESS), Natural Orifice Translumenal Endoscopic Surgery (NOTES) and Computer-Assisted Surgery (CAS).

METHODS

A comprehensive literature search was conducted in order to find article related to LESS, NOTES and CAS in urology. The most relevant papers over the last 10 years were selected in base to the experience from the panel of experts, journal, authorship and/or content.

RESULTS

Seven hundred and fifty manuscripts were found. Papers on LESS describe feasibility/safety in most of the procedures with a clinical experience of more than 300 cases and five compared results to standard laparoscopy without showing significant differences. NOTES accesses have been proved their feasibility/safety in experimental study. In human, the only procedures performed are on kidney and through a hybrid-Transvaginal route. New robots overcome the main drawbacks of the DaVinci® platform. The use of CAS is increasing its popularity in urology.

CONCLUSIONS

LESS has been applied in clinical practice, but only ongoing technical and instrumental refinement will define its future role and overall benefit. The transition to a clinical application of NOTES seems at present only possible with multiple NOTES access and transvaginal access. Robot and Soft Tissue Navigation appear to be important to improve surgical skills. We are already witness to the advantages offered by the former even if costs need to be redefined based on pending long-term results. The latter will probably upgrade the quality of surgery in a near future.