NOTES new frontier: Natural orifice approach to retroperitoneal disease

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

Background

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

Objective

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

Materials and methods

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

Results

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

Conclusion

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

What is new?

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

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Minimally invasive autopsy by using postmortem endoluminal and transluminal endoscopy and EUS

BACKGROUND

Virtual autopsy by using CT imaging has been introduced as an alternative to conventional autopsy and has resulted in an increase in acceptance of autopsy by relatives. Because direct inspection and tissue acquisition is not possible by imaging alone, various endoscopic techniques can be considered of complementary usefulness.

OBJECTIVES

We present the first series of sequential endoscopic techniques including natural orifice transluminal access for minimally invasive autopsy.

SETTING

University hospital, legal medicine department.

SUBJECTS

Twenty deceased subjects.

INTERVENTION

Various flexible endoscopic modalities including EUS, with biopsy or EUS-guided FNA, were attempted. This included transluminal intra-abdominal endoscopic exploration with tissue sampling in a few cases.

MAIN OUTCOME MEASUREMENTS

Completeness of inspection of the luminal and extraluminal cavity as well as tissue acquisition.

RESULTS

Complete upper GI endoscopy was performed in 17 of 20 and EUS in 8 of 8 cases. In addition, transgastric intra-abdominal endoscopy was successfully performed in 5 cases. Adequate histology from biopsy and EUS-guided puncture could be obtained in case of short time intervals post mortem. In 1 case, a rupture of the gastric cardia with bleeding was diagnosed as a significant unexpected finding. New minor pathological findings were revealed on EGD (6/17), GI EUS (3/8), and transgastric inspection (4/5).

LIMITATIONS

Limited number of cases for all procedures.

CONCLUSION

Minimally invasive autopsy by using multiple endoscopic techniques for imaging and tissue acquisition is feasible. The significant value of this technique, in combination with virtual autopsy compared with classic autopsy, warrants further evaluation.

Laparoscopic pancreatectomy for malignancy

Utilization of laparoscopic techniques for resection of the pancreas has slowly gained acceptance in specific situations and is now being applied to more challenging endeavors, such as pancreaticoduodenectomy for cancer. This review provides a summary of laparoscopic applications for pancreatic malignancy, with specific attention to the most common methods of pancreatic resection and their respective oncologic outcomes, including margin status, lymph node retrieval, and survival.