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Xiao X, Liu T, Li X, He L, Lin Y, Feng D. Transvaginal natural orifice transluminal endoscopic surgery for tubal ectopic pregnancy(vNOTESTEP): a protocol for a randomized controlled trial. BMC Pregnancy Childbirth 2025; 25:477. [PMID: 40269766 PMCID: PMC12020209 DOI: 10.1186/s12884-025-07595-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Accepted: 04/10/2025] [Indexed: 04/25/2025] Open
Abstract
BACKGROUND Tubal ectopic pregnancy is a life-threatening condition in early pregnancy. Minimally invasive laparoscopic surgery is increasingly used for the treatment of this disease. Retrospective studies suggest that Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers lower perioperative complications, faster recovery, and better cosmetic outcomes compared to other approaches. However, the lack of comprehensive perioperative and long-term postoperative data limits its widespread adoption in gynecology. METHODS The vNOTESTEP study is a randomized controlled trial (RCT) enrolling 72 patients requiring laparoendoscopic surgery for tubal ectopic pregnancy. After obtaining informed consent, preoperative assessments will be conducted. Following randomization, salpingectomy will be performed using either vNOTES or TU-LESS approach. The postoperative assessment and a structured 5-year follow-up, including eight visits, will be conducted. Baseline sociodemographic and clinical data will be collected from the Hospital Information System and patient interviews. Outcomes will be assessed perioperatively and postoperatively at designated time points (1st, 2nd, and 3rd postoperative day; 1st, 3rd, and 6th month; 1st-5th year). Key long-term outcomes include sexual function, pregnancy, vaginal delivery, and incisional hernia. DISCUSSION This RCT aims to provide robust clinical evidence on the perioperative and long-term outcomes of vNOTES versus TU-LESS for tubal ectopic pregnancy, focusing on key reproductive and surgical outcomes. The study seeks to refine patient selection criteria and contribute to guideline development for gynecologic vNOTES. TRIAL REGISTRATION NUMBER ChiCTR2400082909 (registered on April 10th, 2024).
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Affiliation(s)
- Xinyu Xiao
- Department of Gynecology of Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Chengdu, Sichuan, 610091, People's Republic of China
| | - Tianjiao Liu
- Department of Gynecology of Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Chengdu, Sichuan, 610091, People's Republic of China
| | - Xin Li
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Gynecology of Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Chengdu, Sichuan, 610091, People's Republic of China.
| | - Yonghong Lin
- Department of Gynecology of Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Chengdu, Sichuan, 610091, People's Republic of China.
| | - Dan Feng
- Department of Gynecology of Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, No. 1617, Riyue Avenue, Chengdu, Sichuan, 610091, People's Republic of China.
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Slouha E, Biput SJ, Krumbach B, Clunes LA, Kollias TF. Transvaginal Laparoscopic Appendectomy: A Systematic Review. Cureus 2024; 16:e51962. [PMID: 38333466 PMCID: PMC10852981 DOI: 10.7759/cureus.51962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
Appendectomy remains the gold standard for treating appendicitis, but advancements in laparoscopic techniques have shifted the paradigm. Natural orifice transluminal endoscopic surgery (NOTES) and transvaginal appendectomy (TVA) offer a potentially less invasive alternative to traditional laparoscopic appendectomy (LA). This article systematically reviews the procedures, perceptions, and complications of TVA to assess its viability as a surgical option. Between January 1, 2003, and November 1, 2023, 4832 case reports, case series, and experimental and observational peer-reviewed publications were examined and filtered using the keyword "Transvaginal Laparoscopic Appendectomy." The publications were screened using PRISMA guidelines, and 20 studies were included for analysis and review. Survey results showed that women's acceptance of TVA was 43%, citing reduced invasiveness as a major reason for positive reception. TVA procedures exhibited consistency, with variations in appendectomy methods, appendix removal, and posterior fornix incision closure. Positive outcomes included shorter operation times, reduced postoperative pain, and minimal scarring. Complications were uncommon but included bladder puncture, urinary tract infections, and intra-abdominal abscesses. Indications primarily focused on surgical safety, reduced scarring, and postoperative benefits. Sexual function post-TVA exhibited no significant differences in most cases, with a recovery period of two to four weeks. This systematic review suggests that TVA is a promising alternative to traditional LA, offering potential advantages in terms of postoperative complications. While the existing literature indicates positive outcomes, further research with larger sample sizes and long-term follow-ups is needed to validate the efficacy and safety of TVA and assess how the procedure impacts the reproductive function of patients.
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Affiliation(s)
- Ethan Slouha
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Stefan J Biput
- Medicine, St George's University School of Medicine, St. George's, GRD
| | - Brandon Krumbach
- Anatomy, St. George's University School of Medicine, St. George's, GRD
| | - Lucy A Clunes
- Pharmacology, St. George's University School of Medicine, St. George's, GRD
| | - Theofanis F Kollias
- Microbiology, Immunology, and Pharmacology, St. George's University School of Medicine, St. George's, GRD
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Trends in Minimally Invasive Approaches for Liver Resections-A Systematic Review. J Clin Med 2022; 11:jcm11226721. [PMID: 36431199 PMCID: PMC9697421 DOI: 10.3390/jcm11226721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/01/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND SILS (single incision laparoscopic surgery) and NOTES (natural orifice transluminal endoscopic surgery) are considered breakthroughs in minimally invasive surgery, the first consisting in the surgeon working via a single entrance site and the second via a natural orifice (e.g., oral cavity). METHODS Since 2000 until 2022, the original articles published in the online databases were analyzed. Eligible studies included information about the current therapy of patients with liver surgical pathology and how the two new techniques improve the surgical approach. RESULTS A total of 798 studies were identified. By applying the exclusion criteria, nine studies remained to be included in the review. Two out of nine studies examined the NOTES approach in liver surgery, whereas the other seven focused on the SILS technique. The age of the patients ranged between 24 and 83 years. Liver resections for hepatocellular carcinoma or colorectal metastases were undertaken and biliary or hydatid cysts were removed. The mean procedure time was 95 to 205 min and the average diameter of the lesions was 5 cm. CONCLUSIONS When practiced by multidisciplinary teams, transvaginal liver resection is feasible and safe. The goals of SILS and NOTES are to be less intrusive, more easily tolerated and aesthetic.
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Comparison of Two Different Accesses Single Orifice Percutaneous Endoscopic Surgery in Diagnosis of Ascites of Unknown Origin: A Retrospective Study. JOURNAL OF ONCOLOGY 2022; 2022:1127400. [PMID: 35419055 PMCID: PMC9001135 DOI: 10.1155/2022/1127400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/04/2022] [Accepted: 03/22/2022] [Indexed: 11/18/2022]
Abstract
Background Ascites is a common clinical finding caused by many different diseases, so we developed a technique termed single orifice percutaneous endoscopic surgery (SOPES) which can access peritoneal cavity through the contralateral McBurney's point or umbilicus to seek the underlying causes. In this study, we describe the initial clinical experience of SOPES and compare the application of two accesses. Methods This is a retrospective study performed between 2007 and 2018. Patients with ascites of unknown origin who underwent these two kinds of SOPES were included. Main outcomes were measured by diagnostic accuracy, complication rate, procedure time, time till stitches removal, length of hospital stay, and hospital cost. Results 148 patients successfully undergone SOPES via the contralateral McBurney's point (IM group, n = 70) or the umbilicus (UM group, n = 78). 63 patients in the IM group and 71 patients in the UM group reached clear diagnosis (90.0% vs. 91.0%, p = 0.831). The overall complication rate was 5.4%, while the UM group was higher than the IM group (10.3% vs. 0%, p = 0.017). All complications were resolved after medical treatment, and no mortality resulted from this procedure. The procedure time and the time until stitches removal in the UM group were longer than that in the IM group. There were no significant differences in length of hospital stay and hospital cost between the two groups. Conclusions SOPES, which combines the strength of minimally invasive single orifice incision and flexible angles of examination and instrumentation, is a newly developed flexible endoscopic surgical modality that provides new important clinical valuable in evaluation of ascites of unknown origin. Moreover, SOPES via the contralateral McBurney's point was safer than the umbilicus approach.
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Bulian DR, Sauerwald A, Thomaidis P, Seefeldt CS, Richards DC, Schulz SA, Weltermann NJ, Heiss MM, Eisenberger CF. Does a prior hysterectomy complicate transvaginal/transumbilical hybrid NOTES cholecystectomy?-a comparative analysis of prospectively collected data. Langenbecks Arch Surg 2021; 407:655-662. [PMID: 34964915 PMCID: PMC8933306 DOI: 10.1007/s00423-021-02401-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Hysterectomy alters the anatomy of the posterior vaginal vault used as access for transvaginal/transumbilical hybrid NOTES cholecystectomy (NC), creating potential consequences for the feasibility and complication rate of the procedure. Therefore, the aim of our retrospective analysis of prospectively collected data was to analyze the postoperative course after NC in previously hysterectomized (PH) patients compared with patients who had not undergone hysterectomy (NH). METHODS A total of 126 NH patients and 50 PH patients aged over 42 who had an NC from 12/2008 to 04/2021 were compared regarding age, body mass index (BMI), ASA classification, number of percutaneous trocars, need for intraoperative urinary bladder catheterization, length of procedure, conversion rate, and intraoperative and postoperative complication rate according to the Clavien/Dindo classification, Comprehensive Complication Index (CCI), mortality, and hospital length of stay. RESULTS PH patients were older than NH patients (63.0 vs 51.5 years; P < 0.001) but did not differ significantly in ASA classification (P = 0.595) and BMI (26.8 vs 27.9 kg/m2; P = 0.480). They required more percutaneous trocars (P = 0.047) and longer procedure time (66.0 vs. 58.5 min; P = 0.039). Out of all 287 scheduled NC only one had to be "converted" to traditional laparoscopic cholecystectomy. Intraoperative and postoperative complication rates, Clavien/Dindo classification, CCI, need for intraoperative urinary bladder catheterization, and length of stay did not differ significantly. CONCLUSION Our results indicate an increased degree of difficulty of NC in PH patients, although there is no major impact on intraoperative and postoperative complication rates. Urinary bladder perforation is a specific access-related complication in PH patients.
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Affiliation(s)
- Dirk R Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Axel Sauerwald
- Department for Obstetrics and Gynecology, Holweide Hospital, Neufelder Strasse 32, D-51067, Cologne, Germany
- Department of Gynecology and Obstetrics, St. Marien- Hospital, Hospitalstraße 44, D-52353, Dueren, Germany
| | - Panagiotis Thomaidis
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Claudia S Seefeldt
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Dana C Richards
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Sissy-A Schulz
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Niklas J Weltermann
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Markus M Heiss
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Claus F Eisenberger
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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Vanhooren E, Baekelandt J. Vaginal NOTES surgery in patients with prior hysterectomy: A first case series. Asian J Endosc Surg 2021; 14:811-815. [PMID: 33851773 DOI: 10.1111/ases.12940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/27/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
Abstract
This is a first feasibility on vaginal natural orifice transluminal endoscopic surgery (vNOTES) in patients with prior hysterectomy. Our aim was to gain initial experience on performing vNOTES surgery on prior hysterectomy cases, whereby the main concern is that pelvic adhesions may impede safe transvaginal access. Between January 2017 and February 2020, a single surgeon (J.B.) performed vNOTES surgery on nine patients with a history of hysterectomy. Conventional laparoscopic instruments were inserted transvaginally through a vNOTES port. No abdominal incisions were made. Patient data and perioperative data were analyzed. Mean operating time was 38 minutes and there were no operative complications. Postoperative pain scores were low. The mean size of the adnexal cysts that were removed was 26 mm. In this study, vNOTES surgery was successfully performed in nine patients with prior hysterectomy. Following the IDEAL principles, it is important to report on our initial findings of this IDEAL stage 1 study. The results warrant further investigation in IDEAL stage 2 studies but do not validate the widespread use of this approach.
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Affiliation(s)
- Emma Vanhooren
- Department of Gynecology and Obstetrics, IMELDA Hospital, Bonheiden, Belgium
| | - Jan Baekelandt
- Department of Gynecology and Obstetrics, IMELDA Hospital, Bonheiden, Belgium
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Song ZJ, Shi YQ, Jiang YM, Liu K, Li Y, Wang CG, Zhao R. Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer: A case report. World J Clin Cases 2021; 9:1714-1719. [PMID: 33728316 PMCID: PMC7942039 DOI: 10.12998/wjcc.v9.i7.1714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/22/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pure natural orifice transluminal endoscopic surgery (NOTES) for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges, including loss of triangulation, in-line orientation, and instrument collision. Transvaginal (v) NOTES, however, can overcome these technical challenges. We report a case of pure vNOTES right hemicolectomy for colon cancer, attached with surgical video.
CASE SUMMARY A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy. Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons. The operative time was 200 min and the estimated blood loss was 30 mL. No intraoperative or postoperative complications occurred within 30 d after the surgery. The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3. The patient was discharged at postoperative day 6. The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.
CONCLUSION vNOTES right hemicolectomy, performed by well-experienced surgeons, overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.
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Affiliation(s)
- Zi-Jia Song
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
| | - Yi-Qing Shi
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
| | - Yi-Mei Jiang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
| | - Kun Liu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
| | - You Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
| | - Chang-Gang Wang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 201801, China
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Ho SH, Chiu PWY. Robotic endoscopy in gastroenterology: Has it come of age? JGH Open 2020; 4:782-783. [PMID: 33102744 PMCID: PMC7578321 DOI: 10.1002/jgh3.12413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Shiaw-Hooi Ho
- Department of Medicine, Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Philip Wai-Yan Chiu
- Division of Upper GI & Metabolic Surgery, Department of Surgery Prince of Wales Hospital Shatin Hong Kong
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Jategaonkar PA, Yadav SP, Gupta D. Transvaginal laparoscopic appendectomy using innovative submucosal tunnels: a conducive modification for improving hybrid NOTES access and its critical appraisal. Trop Doct 2020; 50:209-215. [DOI: 10.1177/0049475520921277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Currently, transvaginal natural orifice transluminal endoscopic surgery (NOTES), the most minimally invasive option for laparoscopic surgery, suffers various technological restraints limiting its implementation. We discuss a simple modification for vaginal access to improve the existing hybrid NOTES technique. We retrospectively studied 18 women at our rural hospital in central India, who, under defined criteria, underwent transvaginal appendicectomy using innovative strategically designed submucosal tunnels. The procedure was successfully completed in all but the first three cases. None required additional abdominal trocar or analgesia beyond the first 6 h. The mean operative and hospitalisation times were 27.5 min and 18.5 h, respectively. We had no intraoperative complications and only one patient experienced postoperative self-limiting vaginal spotting. All patients were very pleased with the cosmetic results and sexual life as assessed by locally devised scales. On regular follow-up, all were progressing well. We recommend the method presented, as it is not only feasible and safe but has the potential to improve overall results. Clearly, a larger volume randomised trial would be optimal to confirm our conclusion.
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Affiliation(s)
- Priyadarshan A Jategaonkar
- Professor of Surgery, Surgical Gastroenterologist and Advance Laparoscopic Surgeon, Department of Surgery, Division of GI & Minimal Access Surgery, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sudeep P Yadav
- Senior Resident, Department of Plastic & Reconstructive Surgery, Grant’s Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Dilip Gupta
- Director, Professor and Head, Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
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Foo CC, Yeung CK, Sreedhar B, Cheung JLK, Law WL. Robotic-Assisted Transrectal Cholecystectomy in a Porcine Model. Surg Innov 2019; 26:436-441. [PMID: 30755092 DOI: 10.1177/1553350619829589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background. With increasing experience and technological advancement in surgical instruments, surgeons have explored the feasibility of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). These techniques aim to further reduce surgical trauma, but are not popular due to their inherent pitfalls including clashing of instruments, lack of counter traction, lengthy operating time, and so on. A novel surgical robotic system was designed to overcome the limitations of the existing technologies. Animal trials were conducted to demonstrate its feasibility in performing robotic-assisted transrectal cholecystectomy in a porcine model. Method. The Novel surgical robotic system is a high dexterity, single access port surgical robotic system that enables surgeons to carry out single-port surgical procedure or NOTES. The proposed system’s main features include the ability to perform intraabdominal and pelvic surgeries via natural orifices like the vagina or rectum. The system is equipped with multiple miniaturized (16 mm diameter) internally motorized robotic arms, each with a minimum of 7 degrees of freedom, a dual in vivo camera system, a cannula, and an external swivel system. Results. Robotic-assisted transrectal cholecystectomy was successfully performed in 3 adult male pigs. The estimated blood loss was <10 mL in all 3 cases. There were no intraoperative complications. The system provided good dexterity and clear vision. Conclusions. The trial demonstrated that the system can provide the surgeon a stable platform with adequate spacing for the transrectal insertion of robotic arms, 3-dimensional vision, and enhanced dexterity in performing NOTES cholecystectomy.
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Affiliation(s)
- Chi-Chung Foo
- University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | | | - Biji Sreedhar
- Bio-Medical Engineering (HK) Limited, Cyberport, Hong Kong, China
| | | | - Wai-Lun Law
- University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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Abstract
Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.
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Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Fransisco Borja De Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Silvia Valverde
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
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12
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Müller V, Mogl M, Seika P, Jöns T, Sauer I, Pratschke J, Anuwong A, Zorron R. How I Do It: New Dissector Device Allows for Effective Operative Field in Transoral Endoscopic Thyroid Surgery Using Vestibular Approach. Surg Innov 2018; 25:444-449. [DOI: 10.1177/1553350618785281] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Minimally invasive thyroid and parathyroid resections are rarely performed. Promising new endoscopic transoral approaches to the anterior neck (transoral endoscopic thyroidectomy vestibular approach [TOETVA]) have been described with good results and few complications. This study evaluates a new device to allow the safe entrance of trocars in the subplatysmal space for TOETVA in a cadaver model. Methods. The technique was performed in 4 unilateral thyroidectomies in female cadavers. The technical steps consisted of a 10-mm incision made at the center of the oral vestibule followed by subplatysmal hydrodissection. The blunt dissector is a metallic stick with an olive at the end and promotes progressive gain in subplatysmal space enlarging the operative field. The instrument was inserted creating a space below the platysma to the anterior neck and the strap muscles. Three trocars were inserted in the vestibular area. The dissection begins by cutting the linea alba cervicalis. The isthmus was dissected and transected. Anatomical structures as the superior thyroid artery, parathyroid glands, and the recurrent laryngeal nerve could be safely identified with magnified vision. Results. Optimal operative field due to subplatysmal dissection by the device allowed for exposition of thyroid and parathyroid glands in all cases. Unilateral thyroidectomy was performed in a mean of 54 minutes with excellent aesthetic results. Conclusions. The new device is a promising feature to allow safe transoral thyroid surgery in a cadaver model. Further studies in clinical series are needed to evaluate the broad application of the device.
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Affiliation(s)
- Verena Müller
- Charité–Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Martina Mogl
- Charité–Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Philippa Seika
- Charité–Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Thomas Jöns
- Institute of Integrative Neuroanatomy, Campus Charité Mitte, Humboldt University, Berlin, Germany
| | - Igor Sauer
- Charité–Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | - Johann Pratschke
- Charité–Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum, Berlin, Germany
| | | | - Ricardo Zorron
- Charité–Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum, Berlin, Germany
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Atallah S, Hodges A, Larach SW. Direct target NOTES: prospective applications for next generation robotic platforms. Tech Coloproctol 2018; 22:363-371. [PMID: 29855814 DOI: 10.1007/s10151-018-1788-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/04/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative. METHODS During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy. RESULTS Feasibility was demonstrated in all cases using the Flex® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min. CONCLUSIONS A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.
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Affiliation(s)
- S Atallah
- Endo-Surgical Center of Florida, Department of Colorectal Surgery, Florida Hospital, Orlando, FL, USA.
| | - A Hodges
- Nova Southeastern University, Davie, FL, USA
| | - S W Larach
- Endo-Surgical Center of Florida, Department of Colorectal Surgery, Florida Hospital, Orlando, FL, USA
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Oliveira ALA, Zorron R, Oliveira FMMDE, Santos MBD, Scheffer JP, Rios M, Antunes F. Transcolonic Perirectal NOTES Access (PNA): A feasibility study with survival in swine model. AN ACAD BRAS CIENC 2018; 89:685-693. [PMID: 28562823 DOI: 10.1590/0001-3765201720160541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 01/23/2017] [Indexed: 12/22/2022] Open
Abstract
Transrectal access still has some unsolved issues such as spatial orientation, infection, access and site closure. This study presents a simple technique to perform transcolonic access with survival in a swine model series. A new technique for NOTES perirectal access to perform retroperitoneoscopy, peritoneoscopy, liver and lymphnode biopsies was performed in 6 pigs, using Totally NOTES technique. The specimens were extracted transanally. The flexible endoscope was inserted through a posterior transmural incision and the retrorectal space. Cultures of bacteria were documented for the retroperitoneal space and intra abdominal cavity after 14 days. Rectal site was closed using non-absorbable sutures. There was no bowel cleansing, nor preoperative fasting. The procedures were performed in 6 pigs through transcolonic natural orifice access using available endoscopic flexible instruments. All animals survived 14 days without complications, and cultures were negative. Histopathologic examination of the rectal closure site showed adequate healing of suture line and no micro abscesses. The results of feasibility and safety of experimental Transcolonic NOTES potentially brings new frontiers and future wider applications for minimally invasive surgery. The treatment of colorectal, abdominal and retroperitoneal diseases through a flexible Perirectal NOTES Access (PNA) is a promising new approach.
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Affiliation(s)
- André L A Oliveira
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
| | | | | | - Marcelo B Dos Santos
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
| | - Jussara P Scheffer
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
| | - Marcelo Rios
- Clínica Veterinária-Gávea, Rio de Janeiro, RJ, Brazil
| | - Fernanda Antunes
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
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Yuval JB, Weiss DJ, Paz A, Bachar Y, Brodie R, Shapira Y, Mintz Y. It is time for a better clip applier - 3 mm, percutaneous, non-crushing and locking. MINIM INVASIV THER 2017; 27:221-225. [PMID: 28982276 DOI: 10.1080/13645706.2017.1384392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Since the advent of laparoscopy there have been attempts to minimize abdominal wall incisions. For this purpose smaller instruments have been produced. Our aim was to develop the first 3 mm percutaneous clip applier and to make it better than the standard clips of today. MATERIAL AND METHODS The ClipTip clip is made of Nitinol and has a crocodile shaped jaws, which when apposed effectively seal vessels. The shaft operates as a retractable needle permitting percutaneous insertion. Closing, reopening and reclosing is possible. The physical properties of the device were compared to three commercially available clip appliers. Surgeries were performed on porcine animals by experienced surgeons. RESULTS In comparison to available clips, the superiority of the ClipTip is a combination of wide effective length alongside the ability to withstand strong forces. In live animal studies the Cliptip was inserted into the peritoneal cavity without any injuries. Vessels were ligated successfully and no clip dislodgement or leakage occurred. CONCLUSIONS We developed the next generation clip applier with better properties. Advantages include its length, the needleoscopic caliber, non-crushing effect, locking mechanism and wide aperture. The device has performed safely and effectively in pre-clinical tests. Further studies are planned in humans.
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Affiliation(s)
- Jonathan B Yuval
- a Department of General Surgery , Hadassah Hebrew University Medical Center , Jerusalem , Israel
| | - Daniel J Weiss
- a Department of General Surgery , Hadassah Hebrew University Medical Center , Jerusalem , Israel
| | | | | | - Ronit Brodie
- a Department of General Surgery , Hadassah Hebrew University Medical Center , Jerusalem , Israel
| | | | - Yoav Mintz
- a Department of General Surgery , Hadassah Hebrew University Medical Center , Jerusalem , Israel
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Tinelli A, Tsin DA, Forgione A, Zorron R, Dapri G, Malvasi A, Benhidjeb T, Sparic R, Nezhat F. Exploring the umbilical and vaginal port during minimally invasive surgery. J Turk Ger Gynecol Assoc 2017; 18:143-147. [PMID: 28890429 PMCID: PMC5590211 DOI: 10.4274/jtgga.2017.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
This article focuses on the anatomy, literature, and our own experiences in an effort to assist in the decision-making process of choosing between an umbilical or vaginal port. Umbilical access is more familiar to general surgeons; it is thicker than the transvaginal entry, and has more nerve endings and sensory innervations. This combination increases tissue damage and pain in the umbilical port site. The vaginal route requires prophylactic antibiotics, a Foley catheter, and a period of postoperative sexual abstinence. Removal of large specimens is a challenge in traditional laparoscopy. Recently, there has been increased interest in going beyond traditional laparoscopy by using the navel in single-incision and port-reduction techniques. The benefits for removal of surgical specimens by colpotomy are not new. There is increasing interest in techniques that use vaginotomy in multifunctional ways, as described under the names of culdolaparoscopy, minilaparoscopy-assisted natural orifice surgery, and natural orifice transluminal endoscopic surgery. Both the navel and the transvaginal accesses are safe and convenient to use in the hands of experienced laparoscopic surgeons. The umbilical site has been successfully used in laparoscopy as an entry and extraction port. Vaginal entry and extraction is associated with a lower risk of incisional hernias, less postoperative pain, and excellent cosmetic results.
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Affiliation(s)
- Andrea Tinelli
- Department of Gynecology and Obstetrics, Division of Experimental Endoscopic Surgery, Imaging, Minimally Invasive Therapy and Technology, Vito Fazzi Hospital, Lecce, Italy,Laboratory of Human Physiology, Department of Applied Mathematics, Moscow Institute of Physics and Technology (MIPT), State University, Moscow, Russia
| | - Daniel A Tsin
- The Mount Sinai Hospital of Queens, Long Island City, New York, USA
| | | | - Ricardo Zorron
- Center for Innovative Surgery (ZIC), Center for Bariatric and Metabolic Surgery, Department of General, Visceral and Transplant Surgery, Campus Virchow Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité-Universitätsmedizin, Berlin, Germany
| | - Giovanni Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium
| | - Antonio Malvasi
- Laboratory of Human Physiology, Department of Applied Mathematics, Moscow Institute of Physics and Technology (MIPT), State University, Moscow, Russia,Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care&Research, Bari, Italy
| | - Tahar Benhidjeb
- Consultant, German Board-Surgery; Chairman, Department of Surgery; Chief, General Surgery Danat Al Emarat Hospital, UAE
| | - Radmila Sparic
- Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, University of Belgrade School of Medicine, Belgrade, Serbia
| | - Farr Nezhat
- Department of Obstetrics, Gynecology and Reproductive Medicine, State University of New York at Stony Brook School of Medicine, Stony Brook, NY; Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY, USA,Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
PURPOSE OF REVIEW The recent developments and clinical applications of natural orifice translumenal endoscopic surgery (NOTES)-procedures and technologies are going to be presented. RECENT FINDINGS In experimental as well as clinical settings, NOTES-procedures are predominantly performed in hybrid technique. Current experimental studies focus on the implementation of new surgical approaches as well as on the training of procedures. One emphasis in the clinical application is transrectal and transanal interventions. Transanal total mesorectal excision is equivalent to laparoscopic procedures but with the benefit of an even less invasive access. Transvaginal cholecystectomy can achieve results that are comparable to surgeries that are performed with laparoscopic techniques alone. An analysis of the German NOTES-Register concerning appendectomies as well as the national performance of NOTES-interventions in Switzerland is presented. Apart from intraabdominal approaches, several centers proclaim transoral thyroidectomies and transoral mediastinoscopies. SUMMARY NOTES-procedures are performed in animal experiments as well as in clinical setting although with less frequency. At this time, hybrid techniques using rigid instruments are mainly applied.
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Marsillac AED, Fiorelli RKA, Phillips HN, Novellino P, Oliveira AL, Zorron RPAS. Transaxillary single-port subtotal parathyroidectomy: feasibility study in cadavers. Rev Col Bras Cir 2017; 44:125-130. [PMID: 28658330 DOI: 10.1590/0100-69912017002003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/15/2016] [Indexed: 12/21/2022] Open
Abstract
Objective to test the minimally invasive technique of single-port transaxillary subtotal parathyroidectomy in non-formalized cadavers to evaluate its viability and reproduction. Method we performed ten subtotal parathyroidectomies through a transaxillary TriPort access in cadavers. The technique consisted of access through the axillary fossa, creating a subcutaneous tunnel to the anterior cervical region, for handling of the thyroid gland and dissection and resection of the parathyroid glands. Results all surgeries were successful. The mean time of surgery was 65 minutes (57-79 min), with uncomplicated identification of all anatomical structures. There was no need for complementary incisions in the cervical region. Conclusion the transaxillary single-port subtotal parathyroidectomy technique was feasible and reproducible, suggesting an alternative for minimally invasive cervical surgery.
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Affiliation(s)
- Alexandre Elmães de Marsillac
- - Federal University of the State of Rio de Janeiro (UNIRIO), Department of General and Specialized Surgery, Professional Masters in Videoendoscopic Techniques, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Rossano Kepler Alvim Fiorelli
- - Federal University of the State of Rio de Janeiro (UNIRIO), Department of General and Specialized Surgery, Professional Masters in Videoendoscopic Techniques, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Henrique Neubarth Phillips
- - Federal University of the State of Rio de Janeiro (UNIRIO), Department of General and Specialized Surgery, Professional Masters in Videoendoscopic Techniques, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Pietro Novellino
- - Federal University of the State of Rio de Janeiro (UNIRIO), Department of General and Specialized Surgery, Professional Masters in Videoendoscopic Techniques, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - André Lacerda Oliveira
- - North Fluminense State University (UENF), Department of Post-Graduation, Campos, Rio de Janeiro State, Brazil
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Abstract
OBJECTIVE To analyze the feasibility and safety of Natural Orifice Transluminal Endoscopic Surgery (NOTES) appendectomy, and to analyze separately the transvaginal appendectomy (TVAE) and the transgastric appendectomy (TGAE) procedures. BACKGROUND Laparoscopic appendectomy has rare but relevant complications, namely incisional hernias and neuralgia at the trocar sites, which can potentially be avoided by the NOTES techniques. METHODS The first 217 data sets of the largest NOTES registry worldwide-the German NOTES registry-were analyzed with respect to demographic data, procedural data, and short-term outcomes. Furthermore, TVAEs were compared with TGAEs. RESULTS Almost all procedures were performed in hybrid technique (median of percutaneous trocars: 1). Median age (TVAE: 30.5 yrs vs TGAE: 25 yrs; P < 0.017), body mass index (TVAE: 22.8 kg/m vs TGAE: 24.1 kg/m; P < 0.016), and American Society of Anesthesiologists (ASA) classification (I/II/III; TVAE: 57.1%/41.8%/1.0% vs TGAE: 27.8%/69.4%/2.8%; P < 0.003) significantly differed between both access techniques. Whereas the median number of percutaneous trocars (TVAE: 1 vs TGAE: 1; P < 0.450), the need of additional trocars (TVAE: 6.6% vs TGAE: 13.9%; P < 0.156), the intra, and also postoperative rate of complications (TVAE: 0%/5.5% vs TGAE: 0%/11.1%; P < 1.000/0.258), and the median postoperative hospital stay (TVAE: 3 d vs TGAE: 3 d; P < 0.152) were comparable; the median procedural time (TVAE: 35 minutes vs TGAE: 96 minutes; P < 0.001) and conversion to laparotomy rate (TVAE: 0% vs TGAE: 5.6%; P < 0.023) were significantly less after TVAE. CONCLUSIONS The evaluation of the largest patient collective so far indicates that hybrid NOTES appendectomy is a safe procedure, with advantages for the transvaginal technique with respect to procedural time and conversion rate.
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Schoenberg MB, Magdeburg R, Kienle P, Post S, Eisser PP, Kähler G. Hybrid transgastric appendectomy is feasible but does not offer advantages compared with laparoscopic appendectomy: Results from the transgastric appendectomy study. Surgery 2017; 162:295-302. [PMID: 28442133 DOI: 10.1016/j.surg.2017.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/09/2017] [Accepted: 02/17/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Very few transgastric procedures, the original objective of natural orifice translumenal surgery, have been reported in the international Natural Orifice Translumenal Surgery registers. In addition, most cases were controlled mainly by laparoscopy. To show the feasibility of hybrid transgastric appendectomy and to compare results with laparoscopic a prospective, nonrandomized study was conducted. METHODS From October 2010 to May 2013, patients with acute appendicitis were screened. If the patients met the inclusion criteria, transgastric appendectomy was offered. If the patient decided on laparoscopy, the consenting patients took part in the observational part of the study. The transgastric appendectomy procedure was controlled completely by the gastroscope, although a 3 mm grasper was used to tauten the appendix. Demographic and clinical parameters were collected. Quality of life and pain were measured with a Short Form-8 questionnaire and the Visual Analogue Scale. RESULTS Of the 273 patients who underwent an appendectomy, 65 agreed to take part in this study. Out of these, 30 (46.15%) underwent transgastric appendectomy and 35 (53.85%) underwent laparoscopy. No intraoperative complications were recorded. The operation duration rate was greater in the transgastric appendectomy group (94.5 minutes vs 69 minutes; P < .001). Conversions to open appendectomy and complications were the same. There were no differences in pain preoperatively or postoperatively. In both the transgastric appendectomy and laparoscopic groups, the quality of life of all the subscales increased markedly after successful resection of the pathology. CONCLUSION These preliminary results demonstrate the feasibility of transgastric appendectomy. The postoperative course and quality of life are comparable with laparoscopic appendectomy, but no improvement due to transgastric appendectomy could be demonstrated.
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Affiliation(s)
- Markus B Schoenberg
- Central Interdisciplinary Endoscopy, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany; Department for General, Visceral and Transplantation Surgery, University Hospital Munich, Campus Großhadern, Großhadern, Germany
| | - Richard Magdeburg
- Central Interdisciplinary Endoscopy, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany; Department for Surgery, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Peter Kienle
- Department for Surgery, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Stefan Post
- Department for Surgery, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Paul P Eisser
- Central Interdisciplinary Endoscopy, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany.
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Wang D, Liu Y, Chen D, Li X, Wu R, Liu W, Leung JW, Zhang C, Li Z. Flexible transgastric endoscopic liver cyst fenestration: A feasibility study in humans (with video). Medicine (Baltimore) 2016; 95:e5420. [PMID: 28002325 PMCID: PMC5181809 DOI: 10.1097/md.0000000000005420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
There is no clinical report on the use of natural orifice transluminal endoscopic surgery (NOTES) for the management of patients with large liver cysts.This study aims to evaluate the feasibility and safety of NOTES for liver cyst fenestration in humans using a currently available technique.From February 2009 to June 2010, 4 cases of transgastric endoscopic liver cyst fenestration were performed; in which 3 cases received NOTES only, while 1 case received additional laparoscopic assistance.Mean time to endoscopically locate the liver cyst was 16 minutes (5-22 minutes). Cysts that were present in the left lobe or on the liver surface were easier to locate endoscopically. Transgastric endoscopic liver cyst fenestration was successful in all patients. The use of an occlusion balloon helped in the endoscopic clipping of the gastrotomy incision. Mean operative time was 101.3 minutes (range, 90-112 minutes), and there were no intra- or postoperative complications including infections. All patients recovered well after the surgery, with only minor postoperative throat pain. There was no recurrence at a mean follow-up of 12 months (range, 6-48 months).Small sample size.It may be technically feasible and safe to perform transgastric endoscopic liver cyst fenestration in humans with no recurrence at follow up.
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Affiliation(s)
| | | | - Danlei Chen
- Department of General Surgery, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Xi Li
- Department of General Surgery, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | | | | | - Joseph W. Leung
- Division of Gastroenterology, UC Davis Medical Center, Sacramento, CA
| | - Chuansen Zhang
- Department of Anatomy, Second Military Medical University, Shanghai, China
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Dargar S, De S, Sankaranarayanan G. Development of a Haptic Interface for Natural Orifice Translumenal Endoscopic Surgery Simulation. IEEE TRANSACTIONS ON HAPTICS 2016; 9:333-344. [PMID: 27008674 PMCID: PMC5026958 DOI: 10.1109/toh.2016.2543224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive procedure, which utilizes the body's natural orifices to gain access to the peritoneal cavity. The NOTES procedure is designed to minimize external scarring and patient trauma, however flexible endoscopy based pure NOTES procedures require critical scope handling skills. The delicate nature of the NOTES procedure requires extensive training. Thus, to improve access to training while reducing risk to patients, we have designed and developed the VTEST, a virtual reality NOTES simulator. As part of the simulator, a novel decoupled 2-DOF haptic device was developed to provide realistic force feedback to the user in training. A series of experiments were performed to determine the behavioral characteristics of the device. The device was found capable of rendering up to 5.62N and 0.190 Nm of continuous force and torque in the translational and rotational DOF, respectively. The device possesses 18.1 and 5.7 Hz of force bandwidth in the translational and rotational DOF, respectively. A feedforward friction compensator was also successfully implemented to minimize the negative impact of friction during the interaction with the device. In this work, we have presented the detailed development and evaluation of the haptic device for the VTEST.
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Affiliation(s)
- Saurabh Dargar
- Graduate student in the Biomedical Engineering Department and with the Center for Modeling, Simulation and Imaging in Medicine (CeMSIM) at Rensselaer Polytechnic Institute in Troy, NY, USA
| | - Suvranu De
- Director of CeMSIM and Head of the Department of Mechanical, Aerospace and Nuclear Engineering (MANE) at Rensselaer Polytechnic Institute in Troy, NY, USA
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Comparison of Inflammatory Response to Transgastric and Transcolonic NOTES. Gastroenterol Res Pract 2016; 2016:7320275. [PMID: 27403157 PMCID: PMC4923531 DOI: 10.1155/2016/7320275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 05/22/2016] [Indexed: 11/17/2022] Open
Abstract
Aims. The aim of our study was to determine the physiologic impact of NOTES and to compare the transgastric and transcolonic approaches. Methods. Thirty pigs were randomized to transgastric, transcolonic, or laparoscopic peritoneoscopy. Blood was drawn and analyzed for C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin- (IL-) 1β, IL-6, WBCs, and platelets. Results. Endoscopic closure with an OTSC was successful in all 20 animals. The postoperative course was uneventful in all animals. CRP values rose on day 1 in all animals and slowly declined to baseline levels on day 14 with no differences between the groups (P > 0.05, NS). The levels of TNF-α were significantly increased in the transcolonic group (P < 0.01); however this difference was already present prior to the procedure and remained unchanged. No differences were observed in IL1-β and IL-6 values. There was a temporary rise of WBC on day 1 and of platelets on day 7 in all groups (P > 0.05, NS). Conclusions. Transgastric, transcolonic, and laparoscopic peritoneoscopy resulted in similar changes in systemic inflammatory markers. Our findings do not support the assumption that NOTES is less invasive than laparoscopy.
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Kallidonis P, Panagopoulos V, Kyriazis I, Vasilas M, Liatsikos E. Transvaginal specimen removal in minimally invasive surgery. World J Urol 2016; 34:779-787. [DOI: 10.1007/s00345-016-1770-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 01/16/2016] [Indexed: 02/07/2023] Open
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Lehmann KS, Zornig C, Arlt G, Butters M, Bulian DR, Manger R, Burghardt J, Runkel N, Pürschel A, Köninger J, Buhr HJ. [Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]. Chirurg 2016; 86:577-86. [PMID: 24994591 DOI: 10.1007/s00104-014-2808-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES). AIM The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions. MATERIAL AND METHODS The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis. RESULTS From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations. CONCLUSION The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.
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Affiliation(s)
- K S Lehmann
- Chirurgische Klinik I, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Freie- und Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12200, Berlin, Deutschland,
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Takase Y, Tomizawa N, Enokida Y, Shiraishi T, Katoh R, Suto Y, Sato H, Muroya K, Kurosaki R, Kobayashi K, Arakawa K, Ando T, Takesyohi I. A case of splenic metastasis of ovarian cancer treated with complete laparoscopic splenectomy and transvaginal specimen extraction. Surg Case Rep 2016; 2:26. [PMID: 26976616 PMCID: PMC4791445 DOI: 10.1186/s40792-016-0150-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 03/03/2016] [Indexed: 01/22/2023] Open
Abstract
A 61-year-old woman was diagnosed with right inguinal lymph node and splenic metastasis of ovarian serous cystadenocarcinoma. We performed right inguinal lymph node dissection and total laparoscopic splenectomy in the supine position followed by transvaginal specimen extraction (TVSE). First, using three ports, we extracted the right inguinal lymph node. We repaired the posterior wall of the inguinal canal using a mesh plug. We added two ports and displaced the spleen from the retroperitoneum and lifted it using a snake retractor, disconnecting the hilum using an automatic suturing device. Next, the posterior wall of the vagina was intraperitoneally incised. And an Alexis® laparoscopic system was inserted into the vagina. The cap maintained aeroperitoneum, a collection bag was inserted in the abdominal cavity via the vagina, and the spleen was collected. When the spleen was removed from the body, partial fragmentation of the organ was required in the bag. Organ fragmentation was performed only within the bag, and we made sure not to tear the bag. The vaginal wound was laparoscopically sutured. The patient had no operative complications and was able to actively ambulate at the first day after surgery due to a slight postoperative pain. Total laparoscopic splenectomy with TVSE in the supine position may be a safe and feasible method for selected female patients. This technique enables minimally invasive surgery for female patients with splenic disease.
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Affiliation(s)
- Yoshiaki Takase
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Naoki Tomizawa
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan. .,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan.
| | - Yasuaki Enokida
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Takuya Shiraishi
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan
| | - Ryuji Katoh
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Yujin Suto
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Hiroaki Sato
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Ken Muroya
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Ryo Kurosaki
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Katsumi Kobayashi
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Kazuhisa Arakawa
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Tatsumasa Ando
- Maebashi Red Cross Hospital, 3-21-36 Asahi-chou, Maebashi, Gunma, 371-8511, Japan.,Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
| | - Izumi Takesyohi
- Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-0014, Japan
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Lee GC, Sylla P. Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery. Clin Colon Rectal Surg 2015; 28:181-93. [PMID: 26491411 DOI: 10.1055/s-0035-1555009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.
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Affiliation(s)
- Grace Clara Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Patricia Sylla
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Yip HC, Chiu PWY. Recent advances in natural orifice transluminal endoscopic surgery†. Eur J Cardiothorac Surg 2015; 49 Suppl 1:i25-30. [PMID: 26494866 DOI: 10.1093/ejcts/ezv364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.
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Affiliation(s)
- Hon-chi Yip
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Philip Wai-yan Chiu
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China Department of Surgery, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
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Donatsky AM, Andersen L, Nielsen OL, Meisner S, Jørgensen LN, Rosenberg J, Vilmann P. Gastrotomy Healing After Transgastric Peritoneoscopy: A Randomized Study in a Pig Model. J Laparoendosc Adv Surg Tech A 2015; 25:747-54. [PMID: 26275155 DOI: 10.1089/lap.2015.0271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Reliable closure and infection prevention are the main barriers for implementation of pure transgastric peritoneoscopy. The primary aim of this study was to assess healing of over the scope clip (OTSC) closed gastrotomies. MATERIALS AND METHODS Pure transgastric peritoneoscopy was performed in 7 pigs. The pigs were randomized to 14 or 28 postoperative days (POD) of follow-up. Decontamination of the access route was performed before instrumentation. A full necropsy was performed. Closure was evaluated with histopathological examination of excised gastrorrhaphies. RESULTS Three pigs were allowed 14 POD of follow-up, and 4 pigs were allowed 28 POD of follow-up. Survival was achieved in 6 of the 7 animals; 1 pig was euthanized due to diffuse peritonitis. Based on our definition, full-thickness healing had only been achieved in a single pig allowed 28 POD. With respect to clinical relevancy, full-thickness healing was deemed achieved in 4 of 6 pigs completing follow-up and in all pigs allowed and surviving 28 POD. Access required repeated punctures and the use of several endoscopic instruments. CONCLUSIONS Full-thickness healing of the gastrotomy was only found in a single case when adhering to the per protocol definition. Endoscopic ultrasonography-guided access was difficult. It lacks reproducibility and needs refinement. Despite a combined decontamination regimen, infectious complications still occurred.
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Affiliation(s)
- Anders Meller Donatsky
- 1 Department of Surgery, Hvidovre Hospital, University of Copenhagen , Hvidovre, Denmark
| | - Luise Andersen
- 2 Department of Pathology, Roskilde Hospital, University of Copenhagen , Roskilde, Denmark
| | - Ole Lerberg Nielsen
- 3 Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen , Frederiksberg, Denmark
| | - Søren Meisner
- 4 Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark
| | | | - Jacob Rosenberg
- 5 Department of Surgery, Herlev Hospital, University of Copenhagen , Herlev, Denmark
| | - Peter Vilmann
- 5 Department of Surgery, Herlev Hospital, University of Copenhagen , Herlev, Denmark
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Al Nasser M, Pini G, Gözen AS, Elashry OM, Akin Y, Klein J, Almouhissen T, Rassweiler J. Comparative study for evaluating the cosmetic outcome of small-incision access retroperitoneoscopic technique (SMART) with standard retroperitoneoscopy using the Observer Scar Assessment Scale: are small incisions a big deal? J Endourol 2015; 28:1409-13. [PMID: 25230126 DOI: 10.1089/end.2014.0142] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM To compare the scars and cosmetic results of trocars of 3, 5, and 10 mm in cases by small-incision access retroperitoneoscopic technique pyeloplasty (SMARTp) and standard laparoscopy pyeloplasty (SLp). METHODS Between January 2012 and October 2013, 20 pyeloplasties were performed: 12 with SMARTp and 8 with SLp techniques. A 5-mm homemade balloon trocar was used to create the retroperitoneal space. In SMARTp, 3- and 5-mm trocars were used and in SLp, 5- and 10-mm trocars were used. All patients underwent a ureteral (Double-J) stent placement preoperatively. The study included a total of 72 trocar-site scars: 3 mm (24 scars), 5 mm (24 scars), and 10 mm (24 scars). Cosmetic outcome was assessed at the 3rd, 12th, and 24th month of surgeries by the Observer Scar Assessment Scale (OSAS). RESULTS Mean age was 34.7±10.5 (19-52) years, and mean follow up was 18.7±9.2 months. Fifteen patients (75%) underwent Y-V plasty, and 5 (25%) underwent Anderson-Hynes pyeloplasty. Mean operative time was 125.4±28.7 minutes. There was only minimal blood loss, no need for conversion to standard laparoscopic or open pyeloplasty, no intraoperative complications, and only two postoperative complications were recorded: retroperitoneal hemorrhage and wound infection and both were treated conservatively. There were significant differences between objective questions of "vascularization" in a 3-mm trocar and "thickness" in a 10-mm trocar. Twenty-four months after surgery, the cosmetic data assessed by OSAS showed statistically significant differenecs in favor of the 3-mm trocar sites versus the 10-mm trocar sites (OSAS: 13.8±3.9 vs 24.6±1.7; p=0.006) with no statistically significant difference between 3- and 5-mm port sites. CONCLUSIONS The SMARTp is proved to be an efficacious and tolerable procedure with better cosmetic results and can be used for the treatment of ureteropelvic junction obstruction (UPJO) in suitable patients. We believe that this technique is likely to become an established procedure.
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Affiliation(s)
- Murad Al Nasser
- Department of Urology, Klinikum Heilbronn , Heilbronn, Germany
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Fisichella PM, DeMeester SR, Hungness E, Perretta S, Soper NJ, Rosemurgy A, Torquati A, Sachdeva AK, Patti MG. Emerging Techniques in Minimally Invasive Surgery. Pros and Cons. J Gastrointest Surg 2015; 19:1355-62. [PMID: 25678255 DOI: 10.1007/s11605-015-2766-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 01/29/2015] [Indexed: 01/31/2023]
Abstract
New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.
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Affiliation(s)
- P Marco Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, 1400 VFW Parkway, West Roxbury, Boston, MA, 02132, USA,
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Kayaalp C, Tardu A, Yagci MA, Sumer F. Transjejunal Extraction of Gallbladder After Mini-Laparoscopic Cholecystectomy in Patients with Previous Roux-en-Y Gastric Bypass: A Small Case Series. J Laparoendosc Adv Surg Tech A 2015; 25:577-80. [PMID: 26076050 DOI: 10.1089/lap.2014.0583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The length of incisions on the abdominal wall directly correlates with wound-related morbidities and patient comfort. Both mini-laparoscopy (only ≤5-mm trocars) and natural orifice specimen extraction avoid larger abdominal incisions. This study described a new natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) cholecystectomy technique by combination of these two advanced laparoscopic techniques for cholelithiasis in patients who had prior laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity. PATIENTS AND METHODS Three patients (two males, one female; 39, 62, and 34 years old, respectively) were admitted with symptomatic cholelithiasis (multiple millimeter-sized gallstones), and all had previously had LRYGB. They were treated by mini-laparoscopic cholecystectomy using three 5-mm trocars. The gallbladder was removed through the dilated efferent limb of the jejunum, 5 cm distal from the gastrojejunostomy. Transjejunal extraction was performed under endoscopic guidance. The gallbladder in the jejenum was passed through the anastomosis and extracted with an endoscopic snare by the transoral way. The enterotomy was closed intracorporeally. RESULTS There was no conversion or additional trocar requirement. All the procedures were completed successfully without problems. Respective operating times were 95, 75, and 120 minutes. Only 1 patient required postoperative analgesic; the others did not. The patients started to get a liquid diet on the night of surgery and were discharged on Days 1, 1, and 2, respectively, with normal diet recommendations. There were no morbidities. CONCLUSIONS Mini-laparoscopic cholecystectomy is technically feasible in patients with previous LRYGB. Prior LRYGB was not an obstacle for transoral specimen extraction. The dilated efferent jejunal limb is a good alternative route for natural orifice specimen extraction. This report described the first natural orifice surgery through the small bowel.
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Affiliation(s)
- Cuneyt Kayaalp
- Department of Surgery, Inonu University , Malatya, Turkey
| | - Ali Tardu
- Department of Surgery, Inonu University , Malatya, Turkey
| | | | - Fatih Sumer
- Department of Surgery, Inonu University , Malatya, Turkey
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Bhardwaj N. Will NOTES ever become noticed? ANZ J Surg 2015; 85:204-5. [PMID: 25996005 DOI: 10.1111/ans.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Xu B, Xu B, Zheng WY, Ge HY, Wang LW, Song ZS, He B. Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis. World J Gastroenterol 2015; 21:5393-5406. [PMID: 25954114 PMCID: PMC4419081 DOI: 10.3748/wjg.v21.i17.5393] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/29/2014] [Accepted: 01/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the results of transvaginal cholecystectomy (TVC) and conventional laparoscopic cholecystectomy (CLC) for gallbladder disease.
METHODS: We performed a literature search of PubMed, EMBASE, Ovid, Web of Science, Cochrane Library, Google Scholar, MetaRegister of Controlled Trials, Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC. Data were extracted by two authors. Mean difference (MD), standardized mean difference (SMD), odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models. Statistical heterogeneity was evaluated with the χ2 test. The fixed-effects model was used in the absence of statistically significant heterogeneity. The random-effects model was chosen when heterogeneity was found.
RESULTS: There were 730 patients in nine controlled clinical trials. No significant difference was found regarding demographic characteristics (P > 0.5), including anesthetic risk score, age, body mass index, and abdominal surgical history between the TVC and CLC groups. Both groups had similar mortality, morbidity, and return to work after surgery. Patients in the TVC group had a lower pain score on postoperative day 1 (SMD: -0.957, 95%CI: -1.488 to -0.426, P < 0.001), needed less postoperative analgesic medication (SMD: -0.574, 95%CI: -0.807 to -0.341, P < 0.001) and stayed for a shorter time in hospital (MD: -1.004 d, 95%CI: -1.779 to 0.228, P = 0.011), but had longer operative time (MD: 17.307 min, 95%CI: 6.789 to 27.826, P = 0.001). TVC had no significant influence on postoperative sexual function and quality of life. Better cosmetic results and satisfaction were achieved in the TVC group.
CONCLUSION: TVC is safe and effective for gallbladder disease. However, vaginal injury might occur, and further trials are needed to compare TVC with CLC.
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Atallah S, Martin-Perez B, Keller D, Burke J, Hunter L. Natural-orifice transluminal endoscopic surgery. Br J Surg 2015; 102:e73-92. [PMID: 25627137 DOI: 10.1002/bjs.9710] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/20/2014] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- S Atallah
- Department of Colon and Rectal Surgery, Florida Hospital, Orlando, Florida
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Agresta F, Campanile FC, Vettoretto N, Silecchia G, Bergamini C, Maida P, Lombari P, Narilli P, Marchi D, Carrara A, Esposito MG, Fiume S, Miranda G, Barlera S, Davoli M. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg 2015; 400:429-53. [PMID: 25850631 DOI: 10.1007/s00423-015-1300-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/24/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery. METHODS In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.
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Affiliation(s)
- Ferdinando Agresta
- Department of Surgery, Presidio Ospedaliero di Adria (RO), Adria, RO, Italy,
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Zygomalas A, Kehagias I, Giokas K, Koutsouris D. Miniature Surgical Robots in the Era of NOTES and LESS. Surg Innov 2015; 22:97-107. [DOI: 10.1177/1553350614532549] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.
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Clinical NOTES appendectomy study: comparison of transvaginal NOTES appendectomy in hybrid technique with laparoscopic appendectomy. Int J Colorectal Dis 2015; 30:259-67. [PMID: 25533898 DOI: 10.1007/s00384-014-2081-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE The proposed advantages of NOTES are aimed to assess the comparison with standard procedures. Complications are a major focus of its evaluation. We initiated a prospective comparison between transvaginal hybrid appendectomy versus laparoscopic appendectomy. PATIENTS AND METHODS For each, NOTES and laparoscopic appendectomy, 10 consecutive female patients participated in the study with follow-up documentation for 35 days and after 1 year. Transvaginal appendectomy was considered a non-standard medical procedure and required individual patient's consent. Pre- and postoperative gynecological examinations were performed. Questionnaire-based evaluation included issues related to quality of life in addition to objective clinical findings. The study is approved by the ethics committee of the University of Rostock. RESULTS All women returned questionnaires for evaluation. Age and BMI are comparable. Overall procedure time was significantly shorter in laparoscopy. The only postoperative complication consisted of an intra-abdominal abscess after laparoscopic appendectomy. One patient of the NOTES group suffered from new abdominal pain 3 weeks postoperatively; a mini-laparoscopy showed a normal situation. Significant differences (p < 0.05) of the questionnaire-based comparison with advantages for the NOTES group were found in following items: reduced activity at day 1-14, postoperative pain at day 1, general health conditions at day 1-3 and quality of life at day 3. NOTES patients wished significantly earlier to be discharged and started significantly earlier with activities, but no differences existed after 4 weeks. CONCLUSIONS Transvaginal flexible appendectomy appears to be a safe procedure performed in hybrid technique. Data from the study point to shortened recovery intervals and improved quality of life.
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Yamaguchi T, Abe N, Matsunobu S, Mizuno H, Yanagida O, Takeuchi H, Masaki T, Mori T, Sugiyama M. Single-incision multiport laparoendoscopic surgery using a short-type flexible endoscope and its usefulness in cholecystectomy. Asian J Endosc Surg 2015; 8:48-53. [PMID: 25384706 DOI: 10.1111/ases.12148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 09/12/2014] [Accepted: 09/21/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We previously demonstrated the advantages of a short-type flexible endoscope as a working scope in laparoscopic surgery through single-incision procedures in animal experiments. In this report, we examined the outcomes of laparoscopic surgery through a single incision using a flexible endoscope in a clinical setting. Specifically, we performed cholecystectomy using single-incision multiport laparoendoscopic (SIMPLE) surgery. METHODS Thirteen patients with cholecystolithiasis or gallbladder polyp underwent SIMPLE cholecystectomy using a newly developed short-type flexible endoscope with a working length of 60 cm. Twenty-seven patients underwent standard single-incision laparoscopic cholecystectomy using a 5-mm rigid laparoscope. We retrospectively compared the surgical outcomes between the two groups. RESULTS SIMPLE cholecystectomy using the short-type flexible endoscope was successfully carried out. No gallbladder perforation occurred, but perforation occurred in four cases in the standard laparoscopic cholecystectomy group; however, the difference was not statistically significant. Although no other surgical outcomes differed between the two groups, the flexible endoscope had several advantages over the standard laparoscope. The scope provided a flexible view of the operating field. The gallbladder dissection using the cutting device via the scope was easier and safer than that in standard single-incision laparoscopic cholecystectomy. The water-jet, suctioning, and self-cleaning lens functions of the scope served the surgery well. CONCLUSIONS SIMPLE cholecystectomy using a short-type flexible endoscope has surgical outcomes equivalent to those of standard single-incision laparoscopic cholecystectomy, but this endoscope with multiple functions may make the surgical procedures less stressful and safer.
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Affiliation(s)
- Takashi Yamaguchi
- Department of Surgery, Nakanokouseikai General Hospital, Tokyo, Japan
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Dargar S, Sankaranarayanan G, De S. System characterization of a novel haptic interface for natural orifice translumenal endoscopic surgery simulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2014:375-9. [PMID: 25569975 DOI: 10.1109/embc.2014.6943607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive procedure, which utilizes the body's natural orifices to gain access to the peritoneal cavity. The VTEST(©) is a virtual reality NOTES simulator developed at the CeMSIM at RPI to train surgeons in NOTES. A novel 2 DOF decoupled haptic device was designed and built for this simulator. The haptic device can render 5.62 N and 190.05 N-mm of continuous force and torque respectively. In this work we have evaluated the haptic interface and developed a model to accurately describe the system behavior, to further incorporate into an impedance type controller for realistic haptic rendering in the VTEST(©).
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Transvaginal appendectomy: a systematic review. Minim Invasive Surg 2014; 2014:384706. [PMID: 25614832 PMCID: PMC4295586 DOI: 10.1155/2014/384706] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/04/2014] [Indexed: 01/31/2023] Open
Abstract
Background. Natural orifice transluminal endoscopic surgery (NOTES) is a new approach that allows minimal invasive surgery through the mouth, anus, or vagina. Objective. To summarize the recent clinical appraisal, feasibility, complications, and limitations of transvaginal appendectomy for humans and outline the techniques. Data Sources. PubMed/MEDLINE, Cochrane, Google-Scholar, EBSCO, clinicaltrials.gov and congress abstracts, were searched. Study Selection. All related reports were included, irrespective of age, region, race, obesity, comorbidities or history of previous surgery. No restrictions were made in terms of language, country or journal. Main Outcome Measures. Patient selection criteria, surgical techniques, and results. Results. There were total 112 transvaginal appendectomies. All the selected patients had uncomplicated appendicitis and there were no morbidly obese patients. There was no standard surgical technique for transvaginal appendectomy. Mean operating time was 53.3 minutes (25–130 minutes). Conversion and complication rates were 3.6% and 8.2%, respectively. Mean length of hospital stay was 1.9 days. Limitations. There are a limited number of comparative studies and an absence of randomized studies. Conclusions. For now, nonmorbidly obese females with noncomplicated appendicitis can be a candidate for transvaginal appendectomy. It may decrease postoperative pain and enable the return to normal life and work off time. More comparative studies including subgroups are necessary.
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Transvaginal appendectomy in morbidly obese patient. Case Rep Surg 2014; 2014:368640. [PMID: 25506028 PMCID: PMC4258338 DOI: 10.1155/2014/368640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 10/29/2014] [Indexed: 01/17/2023] Open
Abstract
Introduction. Laparoscopic appendectomy has significant benefits in obese patients. However, morbid obesity can be accepted as an exclusion criterion for natural orifice transluminal endoscopic surgery (NOTES). Here, we present a transvaginal appendectomy in a 66-year-old morbidly obese (BMI 36 kg/m2, ASA III) patient. Case and Technique. Acute appendicitis was suspected based on history, physical examination, laboratory tests, and ultrasound findings. During laparoscopic surgery, a 5 mm trocar was inserted through the umbilicus and a 5 mm telescope was placed. A 12 mm trocar and a 5 mm grasper were inserted separately through the posterior fornix of the vagina under laparoscopic guidance. The appendix was divided with an endoscopic stapler through the transvaginal 12 mm trocar and removed from the same trocar. The operating time was 75 minutes with minimal blood loss (<10 mL). The patient was discharged 16 hours after surgery uneventfully and she did not require any analgesic administration. Conclusion. To the best of our knowledge, this is the first clinical case that focuses on the transvaginal appendectomy at morbid obesity. We can say that morbid obesity does not constitute an obstacle for treatment of acute appendicitis by transvaginal endoscopic surgery.
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Abstract
Transvaginal endoscopic salpingectomy for tubal ectopic pregnancy appears to be feasible and safe and may result in less postoperative pain compared with a laparoscopic approach. Objective: To explore the feasibility, safety, efficacy, and cosmetic outcomes of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy. Methods: From May 2009 to May 2012, we prospectively enrolled 40 patients, each of whom had been scheduled for a salpingectomy because of a tubal ectopic pregnancy, and randomized them into two groups: transvaginal endoscopic surgery and laparoscopic approach. We recorded the estimated blood loss, time of anal exhaust, postoperative pain score, length of stay, and scar assessment scale associated with transvaginal endoscopic access (n = 18) (natural orifice transluminal endoscopic surgery) and laparoscopic salpingectomy (n = 20) (control group) for tubal ectopic pregnancy. The transvaginal salpingectomy was performed with a double-channel endoscope through a vaginal puncture. A single surgeon performed the surgical procedures in patients in both groups. Results: The group that underwent the transvaginal endoscopic procedure reported lesser pain at all postoperative visits than the group that underwent the laparoscopic approach. The duration of time for transvaginal endoscopic surgery was slightly longer than that for the laparoscopic approach. However, there was no statistically significant difference between the two groups in the duration of operative time. The group that underwent transvaginal endoscopic surgery was more satisfied with the absence of an external scar than the group that underwent the laparoscopic procedure, which left a scar. The estimated blood loss, time of anal exhaust, and length of stay were the same in both groups. Conclusion: The safety and efficacy of transvaginal endoscopic salpingectomy for tubal ectopic pregnancy are equivalent to those of the laparoscopic procedure. Lesser postoperative pain and a more satisfactory cosmetic outcome were found with the transvaginal endoscopic procedure, making it the more preferred method and superior to the laparoscopic approach.
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Affiliation(s)
- Boqun Xu
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yawen Liu
- Institute of Digestive Endoscopy & Medical Center for Digestive Diseases, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoyan Ying
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Nanjing Medical University, 121 Jiang Jia Yuan, Xia Guan Qu, Nanjing 210011, China.
| | - Zhining Fan
- Department of Obstetrics and Gynecology, Northern Jiangsu People's Hospital, Yangzhou, China
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Dargar S, Brino C, Matthes K, Sankaranarayanan G, De S. Characterization of force and torque interactions during a simulated transgastric appendectomy procedure. IEEE Trans Biomed Eng 2014; 62:890-9. [PMID: 25398173 DOI: 10.1109/tbme.2014.2369956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We have developed an instrumented endoscope grip handle equipped with a six-axis load cell and measured forces and torques during a simulated transgastric natural orifice translumenal endoscopic surgery appendectomy procedure performed in an EASIE-R ex vivo simulator. The data were collected from ten participating surgeons of varying degrees of expertise which was analyzed to compute a set of six force and torque parameters for each coordinate axis for each of the nine tasks of the appendectomy procedure. The mean push/pull force was found to be 3.64 N (σ = 3.54 N) in the push direction and the mean torque was 3.3 N · mm (σ = 38.6 N · mm) in the counterclockwise direction about the push/pull axis. Most interestingly, the force and torque data about the nondominant x and z axes showed a statistically significant difference (p < 0.05) between the expert and novice groups for five of the nine tasks. These data may be useful in developing surgical platforms especially new haptic devices and simulation systems for emerging natural orifice procedures.
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Wang ZK, Yang YS, Zhang XL, Sun G, Hyder Q, Wu LL, Tang P, Li W. Comparison in efficacy between pure NOTES peritoneoscopy with small or large endoscope and laparoscopy. J Dig Dis 2014; 15:628-635. [PMID: 25244524 DOI: 10.1111/1751-2980.12187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the efficacy and systematic impact of different sized endoscopes for pure transgastric natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy relative to laparoscopy. METHODS A total of 15 dogs were randomly assigned to the small-sized endoscope (SS), large-sized endoscope (LS) and standard laparoscopy (SL) groups. The procedure time, visualization scores for abdominal organs, gastric incision healing times and procedure-associated complications were recorded. Blood samples were collected at 1 h preoperation and at 1 h, 12 h, 2 days and 7 days postoperation. Serum tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels as well as peripheral white blood cell (WBC) counts were analyzed. RESULTS Peritoneoscopy was successfully performed with both pure transgastric NOTES and laparoscopy. The peritoneoscopy required less time to complete in the SL group (44.0 ± 7.0 min) than the LS (83.0 ± 28.9 min) and SS (106.6 ± 81.3 min) groups (P < 0.01), but no statistical difference was observed between the SS and LS groups (P > 0.05). The visualization scores of peritoneal organs among the three groups did not differ significantly (P > 0.05). The gastric incision exhibited satisfactory healing in both the SS and LS groups. Moreover, serum TNF-α and IL-6 levels and WBC counts at each time point were similar among the three groups (P > 0.05). CONCLUSIONS Small-sized endoscope is not superior to a large-sized one for pure transgastric NOTES peritoneoscopy. Pure transgastric NOTES is not less invasive or less time-consuming than laparoscopy.
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Affiliation(s)
- Zi Kai Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Wood SG, Dabu-Bondoc S, Dai F, Mikhael H, Vadivelu N, Roberts KE. Comparison of immediate postoperative pain after transvaginal versus traditional laparoscopic cholecystectomy. Surg Endosc 2014; 28:1141-5. [PMID: 24232050 DOI: 10.1007/s00464-013-3294-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 10/16/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Transvaginal cholecystectomy (TVC) is the most common natural orifice transluminal surgery (NOTES) performed in women, yet there is a paucity of data on intraoperative and immediate postoperative pain management. Previous studies have demonstrated that NOTES procedures are associated with less postoperative pain and faster recovery times. This study analyzes intraoperative and postoperative opioid use for TVC compared with traditional four-port laparoscopic cholecystectomies (LCs). METHODS This is a retrospective analysis of consecutive TVC and LC female patients between August 2009 and August 2012 in an academic institution. We compared demographics, intraoperative and postoperative opioid use and times in the operating room (OR) and in the post anesthesia care unit (PACU). RESULTS A total of 68 TVC and 67 LC patients were included in this study. The TVC and LC groups were similar in terms of age (both 41 years) and body mass index (29 and 31 kg/m2, respectively). The intraoperative preparation, surgical, and emergence times were significantly longer for the TVC than for the LC (p ≤ 0.01). Compared with the LC group, the intraoperative opioid requirement was significantly greater (TVC 27 mg vs. LC 25 mg; p = 0.003), but after adjusting for anesthesia time, the difference in OR opioid consumption became non-significant (p = 0.08). The PACU opioid requirement (TVC 2.5 vs. LC 5 mg; p = 0.04) was significantly lower for the TVC group, and a greater proportion of patients did not need any pain medications (TVC 38 % vs. LC 21 %; p = 0.04), compared with the LC group. The average PACU pain scores were not significantly different between the groups (p = 0.45). CONCLUSION TVC patients did not experience more pain than LC patients. Although the average pain scores of TVC patients did not differ from those of the LC patients, TVC patients did require less pain medication in the PACU.
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Tian Y, Wu SD, Chen YH, Wang DB. Transvaginal laparoscopic appendectomy simultaneously with vaginal hysterectomy: initial experience of 10 cases. Med Sci Monit 2014; 20:1897-901. [PMID: 25300522 PMCID: PMC4206396 DOI: 10.12659/msm.890895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Yu Tian
- Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, China (mainland)
| | - Shuo-Dong Wu
- Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, China (mainland)
| | - Ying-Han Chen
- Department of Gynecology, Shengjing Hospital, China Medical University, Shenyang, China (mainland)
| | - Dan-Bo Wang
- Department of Gynecology, Shengjing Hospital, China Medical University, Shenyang, China (mainland)
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Wood SG, Dai F, Dabu-Bondoc S, Mikhael H, Vadivelu N, Duffy A, Roberts KE. Transvaginal cholecystectomy learning curve. Surg Endosc 2014; 29:1837-41. [PMID: 25294548 DOI: 10.1007/s00464-014-3873-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 09/04/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are few surgeons in the United States, within private practice and academic centers, currently performing transvaginal cholecystectomies (TVC). The lack of exposure to TVC during residency or fellowship training, coupled with a poorly defined learning curve, further limits interested surgeons who want to apply this technique to their practice. This study describes the learning curve encountered during the introduction of TVC to our academic facility. METHODS This study is an analysis of consecutive TVCs performed between August 14, 2009 and August 3, 2012 at an academic center. The TVC patients were divided into sequential quartiles (n = 15/16). The learning curve outcome was measured as the operative time of TVC patients and compared to the operative time of female laparoscopic cholecystectomy (LC) patients performed during the same time period. RESULTS Sixty-one patients underwent a TVC with a mean age of 38 ± 12 years and mean BMI was 29 ± 6 kg/m(2). Sixty-seven female patients who underwent a LC with average age 41 ± 15 years and average BMI 33 ± 12 kg/m(2). The average operative time of LC patients and TVC patients was 48 ± 20 and 60 ± 17 min, respectively. Significant improvement in TVC operative times was seen between the first (n = 15 TVCs) and second quartiles (p = 0.04) and stayed relatively constant for third quartile, during which there was no statistically significant difference between the mean LC operative time for the second and third TVC quartiles CONCLUSIONS The learning curve of a fellowship-trained surgeon introducing TVC to their surgical repertoire, as measured by improved operative times, can be achieved with approximately 15 cases.
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Affiliation(s)
- Stephanie G Wood
- Department of Surgery, Yale School of Medicine, 40 Temple St., Suite 7B, New Haven, CT, 06510, USA,
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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Pucher PH, Sodergren MH, Lord AC, Teare J, Yang GZ, Darzi A. Consumer demand for surgical innovation: a systematic review of public perception of NOTES. Surg Endosc 2014; 29:774-80. [PMID: 25159629 DOI: 10.1007/s00464-014-3769-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 07/22/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND The full scope of benefits offered by NOTES over traditional laparoscopy, if any, is not yet fully clear. Perceived patient demand for truly "scarless surgery" is often referenced one of the driving factors in the continued development of this relatively new technique. The true scale of patient preference and demand for NOTES as a surgical technique is unknown. This review aims to summarise currently available literature on the topic of patient perceptions of NOTES to guide future development of the technique. METHODS A comprehensive search of PubMed and Web of Science electronic databases was performed on 1st Jan 2014. To be considered for inclusion, articles were required to assess and report the perception of NOTES in a sample of laypersons (patients or general public). The primary endpoint assessed was acceptance or preference rates expressed by patients for NOTES procedures. Reasons given for preference or rejection of NOTES were recorded, as well as preferred access routes and any predicting factors of NOTES acceptance. RESULTS Initial search returned 1,334 results, resulting in 15 articles included in final data synthesis. These polled a total of 4,420 subjects. Acceptance of NOTES ranged between 41 and 84 %. Compared to a laparoscopic approach, preference rates for NOTES ranged from 0 to 78 %. Reasons for preferring NOTES were largely centred on potentially reduced recovery time, complications (particularly with reference to hernias) and postoperative pain. Improved cosmesis also played a role, but was secondary to the above issues. Overall, study quality was poor. CONCLUSIONS This review suggests significant public interest in NOTES and scarless surgery in general. Further research and consideration of differences in public perceptions across regions, countries and cultures are required.
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Affiliation(s)
- Philip H Pucher
- Department of Surgery, St Mary's Hospital, Imperial College London, London, W2 1NY, UK
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