Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250)

Evolution of minimally invasive cholecystectomy: a narrative review

BACKGROUND

Laparoscopic cholecystectomy, being a prevalent abdominal surgical procedure, has transitioned through various innovative stages aimed at reducing the procedure's invasiveness. These stages encompass Single-Incision Laparoscopic Cholecystectomy (SILC), Mini Laparoscopic Cholecystectomy (MLC), Natural Orifice Transluminal Endoscopic Surgery (NOTES), and Robotic-Assisted Laparoscopic Cholecystectomy (RALC). The purpose of this review is to trace the evolution of minimally invasive cholecystectomy techniques, assess their status, and identify emerging trends and challenges in the field.

METHOD

An extensive review was performed to explore the evolution and characteristics of SILC, MLC, NOTES, and RALC. The approach involved an in-depth examination of literature available on PubMed, coupled with a critical assessment of surgical outcomes, associated complications, and technical hurdles posed by these methods.

RESULTS

SILC, despite its potential for reduced scarring, exhibits an elevated risk of bile duct damage and incisional hernia occurrences. MLC, mirroring the standard technique closely, presents minor benefits without amplifying postoperative complications, hence, positing itself as a feasible choice for routine elective cholecystectomy. NOTES, although still facing technical challenges, the hybrid transvaginal procedure is gaining clinical interest. RALC, heralded for its augmented precision and dexterity, emerges as a potential future avenue, although necessitating further exploration to ascertain its efficacy and safety.

CONCLUSION

The progression of laparoscopic cholecystectomy methodologies embodies the surgical society's aspiration to minimize invasiveness whilst enhancing patient outcomes. This review endeavors to offer a structured discourse on SILC, MLC, NOTES, and RALC, aspiring to aid the ongoing deliberation on the judicious selection of surgical techniques in clinical practice.

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA)

INTRODUCTION

It has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established.

METHODS

This study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival.

ETHICS AND DISSEMINATION

The study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

An Observational Study Comparing Hybrid Transvaginal Notes and Four-Port Laparoscopic Cholecystectomy

BACKGROUND

Recently, a great interest has arisen in hybrid natural orifice transluminal endoscopic surgery-cholecystectomy (NOTES-C). It has the potential to cause less postoperative pain and may offer better cosmesis over conventional laparoscopic cholecystectomy (CLC).

PATIENTS AND METHODS

A total of 112 females who underwent conventional cholecystectomy were compared with 108 patients of hybrid transvaginal NOTES-cholecystectomy (TV NOTES-C). We compared intraoperative factors, postoperative pain, the analgesic requirement at different intervals, duration of hospital stay, and time to return to normal activities. In addition, cosmesis and patient satisfaction were assessed at four weeks.

RESULTS

Postoperative pain and analgesic requirement were less in the hybrid TV NOTES-C group (p<0.001 at 95% CI). Hybrid TV NOTES-C patients were discharged more frequently within 12 hours (27.5% versus 1.8%; p<0.001) and returned faster (2.22 versus 4.62 days; p<0.001) to normal activities. Cosmetic results and short-term quality of life as assessed by the patient and observer scar assessment scale (POSAS) and short form-36 (SF-36) scores, respectively, were better in the hybrid TV NOTES-C group (p<0.001 at 95% CI).

CONCLUSIONS

Hybrid TV NOTES-C is associated with reduced postoperative analgesic requirements, faster return to normal activities, better cosmesis, and patient satisfaction compared to conventional four-port cholecystectomy.

An Early Prospective Clinical Study to Evaluate the Safety and Performance of the Versius Surgical System in Robot-Assisted Cholecystectomy

OBJECTIVE

The aim of this study was to demonstrate the ability of the Versius Surgical System to successfully and safely complete cholecystectomy.

BACKGROUND

The system has been developed in-line with surgeon feedback to overcome limitations of conventional laparoscopy to enhance surgeon experience and patient outcomes. Here we present results from the cholecystectomy cohort from a completed early clinical trial, which was designed to broadly align with Stage 2b of the Idea, Development, Exploration, Assessment, Long-term follow-up framework for surgical innovation.

METHODS

Procedures were performed between March 2019 and September 2020 by surgical teams consisting of a lead surgeon and operating room (OR) assistants. Male or female patients aged 18 years and over and requiring cholecystectomy were enrolled. The primary endpoint was the rate of unplanned conversion from robot-assisted surgery to conventional laparoscopic or open surgery. Adverse events (AEs) and serious AEs were adjudicated by video review of the surgery and patient study reports by an independent Clinical Expert Committee.

RESULTS

Overall, 134/143 (93.7%) cholecystectomies were successfully completed using the device. Of the 9 (6.3%) conversions to another surgical modality, 7 were deemed to be related to the device. A total of 6 serious AEs and 3 AEs occurred in 8 patients (5.6%), resulting in 4 (2.8%) readmissions to hospital within 30 days of surgery and 1 death.

CONCLUSIONS

This study demonstrates cholecystectomy performed using the device is as safe and effective as conventional laparoscopy and supports the implementation of the device on a wider scale, pending instrument modifications, in alignment with Idea, Development, Exploration, Assessment, Long-term follow-up Stage 3 (Assessment).

Women's Perception of Transgastric and Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) - Impact of Medical Education, Stage of Life and Cross-Cultural Aspects

Introduction

Despite that NOTES produces at least matchable clinical long-term results when compared to laparoscopy, still a restraint within the medical community and among patients is evident. Consequently, it might be meaningful to evaluate factors of patient's NOTES perception to promote its acceptance. NOTES is still quite novel and questionnaires regarding its perception by the public is still lacking even so in the Middle East. Aim of our survey is to investigate the viewpoint of female healthcare staff on NOTES.

Materials and Methods

A total of 350 questionnaires along with written information about Minimally Invasive Surgery and NOTES were distributed among the female staff in a Tertiary-care Hospital in Abu Dhabi, 257 were returned completely anonymously and voluntarily and entered into a database with a response rate of 73%. We surveyed factors like religion, medical background, age as well as history of previous laparoscopy, endoscopy, birth and other aspects that may impact a woman's perception of both transgastric and transvaginal NOTES for cholecystectomy and ovariectomy, respectively.

Results

Univariate analyses revealed the majority of Muslim women to be more receptive to NOTES as a choice of surgical technique for cholecystectomy and for ovariectomy, respectively, when compared to Christians and Hindus. However, when compared to Muslims, Christian and Hindu groups had a larger share of medical professions. Women with a medical background would opt significantly less for NOTES. Among younger women, NOTES cholecystectomy was refused due to anxiety concerning future pregnancies and sexual dysfunction. Multinomial logistic regression analysis determined medical background and with independent predictive value for the overall choice of interventional technique (p<0.001). Marital status played a significant role only in the comparison of laparoscopy vs transgastric NOTES when performing cholecystectomy and ovariectomy (p<0.01).

Conclusion

In this first study emanating from the Middle East, medical education and partly life stage rather than cross-cultural differences seem to influence NOTES perception in women.

Minimally Invasive Cholecystectomy: Transvaginal or Transabdominal Approach-Which Technique Is Preferred by Female Hospital Employees?

Background: Evidence is lacking concerning a clear benefit of single-port laparoscopic cholecystectomy (SILC) and transvaginal cholecystectomy (TVC) over the classical laparoscopic cholecystectomy (CLC). In this study, we investigated the preferences of the operation techniques among female employees in a tertiary university clinic. Materials and Methods: Study participants in the department of general surgery and gynecology were interviewed regarding their personal felt preferences for the mentioned procedures using a standardized illustrated questionnaire. Results: A total of 111 participants were included in the study. In 70.3% of cases, the transvaginal approach was unknown. The classical techniques were preferred in 95.2% of respondents. Participants with a wish for children showed a higher preference for nontransvaginal techniques (P = .011). The acceptance rate of transvaginal techniques among employees of the department of gynecology was higher than those of the department of general surgery (P = .028). Conclusions: The overall acceptance rate for TVC is low. Especially in case of a wish for children, SILC and CLC represent the preferred techniques. The lack of popularity of TVC could be an explanation for the refusal of this technique. Among employees of the gynecologic department, a transvaginal approach was significantly more often accepted. The cosmetic outcome and the knowledge about an operation technique certainly influence the decision making for the preferred surgical method.

Does near-infrared fluorescent cholangiography with indocyanine green reduce bile duct injuries and conversions to open surgery during laparoscopic or robotic cholecystectomy? - A meta-analysis

BACKGROUND

Bile duct injury and conversion-to-open-surgery rates remain unacceptably high during laparoscopic and robotic cholecystectomy. In a recently published randomized clinical trial, using near-infrared fluorescent cholangiography with indocyanine green intraoperatively markedly enhanced biliary-structure visualization. Our systematic literature review compares bile duct injury and conversion-to-open-surgery rates in patients undergoing laparoscopic or robotic cholecystectomy with versus without near-infrared fluorescent cholangiography.

METHODS

A thorough PubMed search was conducted to identify randomized clinical trials and nonrandomized clinical trials with ≥100 patients. Because all near-infrared fluorescent cholangiography studies were published since 2013, only studies without near-infrared fluorescent cholangiography published since 2013 were included for comparison. Incidence estimates, weighted and unweighted for study size, were adjusted for acute versus chronic cholecystitis, and for robotic versus laparoscopic cholecystectomy and are reported as events/10,000 patients. All studies were assessed for bias risk and high-risk studies excluded.

RESULTS

In total, 4,990 abstracts were reviewed, identifying 5 near-infrared fluorescent cholangiography studies (3 laparoscopic cholecystectomy/2 robotic cholecystectomy; n = 1,603) and 11 not near-infrared fluorescent cholangiography studies (5 laparoscopic cholecystectomy/4 robotic cholecystectomy/2 both; n = 5,070) for analysis. Overall weighted rates for bile duct injury and conversion were 6 and 16/10,000 in near-infrared fluorescent cholangiography patients versus 25 and 271/10,000 in patients without near-infrared fluorescent cholangiography. Among patients undergoing laparoscopic cholecystectomy, bile duct injuries, and conversion rates among near-infrared fluorescent cholangiography versus patients without near-infrared fluorescent cholangiography were 0 and 23/10,000 versus 32 and 255/10,000, respectively. Bile duct injury rates were low with robotic cholecystectomy with and without near-infrared fluorescent cholangiography (12 and 8/10,000), but there was a marked reduction in conversions with near-infrared fluorescent cholangiography (12 vs 322/10,000).

CONCLUSION

Although large comparative trials remain necessary, preliminary analysis suggests that using near-infrared fluorescent cholangiography with indocyanine green intraoperatively sizably decreases bile duct injury and conversion-to-open-surgery rates relative to cholecystectomy under white light alone.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

"Gallbladder disease is one of the most common gastrointestinal diseases encountered in clinical practice. Surgical removal and percutaneous drainage are both widely available and effective in the management of acute cholecystitis. Several endoscopic approaches exist as an alternative to these interventions. These include transpapillary approaches via endoscopic retrograde cholangiopancreatography (ERCP), transmural drainage and access approaches via endoscopic ultrasound (EUS), and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery (NOTES) techniques. This article reviews the epidemiology and pathophysiology of gallbladder diseases and discusses the various percutaneous, surgical, and endoscopic approaches to managing gallbladder disease."

Does obesity influence the results in Transvaginal Hybrid-NOTES cholecystectomy?

BACKGROUND

Morbidly obese patients are usually excluded from studies that compare Transvaginal Hybrid-NOTES Cholecystectomy (TVC) with traditional laparoscopic cholecystectomy. Therefore, these study results cannot necessarily be transferred to this group of patients. In this study, we have analyzed and compared the outcomes of the procedure with obese and non-obese patients.

METHODS

Data from a prospectively maintained database were retrospectively analyzed. All the TVCs performed in our clinic since 2008 were divided into groups according to their body mass index (BMI). Within these groups, we evaluated the following outcome parameters: age, ASA classification, procedural time, number of percutaneous trocars, intra- and postoperative complications, and postoperative hospital stay. Additionally, the posthospital surgical and gynecological follow-up was evaluated for additional complications and patients with class III obesity were contacted to determine further parameters.

RESULTS

Six underweight, 76 normal weight, 72 overweight, 48 class I obesity, 15 class II obesity, and 20 class III obesity patients were analyzed. ASA classification (P < 0.001), procedural time (P < 0.001), and number of percutaneous trocars (P < 0.001) significantly increased with the BMI. By contrast, intra- and postoperative complications (P = 0.134 and P = 0.571), as well as postoperative hospital stay (P = 0.076) did not depend on the BMI. Neither did the classification according to Clavien/Dindo show a significant relation (P = 0.640). Lethality was zero. All posthospital gynecological follow-ups were inconspicuous. Telephone follow-up of class III obesity patients reached a rate of 85% after median 3.4 years. There were no additional complications or problems during sexual intercourse. The satisfaction with the cosmetic and the overall result was very high.

CONCLUSIONS

Although the results of existing studies including normal-weight or merely moderately obese patients can hardly be applied to morbidly obese patients, especially regarding procedural time and the number of percutaneous trocars, obesity should not be an exclusion criterion for TVC, regardless of its magnitude.

Comparison of postoperative pain at umbilical wound after conventional laparoscopic cholecystectomy between transumbilical and infraumbilical incisions: a randomized control trial

BACKGROUND

Transumbilical incision has been applied in single-incision laparoscopy. Evidence for the effect of transumbilical incision on postoperative pain compared with infraumbilical incision is still lacking.

METHODS

A randomized controlled trial (RCT) was conducted in a university hospital. Patients who underwent conventional laparoscopic cholecystectomy were randomized to have transumbilical or infraumbilical incision. Postoperative pain was measured using visual analog score at 6, 24 h, and 7 days post operation. Secondary outcomes were analgesic usage, length of stay, superficial surgical site infection (SSI), wound numbness, and hypersensitivity. Risk ratio and mean difference (MD) along with their 95% confidence intervals (CIs) were estimated. Adjusted analysis was done, if clinical unbalanced characteristics presented. The study was registered at http://ClinicalTrial.gov (ID NCT02738710).

RESULTS

A total of 102 patients were enrolled in which 51 patients were randomized to each interventional group. Postoperative pain was not significantly different between the groups with the MD of - 0.07 (95% CI - 0.47, 0.35). Paracetamol usage was significantly 1 tab (95% CI - 1.9, - 0.1) less after transumbilical incision, but this was not significant after adjusting for unbalanced characteristics. Superficial SSI rate was much higher in the transumbilical than the infraumbilical group, i.e., 16 versus 4%, but this was not significant (p = 0.070). Satisfaction scores at 3 months were not different between the groups, with the corresponding means of 8.9 [standard deviation (SD) 1.3] and 9.0 (SD 1.0).

CONCLUSIONS

Transumbilical incision had non-significant different pain compared to infraumbilical incision. Most patients in both groups were satisfied with the operation at 3 months. A further large RCT is required for comparing SSI between the two incisions.

Laparoscopic cholecystectomy versus transvaginal natural orifice transluminal endoscopic surgery cholecystectomy: results of a prospective comparative single-center study

BACKGROUND AND AIMS

Laparoscopic cholecystectomy (LC) in female individuals has been challenged recently by transvaginal natural orifice transluminal endoscopic surgery cholecystectomy (TVC). TVC has not been widely accepted as a standard procedure, even though it is reported to be a safe and painless alternative to LC. This prospective comparative study aims to not only prove equality of TVC and LC but to underline the advantages of TVC over LC with regard to postoperative pain.

METHODS

This study presents an analysis of a single-center and single-surgeon study with 226 unselected consecutive cholecystectomies performed as either TVC or LC.

RESULTS

A total of 226 female patients underwent surgery with either LC (136 cases) or TVC (90 cases). There were no postoperative adverse events. Twenty-two patients (24.2%) in the TVC group indicated 0 (no pain) on a visual analog scale postoperatively, whereas only 5 patients (3.7%) did so in the LC group (P = < .0001). Overall consumption of non-steroidal anti-inflammatory drugs was significantly less (P < .0001; t test) in the TVC group (mean, 1.2 ± 0.11 g) compared with the LC group (mean, 2.1 ± 0.1 g). Twenty-three patients (25.5%) in the TVC group needed no postoperative analgesics at all.

CONCLUSIONS

TVC is a safe and painless procedure for patients with symptomatic cholelithiasis who are from various ethnic and cultural origins. This benefit, along with an equal safety profile compared with LC, should pave the way for wider application of TVC in women.

Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study

BACKGROUND AND STUDY AIMS

The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment.

METHODS

Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination.

RESULTS

Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002).

CONCLUSIONS

After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.

Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery

Background

Hybrid natural-orifice transluminal endoscopic surgery (NOTES), combining access through a natural orifice with small-sized abdominal trocars, aims to reduce pain and enhance recovery. The objective of this systematic review and meta-analysis was to compare pain and morbidity in hybrid NOTES and standard laparoscopy.

Methods

A systematic literature search was performed to identify RCTs and non- RCTs comparing hybrid NOTES and standard laparoscopy. The main outcome was pain on postoperative day (POD) 1. Secondary outcomes were pain during the further postsurgical course, rescue analgesia, complications, and satisfaction with the cosmetic result. The results of meta-analysis in a random-effects model were presented as odds ratio (ORs) or standard mean differences (MDs) with 95 per cent confidence intervals.

Results

Six RCTs and 21 non-randomized trials including 2186 patients were identified. In hybrid NOTES the score on the numerical pain scale was lower on POD 1 (−0·75, 95 per cent c.i. −1·09 to −0·42; P = 0·001) and on POD 2–4 (−0·58, −0·91 to −0·26; P &lt; 0·001) than that for standard laparoscopy. The need for rescue analgesia was reduced in hybrid NOTES (OR 0·36, 0·24 to 0·54; P &lt; 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P &lt; 0·001) was not significant when only RCTs were considered (OR 0·83, 0·43 to 1·60; P = 0·570). The score for cosmetic satisfaction was higher after NOTES (MD 1·14, 0·57 to 1·71; P &lt; 0·001).

Conclusion

Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.

Safety Outcomes of NOTES Cholecystectomy Versus Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

Natural orifice transluminal endoscopic surgery (NOTES) is an endoscopic technique whereby surgical interventions can be performed with a flexible endoscope passed through a natural orifice (mouth, vulva, urethra, anus) then through a transluminal opening of the stomach, vagina, bladder, or colon. Although in the early stage of research and development, NOTES has been clinically applied across the globe, above all the transvaginal cholecystectomy is among the most frequently performed procedures. In the existing 2 types of transvaginal routes, the hybrid NOTES cholecystectomy (NC) is more likely to be accepted. However, there has been controversy regarding the safety outcomes of hybrid NC in comparison with classical laparoscopic cholecystectomy (LC). The primary objective of this meta-analysis is to compare the characteristics between NC and classical LC.

MATERIALS AND METHODS

A meta-analysis of eligible studies comparing NC with classical LC was performed to evaluate the safety outcomes including wound complications, other postoperative complications and intraoperative conversion between the 2 groups.

RESULTS

Pooling 3 randomized controlled trials (n=157) and 7 nonrandomized trial (n=593) demonstrated that the rates of wound complications and other postoperative complications in NC group did not significantly differ from those of classical LC group [wound complications: ratio difference (RD)=-0.02, 95% confidence interval (CI) -0.04to 0.01, P=0.23; other postoperative complication: RD=-0.01; 95% CI, -0.03 to 0.02; P=0.6]. The intraoperative conversion rate in NC groups was higher than that of LC groups (RD=0.03; 95% CI, 0.01-0.06; P=0.02).

CONCLUSIONS

There is no significate difference between the safety of NC and laparoscope cholecystectomy. NC is associated with a higher rate of intraoperative conversion when compared with LC. It is worthy of further promotion and validation in clinical settings.

Minilaparoscopy-assisted transumbilical laparoscopic cholecystectomy

The role of laparoscopy in the modern surgery era is well established. With the prospect of being able to improve the already privileged current situation, new alternatives have been proposed, such as natural orifice endoscopic surgery (NOTES), the method for single transumbilical access (LESS - Laparo-endoscopic single-site surgery) and minilaparoscopy (MINI). The technique proposed by the authors uses a laparoscope with an operative channel like the flexible endoscope used in NOTES. All operative times are carried out through the umbilical trocar as in LESS, and assisted by a minilaparoscopy grasper. This new technic combines, and results from, the rationalization of technical particularities and synergy of these three approaches, seeking to join their advantages and minimize their disadvantages. RESUMO O papel da videolaparoscopia na era moderna da cirurgia encontra-se bem estabelecido. Com a perspectiva de ser possível melhorar a já privilegiada situação atual, novas alternativas têm sido propostas, como a cirurgia por orifícios naturais (NOTES), o método por acesso único transumbilical (LESS - Laparo-endoscopic single-site surgery) e a minilaparoscopia (MINI). A técnica proposta pelos autores utiliza-se de óptica com canal de trabalho como o endoscópio flexível do NOTES, executa-se todos os tempos operatórios pelo trocarte umbilical, como no LESS, e é assistido por pinça de minilaparoscopia. Esta nova técnica combina e resulta da racionalização de particularidades técnicas e do sinergismo destas três abordagens, buscando agregar suas vantagens e minimizar as suas desvantagens.

An innovative procedure of laparoscope combined with endoscopy for gastrointestinal stromal tumor resection and cholecystectomy: A case report and literature review

The present study reports a novel approach to laparoscopic and endoscopic cooperative surgery for gastric gastrointestinal stromal tumor (GIST) resection and cholecystectomy, and conducts a review of the associated literature. The novel surgical procedure was performed on one patient who was diagnosed with a GIST and cholecystic polypus. The GIST was resected using an insulation-tipped diathermic electrosurgical knife under the guide of an endoscope. Subsequently, a cholecystectomy was performed by inserting two more 5-mm trocars and instruments transumbilically, guided using an endoscope. The tumor and the gallbladder were exteriorized using a peroral approach and the incision lining of the stomach was sutured laparoscopically. The procedure was successfully performed and the patient experienced no discomfort during the 5-year follow-up. In conclusion, the present study demonstrates that laparoscopic and endoscopic cooperative surgery is feasible and would be an ideal choice for invisible abdominal scar surgery, in particular for multi-visceral resection.

[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]

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.

Endoscopic surgery - exploring the modalities

The adoption of endoscopic surgery continues to expand in clinical situations with the recent natural orifice transluminal endoscopic surgery technique enabling abdominal organ resection to be performed without necessitating any skin incision. In recent years, the development of numerous devices and platforms have allowed for such procedures to be carried out in a safer and more efficient manner, and in some ways to better simulate triangulation and surgical tasks (e.g., suturing and dissection). Furthermore, new novel techniques such as submucosal tunneling, endoscopic full-thickness resection and hybrid endo-laparoscopic approaches have further widened its use in more advanced diseases. Nevertheless, many of these new innovations are still at their pre-clinical stage. This review focuses on the various innovations in endoscopic surgery, with emphasis on devices and techniques that are currently in human use.

New minimally invasive approaches for cholecystectomy: Review of literature

Laparoscopic cholecystectomy is the most commonly performed abdominal intervention in Western countries. In an attempt to reduce the invasiveness of the procedure, surgeons have developed single-incision laparoscopic cholecystectomy (SILC), minilaparoscopic cholecystectomy (MLC) and natural orifice transluminal endoscopic surgery (NOTES). The aim of this review was to determine the role of these new minimally invasive approaches for elective laparoscopic cholecystectomy in the treatment of gallstone related disease. Current literature remains insufficient for the correct assessment of emerging techniques for laparoscopic cholecystectomy. None of these procedures has demonstrated clear benefits over conventional laparoscopic cholecystectomy. SILC cannot be currently recommended as it can be associated with an increased risk of bile duct injury and incisional hernia incidence. NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice. As it is standardized and almost identical to the standard laparoscopic technique, MLC could lead to limited benefits without exposing patients to increased postoperative complications, being therefore adoptable for routine elective cholecystectomy. Technical challenges of SILC and NOTES cholecystectomy could be addressed with the evolution of new surgical tools that need to catch up with the innovative minds of surgeons. Regardless the place of these approaches in the future, robotization may be necessary to impose them as standard treatment.

Comparison of outcome and side effects between conventional and transvaginal laparoscopic cholecystectomy: a meta-analysis

Transvaginal laparoscopic cholecystectomy (TVC) is becoming an attractive alternative to conventional laparoscopic cholecystectomy (CLC). We conducted a meta-analysis study to compare the outcome and side effects between TVC and CLC. Clinical studies on TVC with CLC as control were identified by searching PubMed and EMBASE (from 2007 to December 2013). Nine studies were identified for meta-analysis. Our results showed that TVC required much longer operative time [MD, 30.82; 95% confidence interval (CI), 13.00-48.65; P=0.0007] and had significantly lower pain score on postoperative day 1 as compared with CLC (MD, -1.77; 95% CI, -2.91 to -0.63; P=0.002). No statistical difference in days of hospital stay (MD, -1.60; 95% CI, -4.73 to 1.54; P=0.32) and number of complications was found between the 2 groups (risk ratio, 0.52; 95% CI, 0.25-1.10; P=0.09). Safety of TVC is similar as CLC. In conclusion, TVC patients have significantly less postoperative pain but need much longer operative time.

Systematic analysis of the safety and benefits of transvaginal hybrid-NOTES cholecystectomy

AIM: To evaluate transvaginal hybrid-NOTES cholecystectomy (TVC) during its clinical establishment and compare it with the traditional laparoscopic technique (LC).

METHODS: The specific problems and benefits of TVC were reviewed using a registry analysis, a comparative cohort study and a randomized clinical trial. At first, feasibility, safety and specific complications of the TVC were analyzed based on the first 488 data sets of the German NOTES Registry (GNR). Hereafter, we compared the early postoperative results of our first 50 TVC-patients with those of 50 female LC-patients matched by age, BMI and ASA classification. The same cohort was contacted an average of two years later to evaluate long-term results concerning pain and satisfaction with the aesthetic results and the overall postoperative results as well as sexual intercourse by means of two domains of the German version of the Female Sexual Function Index (FSFI-d). Consequently, we performed a randomized clinical trial comparing 20 TVC-patients with 20 needlescopic/3-trocar cholecystectomies (NC) also concerning the early postoperative results as well as pain, satisfaction and quality of life by means of the Eypasch Gastrointestinal Quality of Life Index (GIQLI) in the later course. Finally, we discussed the results in accordance with other published studies.

RESULTS: The complication (3.5%) and conversion rates (4.1%) for TVC were low in the GNR and comparable to those of the LC. Access related intraoperative complications included injuries to the bladder (n = 4; 0.8%) and bowel (n = 3; 0.6%). The study cohort revealed less postoperative pain after TVC comparing to the LC-patients on the day of surgery (NRS, 1.5/10 vs 3.1/10, P = 0.003), in the morning (NRS, 1.9/10 vs 2.8/10, P = 0.047) and in the evening (NRS, 1.1/10 vs 1.8/10, P = 0.025) of postoperative day (POD) one. The randomized clinical trial consistently found less cumulative pain until POD 2 (NRS, 8/40 vs 14/40, P = 0.043), as well as until POD 10 (NRS, 22/190 vs 41/190, P = 0.010). Furthermore, the TVC-patients had a better quality of life on POD 10 than did the LC-patients (GIQLI, 124/144 vs 107/144, P = 0.028). The complication rates were comparable and no specific problems were detected in the long-term follow-up for sexual intercourse for either group. The TVC-patients were more satisfied with the aesthetic result in the long-term course in the matched cohort analysis (1.00 vs 1.88, P < 0.001) as well as in the randomized clinical trial (1.00 vs 1.70, P < 0.001) when compared with the LC-patients.

CONCLUSION: TVC is a feasible procedure with a high safety profile and has advantages in regard to postoperative pain and aesthetic results when compared with LC or NC.

Women’s Perception of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Objective. Over the past 8 years, natural orifice transluminal endoscopic surgery (NOTES) has developed from preclinical to routine clinical practice. However, there are still concerns regarding the transvaginal approach. In our survey, we were interested in females with a professional medical background, thus having at least a basic medical understanding, which might discriminate between objective and subjective concerns. Material and Methods. A questionnaire with 14 items was distributed among 1895 female physicians and nursing and administration staff of the University Medical Center Hamburg-Eppendorf. In addition, a qualitative literature review was performed. Data analysis was carried out using statistical package R version 2.15.0. Results. The questionnaire was answered anonymously by 553 employees (29%). Fifty-seven percent were nurses, 18.6% belonged to administration, and 17% were physicians. A total of 63.1% of our respondents would choose the transvaginal NOTES technique for an assumed ovariectomy, while only 30.4% would choose this access for cholecystectomy. Doubts regarding transvaginal NOTES were related to sexual dysfunction (44.8%), its experimental nature (43.8%), future pregnancies (36.8%), and ethical reasons (30.3%). The literature review showed that women’s perception of the transvaginal access is documented very heterogeneously and therefore difficult to compare. Conclusions. Despite the good reported results of NOTES and the medical background of the surveyed female employees, our study and the literature review clearly shows that there are  fears regarding the transvaginal access, which might be a result of limited information. More accurate explanation of the available methods by the attending surgeon can lead to a better choice of the patient’s preferred method.

Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis

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.

Natural-orifice transluminal endoscopic surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transvaginal/transumbilical hybrid--NOTES--versus 3-trocar needlescopic cholecystectomy: short-term results of a randomized clinical trial

In a randomized clinical trial, needlescopic 3-trocar cholecystectomy was compared with transvaginal/transumbilical hybrid—NOTES—technique for symptomatic cholecystolithiasis. We found significantly less pain despite less analgesics, increased satisfaction with the aesthetic result, and improved postoperative quality of life in the NOTES group. Furthermore, both techniques were equal in terms of safety.

Objective:

For cholecystectomy, both the needlescopic cholecystectomy (NC) 3-trocar technique using 2 to 3 mm trocars and the umbilical-assisted transvaginal cholecystectomy (TVC) technique have found their way into clinical routine. This study compares these 2 techniques in female patients who are in need of an elective cholecystectomy.

Background:

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical concept permitting scarless intra-abdominal operations through natural orifices, such as the vagina. Because of the lack of an adequately powered trial, we designed this first randomized controlled study for the comparison of TVC and NC.

Methods:

This prospective, randomized, nonblinded, single-center trial evaluates the safety and effectiveness of TVC (intervention), compared with NC (control) in female patients with symptomatic cholecystolithiasis. The primary endpoint was intensity of pain until the morning of postoperative day (POD) 2. Secondary outcomes were among others intra- and postoperative complications, procedural time, amount of analgesics used, pain intensity until POD 10, duration of hospital stay, satisfaction with the aesthetic result, and quality of life on POD 10 as quantified with the Eypasch Gastrointestinal Quality of Life Index (GIQLI).

Results:

Between February 2010 and June 2012, 40 patients were randomly assigned to the interventional or control group. All patients completed follow-up. Procedural time, length of postoperative hospital stay, and the rate of intra- and postoperative complications were similar in the 2 groups. However, significant advantages were found for the transvaginal access regarding pain until POD 2, but also until POD 10 (P = 0.043 vs P = 0.010) despite significantly less use of peripheral analgesics (P = 0.019). In the TVC group, patients were significantly more satisfied with the aesthetic result (P < 0.001) and had a significantly better GIQLI (P = 0.028).

Conclusions:

Although comparable in terms of safety, TVC caused less pain, increased satisfaction with the aesthetic result, and improved postoperative quality of life in the short term.

Laparoscopic cholecystectomy: consensus conference-based guidelines

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.

Safety of transvaginal hybrid NOTES cholecystectomy: a systematic review and meta-analysis

BACKGROUND

Despite increasing data regarding clinical outcomes following transvaginal hybrid NOTES cholecystectomy (TVC), a consensus regarding safety based on comparative studies has yet to be reached. The aim of this systematic review and meta-analysis was to compare safety and clinical outcomes of TVC with conventional laparoscopic cholecystectomy (CLC) for the treatment of benign gallstone disease.

METHODS

A comprehensive search for published studies comparing TVC and CLC was performed. Review of each study was conducted and data were extracted. All pooled outcome measures were determined using random-effects models.

RESULTS

Data were retrieved from 14 studies describing 1,145 patients. There was no difference in total complications (POR = 0.68; 95 % CI 0.40-1.14; P = 0.14), incidence of bile duct injury (POR = 1.33; 95 % CI 0.31-5.66; P = 0.70), Clavien-Dindo Grade II (POR = 0.48; 95 % CI 0.14-1.60; P = 0.23) or Grade III (POR = 0.63; 95 % CI 0.24-1.65; P = 0.34) complications between TCV and CLC. Time of return to normal activities was significantly reduced in the TVC group (WMD = -4.86 days; 95 % CI -9.33 to -0.39; P = 0.03), and there was a non-significant reduction in postoperative pain on days 1 (WMD = -0.80; 95 % CI -1.60 to 0.01; P = 0.05) and 3 (WMD = -0.89; 95 % CI -1.77 to -0.01; P = 0.05).

CONCLUSIONS

TVC is safe when performed by appropriately trained surgeons and may be associated with a faster return to normal activities and decreased postoperative pain.

The transvaginal hybrid NOTES versus conventionally assisted laparoscopic sigmoid resection for diverticular disease (TRANSVERSAL) trial: study protocol for a randomized controlled trial

Background

Natural orifice transluminal endoscopic surgery (NOTES) is the consequence of further development of minimally invasive surgery to reduce abdominal incisions and surgical trauma. The potential benefits are expected to be less postoperative pain, faster convalescence, and reduced risk for incisional hernias and wound infections compared to conventional methods. Recent clinical studies have demonstrated the feasibility and safety of transvaginal NOTES, and transvaginal access is currently the most frequent clinically applied route for NOTES procedures. However, despite increasing clinical application, no firm clinical evidence is available for objective assessment of the potential benefits and risks of transvaginal NOTES compared to the current surgical standard.

Methods

The TRANSVERSAL trial is designed as a randomized controlled trial to compare transvaginal hybrid NOTES and laparoscopic-assisted sigmoid resection. Female patients referred to elective sigmoid resection due to complicated or reoccurring diverticulitis of the sigmoid colon are considered eligible. The primary endpoint will be pain intensity during mobilization 24 hours postoperatively as measured by the blinded patient and blinded assessor on a visual analogue scale (VAS). Secondary outcomes include daily pain intensity and analgesic use, patient mobility, intraoperative complications, morbidity, length of stay, quality of life, and sexual function. Follow-up visits are scheduled 3, 12, and 36 months after surgery. A total sample size of 58 patients was determined for the analysis of the primary endpoint. The confirmatory analysis will be performed based on the intention-to-treat (ITT) principle.

Discussion

The TRANSVERSAL trial is the first study to compare transvaginal hybrid NOTES and conventionally assisted laparoscopic surgery for colonic resection in a randomized controlled setting. The results of the TRANSVERSAL trial will allow objective assessment of the potential benefits and risks of NOTES compared to the current surgical standard for sigmoid resection.

Trial registration

The trial protocol was registered in the German Clinical Trials Register ( DRKS00005995) on March 27, 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-454) contains supplementary material, which is available to authorized users.

Transvaginal cholecystectomy learning curve

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.

Transvaginal hybrid NOTES cholecystectomy--results of a randomized clinical trial after 6 months

INTRODUCTION

For cholecystectomy (CHE), both the needlescopic three-trocar technique with 2-3-mm instruments (needlescopic cholecystectomy (NC)) and the umbilically assisted transvaginal technique with rigid instruments (transvaginal cholecystectomy (TVC)) have been established for further reduction of the trauma remaining from laparoscopy.

METHODS

To compare the further outcome of both techniques for elective CHE in female patients, we analyzed the secondary end points of a prospective randomized single-center trial (needlescopic versus transvaginal cholecystectomy (NATCH) trial; ClinicalTrials.gov Identifier: NCT0168577), in particular, satisfaction with aesthetics, overall satisfaction, abdominal pain, and incidence of trocar hernias postoperatively at both 3 and 6 months. After 3 months, the domains "satisfaction" and "pain" of the German version of the Female Sexual Function Index (FSFI-d) were additionally evaluated to detect respective complications. A gynecological control examination was conducted in all TVC patients after 6 months.

RESULTS

Forty patients were equally randomized into the therapy and the control groups between February 2010 and June 2012. No significant differences were found for overall satisfaction with the surgical result, abdominal pain, sexual function, and the rate of trocar hernias. However, aesthetics were rated significantly better by TVC patients both after 3 and after 6 months (P = 0.004 and P < 0.001). There were no postoperative pathological gynecological findings.

CONCLUSIONS

Following TVC, there is a significantly better aesthetic result as compared to NC, even at 3 and 6 months after the procedure. No difference was found for sexual function.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

BACKGROUND

NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.

METHODS

Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.

RESULTS

At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.

CONCLUSION

As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods-combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

Evolving endoscopic surgery

Since the days of Albukasim in medieval Spain, natural orifices have been regarded not only as a rather repugnant source of bodily odors, fluids and excreta, but also as a convenient invitation to explore and treat the inner passages of the organism. However, surgical ingenuity needed to be matched by appropriate tools and devices. Lack of technologically advanced instrumentation was a strong deterrent during almost a millennium until recent decades when a quantum jump materialized. Endoscopic surgery is currently a vibrant and growing subspecialty, which successfully handles millions of patients every year. Additional opportunities lie ahead which might benefit millions more, however, requiring even more sophisticated apparatuses, particularly in the field of robotics, artificial intelligence, and tissue repair (surgical suturing). This is a particularly exciting and worthwhile challenge, namely of larger and safer endoscopic interventions, followed by seamless and scarless recovery. In synthesis, the future is widely open for those who use together intelligence and creativity to develop new prototypes, new accessories and new techniques. Yet there are many challenges in the path of endoscopic surgery. In this new era of robotic endoscopy, one will likely need a virtual simulator to train and assess the performance of younger doctors. More evidence will be essential in multiple evolving fields, particularly to elucidate whether more ambitious and complex pathways, such as intrathoracic and intraperitoneal surgery via natural orifice transluminal endoscopic surgery (NOTES), are superior or not to conventional techniques.

The experience of transumbilical endoscopic appendectomies

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 ± 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 ± 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.

Fewer-than-four ports versus four ports for laparoscopic cholecystectomy

BACKGROUND

Traditionally, laparoscopic cholecystectomy is performed using two 10-mm ports and two 5-mm ports. Recently, a reduction in the number of ports has been suggested as a modification of the standard technique with a view to decreasing pain and improving cosmesis. The safety and effectiveness of using fewer-than-four ports has not yet been established.

OBJECTIVES

To assess the benefits (such as improvement in cosmesis and earlier return to activity) and harms (such as increased complications) of using fewer-than-four ports (fewer-than-four-ports laparoscopic cholecystectomy) versus four ports in people undergoing laparoscopic cholecystectomy for any reason (symptomatic gallstones, acalculous cholecystitis, gallbladder polyp, or any other condition).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2013), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal to September 2013.

SELECTION CRITERIA

We included all randomised clinical trials comparing fewer-than-four ports versus four ports, that is, with standard laparoscopic cholecystectomy that is performed with two ports of at least 10-mm incision and two ports of at least 5-mm incision.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials and extracted the data. We analysed the data using both the fixed-effect and the random-effects models. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis, whenever possible.

MAIN RESULTS

We found nine trials with 855 participants that randomised participants to fewer-than-four-ports laparoscopic cholecystectomy (n = 427) versus four-port laparoscopic cholecystectomy (n = 428). Most trials included low anaesthetic risk participants undergoing elective laparoscopic cholecystectomy. Seven of the nine trials used a single port laparoscopic cholecystectomy and the remaining two trials used three-port laparoscopic cholecystectomy as the experimental intervention. Only one trial including 70 participants had low risk of bias. Fewer-than-four-ports laparoscopic cholecystectomy could be completed successfully in more than 90% of participants in most trials. The remaining participants were mostly converted to four-port laparoscopic cholecystectomy but some participants had to undergo open cholecystectomy.There was no mortality in either group in the seven trials that reported mortality (318 participants in fewer-than-four-ports laparoscopic cholecystectomy group and 316 participants in four-port laparoscopic cholecystectomy group). The proportion of participants with serious adverse events was low in both treatment groups and the estimated RR was compatible with a reduction and substantial increased risk with the fewer-than-four-ports group (6/318 (1.9%)) and four-port laparoscopic cholecystectomy group (0/316 (0%)) (RR 3.93; 95% CI 0.86 to 18.04; 7 trials; 634 participants; very low quality evidence). The estimated difference in the quality of life (measured between 10 and 30 days) was imprecise (standardised mean difference (SMD) 0.18; 95% CI -0.05 to 0.42; 4 trials; 510 participants; very low quality evidence), as was the proportion of participants in whom the laparoscopic cholecystectomy had to be converted to open cholecystectomy between the groups (fewer-than-four ports 3/289 (adjusted proportion 1.2%) versus four port: 5/292 (1.7%); RR 0.68; 95% CI 0.19 to 2.35; 5 trials; 581 participants; very low quality evidence). The fewer-than-four-ports laparoscopic cholecystectomy took 14 minutes longer to complete (MD 14.44 minutes; 95% CI 5.95 to 22.93; 9 trials; 855 participants; very low quality evidence). There was no clear difference in hospital stay between the groups (MD -0.01 days; 95% CI -0.28 to 0.26; 6 trials; 731 participants) or in the proportion of participants discharged as day surgery (RR 0.92; 95% CI 0.70 to 1.22; 1 trial; 50 participants; very low quality evidence) between the two groups. The times taken to return to normal activity and work were shorter by two days in the fewer-than-four-ports group compared with four-port laparoscopic cholecystectomy (return to normal activity: MD -1.20 days; 95% CI -1.58 to -0.81; 2 trials; 325 participants; very low quality evidence; return to work: MD -2.00 days; 95% CI -3.31 to -0.69; 1 trial; 150 participants; very low quality evidence). There was no significant difference in cosmesis scores at 6 to 12 months between the two groups (SMD 0.37; 95% CI -0.10 to 0.84; 2 trials; 317 participants; very low quality evidence).

AUTHORS' CONCLUSIONS

There is very low quality evidence that is insufficient to determine whether there is any significant clinical benefit in using fewer-than-four-ports laparoscopic cholecystectomy compared with four-port laparoscopic cholecystectomy. The safety profile of using fewer-than-four ports is yet to be established and fewer-than-four-ports laparoscopic cholecystectomy should be reserved for well-designed randomised clinical trials.

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra-abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra-abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES-related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES-related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.

Transvaginal organ extraction: potential for broad clinical application

BACKGROUND

Natural orifice transluminal endoscopic surgery procedures have evolved over the past few years. A transvaginal approach is a promising alternative for intraperitoneal procedures. Our objective was to evaluate the safety and feasibility of transvaginal organ extraction.

METHODS

This institutional review board-approved protocol involved retrospective review of an ongoing prospective study. Female subjects who presented to our hospital for elective cholecystectomy, appendectomy, or sleeve gastrectomy were offered participation in the study. Eligible patients met the following criteria: age between 18 and 75, diagnosis of gallbladder disease, acute appendicitis, or morbid obesity who desired surgical treatment. A hybrid transvaginal natural orifice approach was used in this series.

RESULTS

Thirty-four women underwent transvaginal organ extraction between September 2007 and January 2012. The mean age was 40 ± 12.1 years (range 23-63 years). The mean body mass index was 27 ± 6.4 kg/m(2) (range 16-43 kg/m(2)). All patients had an American Society of Anesthesiologists classification of two or below. The mean operative time for cholecystectomy, appendectomy, and sleeve gastrectomy was 90, 71, and 135 min, respectively. There were no conversions to open operation and no intraoperative complications. The mean hospital stay was 2 days for all cases. Patients were followed for a mean of 24 months (range 1-61 months). There were two pregnancies and two successful vaginal deliveries. Six patients (18 %) had minor complaints of spotting or heavy menses in the immediate postoperative period that resolved with conservative measures. There were no abdominal wall complications. There were no long-term complications and no mortalities.

CONCLUSIONS

This initial experience suggests that this surgical approach is safe, does not increase length of stay, and has no long-term vaginal complications. Given this attractive profile, a transvaginal approach may prove to be a superior mode of organ extraction, although randomized studies and long-term follow-up are needed.

Single incision versus conventional laparoscopic cholecystectomy outcomes: a meta-analysis of randomized controlled trials

BACKGROUND

Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue.

METHODS

Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).

RESULTS

25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar.

CONCLUSIONS

SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.

Single incision versus conventional laparoscopic cholecystectomy outcomes: a meta-analysis of randomized controlled trials

BACKGROUND

Previous meta-analyses that compared the outcome of SILC and CLC have not presented consistent conclusions. This meta-analysis was performed after adding many recent RCTs, to clarify this issue.

METHODS

Relevant articles published in English were identified by searching PubMed, Embase, Web of Knowledge, and the Cochrane Controlled Trial Register from January 1997 to February 2013. Reference lists of the retrieved articles were reviewed to identify additional articles. Primary outcomes (postoperative pain scores, cosmetic score, and length of incision) and secondary outcomes (operating time, blood loss, conversion rates, postoperative complications, postoperative hospital stay, time to initial oral intake, and time to resume work) were pooled. Quantitative variables were calculated using the weighted mean difference (WMD), and qualitative variables were pooled using odds ratios (OR).

RESULTS

25 appropriate RCTs were identified from 2128 published articles. 1841 patients were treated, 944 with SILC and 897 with CLC. SILC was superior to CLC in cosmetic score (WMD = 1.155, P<0.001), shorter length of incision (WMD = -3.285, P = 0.029), and postoperative pain within 12 h (VAS in 3-4 h, WMD = -0.704, P = 0.026; VAS in 6-8 h, WMD = -0.613, P = 0.010). CLC was superior to SILC in operating time (OT) (WMD = 13.613, P<0.001) and need of additional instruments (OR = 7.448, P<0.001). Other secondary outcomes were similar.

CONCLUSIONS

SILC offered a better cosmetic result and less postoperative pain for patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder. However, SILC was associated with a longer OT and required additional instruments.

The Impact of New Instruments on Surgical Performance in Natural Orifice Translumenal Endoscopic Surgery

Natural Orifice Translumenal Endoscopic Surgery (NOTES) is a recent emerging technique for performing general surgery procedures such as cholecystectomy (gallbladder removal). However, the advantages of NOTES over conventional laparoscopic surgery, the current gold standard, are still questionable. The aim of this study was to show the impact of introducing new surgical instruments in the NOTES technique on surgical performance in a cholecystectomy as compared to conventional laparoscopic surgery. A set of videos from real cholecystectomy cases performed using these two different techniques were analyzed. Hierarchical task decomposition and timeline analysis were conducted for each technique. A comparison to show variations between the two techniques at the task level is presented to highlight the technical issues, and their effects on performance, associated with the use of current endoscopic tools in the NOTES technique. The results show a longer procedural time in the NOTES technique than in the laparoscopic technique with the highest increase in surgical time for dissection tasks. The tools used for dissection were also shown to be inadequate for the task based on the motion analysis. Using this systematic method of analysis, new surgical techniques can be assessed based on performance measures, while areas of design improvement in surgical tools can be identified and related to the performance assessment.