Natural orifice translumenal endoscopic surgery: a critical review

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

Endoscopic Applications of Near-Infrared Photoimmunotherapy (NIR-PIT) in Cancers of the Digestive and Respiratory Tracts

Near-infrared photoimmunotherapy (NIR-PIT) is a newly developed and promising therapy that specifically destroys target cells by irradiating antibody-photo-absorber conjugates (APCs) with NIR light. APCs bind to target molecules on the cell surface, and when exposed to NIR light, cause disruption of the cell membrane due to the ligand release reaction and dye aggregation. This leads to rapid cell swelling, blebbing, and rupture, which leads to immunogenic cell death (ICD). ICD activates host antitumor immunity, which assists in killing still viable cancer cells in the treated lesion but is also capable of producing responses in untreated lesions. In September 2020, an APC and laser system were conditionally approved for clinical use in unresectable advanced head and neck cancer in Japan, and are now routine in appropriate patients. However, most tumors have been relatively accessible in the oral cavity or neck. Endoscopes offer the opportunity to deliver light deeper within hollow organs of the body. In recent years, the application of endoscopic therapy as an alternative to surgery for the treatment of cancer has expanded, providing significant benefits to inoperable patients. In this review, we will discuss the potential applications of endoscopic NIR-PIT, especially in thoracic and gastrointestinal cancers.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

vNOTES for adnexal procedures

This work aims to describe the technique and review all transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for adnexal procedures performed and to acknowledge vNOTES as an alternative to conventional laparoscopy. The procedure consisted of an incision in the Pouch of Douglas, insertion of a single port device, laparoscopic surgery through the device, extraction of specimens through the vagina and closure of the vaginal apex with a direct suture. Eighteen procedures have been successfully completed, 1 patient required conversion to conventional abdominal surgery due to intolerance to pneumoperitoneum. Surgeries' length range was 45-210 minutes. The estimated blood loss was less than 100 mL. The patients required minimal analgesia, were discharged the day after and had no postoperative complications. No patients complained of dyspareunia. Two patients conceived after surgery. vNOTES is a safe and desirable approach to the adnexa and a reasonable alternative to conventional laparoscopy or vaginal surgery.Impact statementWhat is already known on this subject? Natural Orifice Transluminal Surgery (NOTES) is a technique used to access the abdominal cavity through natural orifice. Compared to conventional laparoscopy, it's expected to have fewer complications.What do the results of this study add? This is one of the few works addressing vNOTES adnexal surgery, which appears to be a good alternative to conventional laparoscopy.What are the implications of these findings for clinical practice and/or further research? vNOTES may be a desirable approach to the adnexa. This work opens a door to new research regarding vNOTES in more complex gynaecologic procedures.

A History of Flexible Gastrointestinal Endoscopy

Surgeons have been involved, since the beginning, in the development and evolution of endoscopy. They have been instrumental in developing new methods and have been actively involved in most of the therapeutic applications. The continued evolution of endoscopic technique is inevitable and will involve the integration of new technology with innovative thinking.

Clinical adoption of robotics in endoscopy: Challenges and solutions

The endoscope was traditionally used as a diagnostic instrument. In past decades, it has increasingly been adapted for therapeutic intents. Subsequently, the master–slave robotic concept was introduced into the field of endoscopy to potentially reduce the difficulty and complication rates of endoscopic therapeutic procedures. As interest in robotic endoscopy intensified, progressively more robotic endoscopic platforms were developed, tested, and introduced. Nevertheless, the future of robotic endoscopy hinges on the ability to meet specific clinical needs of procedurists. Three aspects are vital in ensuring continued success and clinical adoption of the robotic endoscope—demonstration of clinical safety and cost‐efficacy of the device, widespread availability of directed training opportunities to enhance technical skills and clinical decision‐making capabilities of the procedurist, and continued identification of new clinical applications beyond the current uses of the device. This review provides a brief discussion of the historical development of robotic endoscopy, current robotic endoscopic platforms, use of robotic endoscopy in conventional therapeutic endoscopic procedures, and the future of robotic endoscopy.

The evolution of TIF: transoral incisionless fundoplication

Transoral incisionless fundoplication (TIF) was introduced in 2006 as a concerted effort to produce a natural orifice procedure for reflux. Since that time, the device, as well as the procedure technique, has evolved. Significant research has been published during each stage of the evolution, and this has led to considerable confusion and a co-mingling of outcomes, which obscures the results of the current device and procedure. This report is intended to review the identified stages and literature associated with each stage to date and to review the current state of treatment outcomes.

A Pilot Study of Endoscopic Submucosal Dissection Using an Endoscopic Assistive Robot in a Porcine Stomach Model

Background/Aims

Endoscopic assistive devices have been developed to reduce the complexity and improve the safety of surgeries involving the use of endoscopes. We developed an assistive robotic arm for endoscopic submucosal dissection (ESD) and evaluated its efficiency and safety in this in vitro pilot study.

Methods

ESD was performed using an auxiliary transluminal endoscopic robot. An in vitro test bed replicating the intra-abdominal environment and pig stomachs were used for the experiment. Participants were divided into skilled operators and unskilled operators. Each group performed ESD 10 times by using both conventional and robot-assisted methods. The perforation incidence, operation time, and resected mucous membrane size were measured.

Results

For the conventional method, significant differences were noted between skilled and unskilled operators regarding operation time (11.3 minutes vs 26.7 minutes) and perforation incidence (0/10 vs 6/10). Unskilled operators showed a large decrease in the perforation incidence with the robot-assisted method (conventional method vs robot-assisted method, 6/10 vs 1/10). However, the operation time did not differ between the conventional and robot-assisted methods. On the other hand, skilled operators did not show differences in the operation time and perforation incidence between the conventional and robot-assisted methods. Among both skilled and unskilled operators, the operation time decreased with the robot-assisted method as the experiment proceeded.

Conclusions

The surgical safety of unskilled operators greatly improved with robotic assistance. Thus, our assistive robotic arm was beneficial for ESD. Our findings suggest that endoscopic assistive robots have positive effects on surgical safety.

Transvaginal laparoscopic ovariectomy in 60 dogs: Description of the technique and comparison with 2-portal-access laparoscopic ovariectomy

OBJECTIVE

To describe a transvaginal laparoscopic ovariectomy (TLOVE) in dogs and compare duration and perioperative complications between TLOVE and 2-portal-access laparoscopic OVE (LapOVE).

STUDY DESIGN

Retrospective study.

ANIMALS

Female client-owned dogs (60 in TLOVE group and 202 in LapOVE group) between 6 and 103 months of age with body weights between 10 and 33 kg.

METHODS

Ovariectomy was performed either through a transvaginal approach (TLOVE) or 2-portal-access laparoscopy (LapOVE). Dog characteristics (breed, weight, body condition score, age), surgical procedure time, and perioperative complications were compared between groups.

RESULTS

The time required to complete TLOVE (34.3 ± 9.9 minutes) was longer than that for LapOVE (22.3 ± 3.2 minutes, P < .001). Intraoperative complications were encountered in 3 of 60 dogs undergoing TLOVE and 0 of 202 in the LapOVE group. Postoperative complications were not present in the TLOVE group. Suture dehiscence due to early removal of the Elizabethan collar occurred in 4 dogs after LapOVE.

CONCLUSION

Transvaginal laparoscopic OVE was completed without postoperative complications in all dogs of this study although TLOVE took about 15 minutes longer to complete than LapOVE.

CLINICAL SIGNIFICANCE

Transvaginal laparoscopic OVE provides a minimally invasive surgical alternative for OVE in dogs weighing 10-33 kg and aged 6-103 months, eliminating incisions through the abdominal wall, placement of suture material, and application of an Elizabethan collar.

A Specimen Extraction Instrument Based on Braided Fiber Tube for Natural Orifice Translumenal Endoscopic Surgery

Natural orifice translumenal endoscopic surgery (NOTES) has offered significant advantages of less pain, reduced recovery time, and minimized scar after operation, demonstrating a promising development prospect. However, the large-size specimen extraction remains challenging for NOTES, due to the narrow space of the human natural orifices. To address such difficulties, a specimen extraction method that utilizes the braided fiber tube (BFT) structure with excellent retractility to accommodate and bind the bulky specimen has been proposed. Based on the theory of helical spring, the geometric model and the mechanical model of the BFT are established, and experiments have been performed to verify the accuracy of the derived mechanical model. In addition, a tensile test of using the BFT to extract large specimens via a small channel is carried out, which verifies the stable extraction performance of the proposed design. The BFT will not be damaged when extracting the specimen with a diameter less than 1.75 times of the channel diameter. A NOTES-specific specimen extraction instrument is designed according to the characteristics of NOTES, and it has three degrees-of-freedom and is able to actively capture different specimen by using a suction cup. Finally, specimen extraction experiments on NOTES multitasking platform phantom have been conducted using the prototyped instrument to validate its feasibility and effectiveness.

Current and emerging robotic assisted intervention for Notes

INTRODUCTION

Natural orifices transluminal endoscopic surgery (notes) procedures are limited by a number of factors including closure of the internal entry point, loss of triangulation, and unstable operative platform. Areas covered: In this paper, new technical developments in different aspects of robotic assisted NOTES interventions are reviewed. We further address new research opportunities for more widespread clinical acceptance of robotic assisted NOTES procedures. Expert commentary: The application of robotics in NOTES intervention is still in its infancy. The development of more compact, smart and intuitive robotic NOTES systems holds much promise for the future of NOTES application.

A single case of single-port access laparoscopic appendectomy during the puerperium

Laparoscopic appendectomy is now widely practiced for the treatment of acute appendicitis. As result of increased demand for minimally invasive surgery, single-incision access was introduced and is being performed in various abdominal surgeries. Conventional laparoscopic appendectomy (LA) is gradually being performed in pregnant women. A 33-year-old woman was referred to our department at 39 weeks and 1 day of gestation due to abdominal pain. She was aware of her gastroepiploic pain even after the delivery. Though it was past 2 days, she was not recovering from right lower abdominal pain, so she was transferred to the Department of Gynecology at our hospital on the same day. Although an antibiotic was administered, the right abdominal pain did not improve, and she was referred to our department from the Department of Gynecology. We performed single-port LA (SP-LA). The total operation time was 63 minutes, and the estimated blood loss was 0 mL. She was discharged with no complications on postoperative day 7. We report our initial experience with single-port LA (SP-LA) using the glove technique for treatment of acute appendicitis in a postpartum woman. SP-LA using the glove technique was performed successfully during the puerperium without prolongation of operation time. This approach is less invasive, offers a much better cosmetic result than with conventional methods, and can be performed safely and at low cost.

Magnetic Surgical Instruments for Robotic Abdominal Surgery

This review looks at the implementation of magnetic-based approaches in surgical instruments for abdominal surgeries. As abdominal surgical techniques advance toward minimizing surgical trauma, surgical instruments are enhanced to support such an objective through the exploration of magnetic-based systems. With this design approach, surgical devices are given the capabilities to be fully inserted intraabdominally to achieve access to all abdominal quadrants, without the conventional rigid link connection with the external unit. The variety of intraabdominal surgical devices are anchored, guided, and actuated by external units, with power and torque transmitted across the abdominal wall through magnetic linkage. This addresses many constraints encountered by conventional laparoscopic tools, such as loss of triangulation, fulcrum effect, and loss/lack of dexterity for surgical tasks. Design requirements of clinical considerations to aid the successful development of magnetic surgical instruments, are also discussed.

Flexible endoscopic robot

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical procedure during which abdominal operations can be performed with an endoscope passed through a natural orifice through an internal incision in the stomach, vagina, bladder or colon. NOTES is still evolving and many barriers stand on its way before it can gain acceptance in modern surgical practice. Effective access to the peritoneal cavity, closure techniques of the natural orifice access sites, development of a multitasking platform to accomplish procedures and support for special orientation are only a handful of its known limitations. Although the endoscope and conventional tools are useful for simple procedures, many important and complicated procedures are currently not possible due to limitation of degree of freedom (DOF) of the end effectors. We have developed a Master and Slave Transluminal Endoscopic Robot (MASTER) with nine degrees of freedom (DOF) in end effectors, which are long and flexible so as to enhance endoscopic procedures and NOTES. Using MASTER we have successfully performed endoscopic sub-mucosal dissections (ESD) to segmental hepatectomies in animal models. Thus, the MASTER robotic system shows great potential to perform new surgical procedures that are otherwise not possible with conventional endoscopic tools.

Surgical management of acute cholecystitis

BACKGROUND

Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis.

METHODS

A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used.

RESULTS

Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis.

CONCLUSIONS

Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advances in minimally invasive surgery in pediatric patients

Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.

Natural-orifice translumenal endoscopic surgery (NOTES): minimally invasive evolution or revolution?

Since the first animal experimental laparoscopy in 1902, minimal access techniques have revolutionized surgery. Using the natural orifice dates back to at least the second century when Soranus performed a vaginal hysterectomy. The main difference between traditional endolumenal surgery and the translumenal approach of natural-orifice translumenal endoscopic surgery (NOTES) is the intentional puncture of a healthy organ in NOTES to access a cavity or other organ. The aim of this review was to examine the past, present, and potential future role of NOTES in the context of other developments in minimal access surgery. NOTES is at an early stage in its development and a convincing benefit over laparoscopy has not been demonstrated. Concerns regarding complications, for example of viscerotomy closure, have limited the widespread uptake of pure NOTES. However, it is likely that technological advances for NOTES surgery will enhance conventional laparoscopic and endoscopic techniques.

Advances in laparoscopic techniques and instrumentation in standing equine surgery

Equine standing surgery and laparoscopy are becoming increasingly important aspects of equine surgery. Laparoscopic advancements lag behind the human medical field, mainly due to decreased access to appropriate training and instrumentation. It is nearly impossible to cover the topic of equine standing surgery without discussing advances in laparoscopy, because without such advances, equine standing surgery lacks potential for forward progress. Although novel standing techniques continue to be published, the addition of minimally invasive laparoscopic techniques adds an entirely new dimension and provides a plethora of procedures to surgeons practicing equine standing surgery.

Articulated Manipulator With Multiple Instruments for Natural Orifice Transluminal Endoscopic Surgery

This paper presents an articulated manipulator with multiple instruments for natural orifice endoscopic transluminal endoscopic surgery (NOTES). This robotic system is made up of four major components, namely a multifunctional manipulator, a robot-connecting arm, an articulated drive mechanism, and a surgeon control console. The manipulator, capable of changing instruments in situ at the surgical site, was developed to reduce infection risk, improve surgical workflow, and encourage solo surgery by providing surgeons with all the required instruments. The robot-connecting arm serves as an experimental platform for future bimanual robot configurations. To facilitate stable positioning and optimal orientation of the robot, the articulated drive mechanism was also created. The surgeon control console provides a user-friendly platform to receive system input from surgeons. Benchtop testing showed adequate articulation and tool-tip forces for accomplishment of typical tasks in abdominal surgery. This system leverages the benefits both of cable-wire actuation systems and of direct motor embedding on different components to achieve better tool triangulation, higher instrument grasping force, and improved positioning at the surgical site.

Transumbilical laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunal anastomosis

Single-port laparoscopic surgery has undergone significant development over the past 5 years. Single port is used in various procedures, including bariatric surgery. The aim of this paper is to describe a surgical technique for gastric bypass with a transumbilical approach (transumbilical gastric bypass-TUGB) with hand-sewn gastrojejunostomy, in selected patients who may be benefited by a better cosmetic result. The procedure begins with a transumbilical vertical incision. We use the GelPOINT single-port device and a 5-mm assistant trocar in the left flank (in the first two cases, a 2-mm subxiphoid liver retractor was used). A gastric pouch is made and calibrated with a 36-Fr bougie. The gastrojejunal anastomosis is performed by hand-sewing in two layers. A Roux-en-Y with a biliary limb of 50 cm and an alimentary limb of 120 cm is performed with a stapler. Three women were subjected to TUGB. The women were aged 28, 31, and 42 years; they had body mass indexes of 40.3, 33, and 38.2; and the operating times were 150, 200, and 150 min, respectively. The first two women underwent a Roux-en-Y gastric bypass (RYGB), and the last woman underwent a RYGB with a resection of the stomach remnant. There were no conversions to open or multitrocar techniques. No complications or deaths occurred. The three patients were satisfied with the cosmetic result. The technique described for TUGB is a feasible procedure for surgeons who have previous experience with the transumbilical approach.

Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia: the United States human experience

BACKGROUND

From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia.

METHODS

Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue.

RESULTS

Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg).

CONCLUSIONS

TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.

Safety of culdotomy as a surgical approach: implications for natural orifice transluminal endoscopic surgery

OBJECTIVE

To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES).

METHODS

A retrospective chart review of women undergoing culdotomy for tubal sterilization (N 219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications.

RESULTS

No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P = .068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI <30 (11.4% versus 1.5%, P = .011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries.

CONCLUSION

Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Performance of Multiple Transgastric Procedures Using the Natural Orifice Transluminal Endoscopic Surgery Technique: Is Pure NOTES Satisfactory?

Background/Aims

Although several groups have demonstrated the usefulness of natural orifice transluminal endoscopic surgery (NOTES), there is still concern about frequent serious adverse events. We performed this study to determine the technical feasibility and safety of pure NOTES with a transgastric approach in a porcine model from the endoscopist's point of view.

Methods

Diagnostic peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation with a transgastric approach using a two-channel therapeutic endoscope were performed in 10 healthy female minipigs. These procedures were performed in two acute models and eight survival models in consecutive order.

Results

The technical success rate was 100% for peritoneoscopy (10/10), liver biopsy (5/5), salpingo-oophorectomy (10/10), and Fallopian tube ligation (10/10). Eight cases of adverse events occurred, including one case of splenic injury, one case of bleeding after liver biopsy, two cases of small bowel adhesion after salpingo-oophorectomy, two cases of hematoma at the salphingo-oophorectomy site, and two cases of partial dehiscence at the gastric closure site. The gastric puncture site was closed with seven to eight hemoclips in four cases and two hemoclips and an endoloop in four cases.

Conclusions

The use of pure NOTES for peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation may be technically feasible, but considerable adverse events can occur during or after the procedure. Further studies utilizing specialized techniques overcome several limitations of pure NOTES are therefore necessary.

Real-time computed tomography-based augmented reality for natural orifice transluminal endoscopic surgery navigation

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) is technically challenging owing to endoscopic short-sighted visualization, excessive scope flexibility and lack of adequate instrumentation. Augmented reality may overcome these difficulties. This study tested whether an image registration system for NOTES procedures (IR-NOTES) can facilitate navigation.

METHODS

In three human cadavers 15 intra-abdominal organs were targeted endoscopically with and without IR-NOTES via both transgastric and transcolonic routes, by three endoscopists with different levels of expertise. Ease of navigation was evaluated objectively by kinematic analysis, and navigation complexity was determined by creating an organ access complexity score based on the same data.

RESULTS

Without IR-NOTES, 21 (11·7 per cent) of 180 targets were not reached (expert endoscopist 3, advanced 7, intermediate 11), compared with one (1 per cent) of 90 with IR-NOTES (intermediate endoscopist) (P = 0·002). Endoscope movements were significantly less complex in eight of the 15 listed organs when using IR-NOTES. The most complex areas to access were the pelvis and left upper quadrant, independently of the access route. The most difficult organs to access were the spleen (5 failed attempts; 3 of 7 kinematic variables significantly improved) and rectum (4 failed attempts; 5 of 7 kinematic variables significantly improved). The time needed to access the rectum through a transgastric approach was 206·3 s without and 54·9 s with IR-NOTES (P = 0·027).

CONCLUSION

The IR-NOTES system enhanced both navigation efficacy and ease of intra-abdominal NOTES exploration for operators of all levels. The system rendered some organs accessible to non-expert operators, thereby reducing one impediment to NOTES procedures.

Natural orifice transluminal endoscopic surgery in urology: Review of the world literature

Natural orifice transluminal endoscopic surgery (NOTES) has gained momentum in the recent urologic literature as a new surgical approach for intra-abdominal organs with scarless and painless postoperative recoveries. We sought to review the published literature concerning the safety and reproducibility of NOTES in urology. PubMed literature review of articles published in the English language was performed over a 10-year period, i.e., between 2001 and 2011; all articles were critically reviewed and analyzed. Despite its novelty, pure or hybrid surgical approaches have been adapted in performing NOTES. NOTES essentially utilizes transluminal flexible endoscopic instruments along with laparoscopic instruments to gain access to abdominal, pelvic, and/or retroperitoneal cavities. The preliminary results of NOTES in surgery and to a limited extent in urology appear promising, yet further research in animal survival and human cadaveric models is requisite prior to human applications, especially for complex surgeries. Future innovative research, particularly biomedical engineering, should be directed to improving the technicality and mechanistic application of NOTES; hence, better safety and efficacy of NOTES.

Laparoscopic surgery of the spleen through single umbilical incision

Introduction

Single incision transumbilical laparoscopic procedures are the next step in development of minimally invasive surgery. Recent studies prove that the new technique can be a safe alternative to multiport laparoscopy; therefore it is becoming more and more popular.

Aim

We present our preliminary experience with single incision laparoscopy of the spleen.

Material and methods

We analyse a group of 9 patients (7 women and 2 men) in whom we attempted single incision laparoscopic surgery of the spleen.

Results

Single incision laparoscopy was successful in all patients – in 7 of them we performed splenectomy and in 2 unroofing of the splenic cyst. Additionally, in 3 patients we performed concomitant cholecystectomy. The operative technique was identical to multiport procedures. One patient required reoperation due to intra-abdominal bleeding from the wound on the first postoperative day. In one patient due to superficial injury of the stomach wall continuous suture was used to prevent perforation. In our opinion these complications are not the result of the new technique.

Conclusions

The described technique can become a safe alternative to multiport laparoscopy. It is a reasonable alternative in young patients to whom an excellent cosmetic effect is particularly important because until now it is the only documented advantage of this surgical technique.

Development of tasks and evaluation of a prototype forceps for NOTES

BACKGROUND AND OBJECTIVES

Few standardized testing procedures exist for instruments intended for Natural Orifice Translumenal Endoscopic Surgery. These testing procedures are critical for evaluating surgical skills and surgical instruments to ensure sufficient quality. This need is widely recognized by endoscopic surgeons as a major hurdle for the advancement of Natural Orifice Translumenal Endoscopic Surgery.

METHODS

Beginning with tasks currently used to evaluate laparoscopic surgeons and instruments, new tasks were designed to evaluate endoscopic surgical forceps instruments.

RESULTS

Six tasks have been developed from existing tasks, adapted and modified for use with endoscopic instruments, or newly designed to test additional features of endoscopic forceps. The new tasks include the Fuzzy Ball Task, Cup Drop Task, Ring Around Task, Material Pull Task, Simulated Biopsy Task, and the Force Gauge Task. These tasks were then used to evaluate the performance of a new forceps instrument designed at Pennsylvania State University.

CONCLUSIONS

The need for testing procedures for the advancement of Natural Orifice Translumenal Endoscopic Surgery has been addressed in this work. The developed tasks form a basis for not only testing new forceps instruments, but also for evaluating individual performance of surgical candidates with endoscopic forceps instruments.

On-demand endoscopic CO2 insufflation with feedback pressure regulation during natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy induces minimal hemodynamic and respiratory changes

BACKGROUND

Endoscopic insufflation has been associated with marked increase in intra-abdominal pressure (IAP) and hemodynamic and respiratory changes during transgastric surgery.

OBJECTIVE

To investigate the hemodynamic and respiratory effects during intraperitoneal cavity exploration through 3 different natural orifice transluminal endoscopic surgery (NOTES) access locations compared with laparoscopy.

DESIGN AND SETTING

Survival experiments using 40 female pigs randomized to transgastric, transcolonic, transvaginal, and laparoscopic peritoneoscopy.

INTERVENTIONS

On-demand endoscopic insufflation of CO(2) with feedback pressure regulation was used in NOTES with a maximum pressure of 14 mm Hg. In the laparoscopy group, the IAP was maintained at 14 mm Hg. NOTES procedures were performed by an endoscopist (with the assistance of a gynecologist in the transvaginal group and a second endoscopist in the transgastric and transrectal groups) and laparoscopy by 2 surgeons.

MAIN OUTCOME MEASUREMENTS

Invasive hemodynamic and respiratory data. Blood samples were drawn for gas analyses.

RESULTS

All experiments except one in the transrectal group were completed. The IAP was significantly lower in all NOTES groups compared with the laparoscopy group. A significant increase in mean systemic arterial blood pressure was observed in the laparoscopy group at 15 and 30 minutes of intraperitoneal cavity exploration, but it remained unchanged during all NOTES procedures. An increase in airway pressures was observed at 15 and 30 minutes of peritoneoscopy in the animals undergoing laparoscopy, whereas those parameters remained unchanged in the NOTES groups. The laparoscopy group showed a significant impairment in pulmonary gas exchange (decrease in Pao(2), increase in Paco(2), and decrease in arterial pH) after 30 minutes of peritoneoscopy, whereas only a slight increase in Paco(2) was observed in the transrectal and transvaginal groups.

LIMITATIONS

Healthy animal model.

CONCLUSION

On-demand endoscopic insufflation of CO(2) with feedback pressure regulation can minimize the risk of hemodynamic and respiratory compromise caused by acute changes in IAP.

Minimally invasive cystectomy approaches in the treatment of bladder cancer

Bladder cancer is the most frequently occurring tumor of the urinary system, with over 10,000 new diagnoses each year in the UK. Approximately 70% of these are non-muscle-invasive and limited to the mucosa (Ta) or submucosa (T1). These tumors are generally managed with transurethral resection followed by adjuvant intravesical chemo- or immuno-therapy and regular cystoscopic surveillance. The principal end points in the management of these tumors are prevention of recurrence and progression. Muscle-invasive bladder cancer is a life-threatening disease with overall 5-year mortality of 50%. Neoadjuvant chemotherapy, where possible followed by radical surgery, is currently considered the best standard of care. Open radical cystectomy is the gold-standard treatment for muscle-invasive or high-risk non-muscle-invasive (multifocal or recurrence after intravesical therapy) bladder cancer. Historically, this procedure has carried significant morbidity, although mortality of open radical cystectomy has reduced to 1-2% owing to improvements in anesthesia and intensive care facilities. Over the last 15 years, minimally invasive techniques in radical cystectomy have evolved, with the aim of reducing morbidity. In this article, we review the development of laparoscopic radical cystectomy and robot-assisted radical cystectomy, along with current evidence on perioperative morbidity and medium-term oncological outcomes.

Efficacy and safety of transgastric closure in natural orifice transluminal endoscopic surgery using the OTSC system and T-bar sutures: a survival study in a porcine model

BACKGROUND

In natural orifice transluminal endoscopic surgery (NOTES), procedures are performed with an endoscope passed through a natural orifice. One of the most important factors that will determine the future of transgastric NOTES is obtaining a reliable closure of the access site. The aim of this study was to determine the efficacy and safety of transgastric closure using the over-the-scope clip (OTSC) system or T-bar sutures.

METHODS

We performed a survival study that included 15 pigs. A standardized transgastric approach to the peritoneal cavity and a peritoneoscopy were performed. The gastrotomy was closed using the OTSC system or T-bar sutures. The gastrotomy closure was tested for leaks with the methylene blue test. All animals were observed for 2 weeks before they were sacrificed and necropsy was performed. Histopathological examination of tissue samples retrieved from the access sites was performed.

RESULTS

There were no perioperative complications. The methylene blue test did not demonstrate any leakage of fluid. Necropsy after 2 weeks confirmed completeness of gastric closure in all animals with full-thickness healing and no spillage of gastric contents into the peritoneal cavity. No differences between the OTSC system and T-bar sutures were observed.

CONCLUSION

We observed no differences between the efficacy and safety of the OTSC system and those of T-bar sutures used in closing gastric incisions in NOTES. Both methods are safe and effective.

Single-incision laparoscopic splenectomy versus conventional multiport laparoscopic splenectomy: a retrospective comparison of outcomes

BACKGROUND

The authors report their experience with single-incision laparoscopic splenectomy (SLS) and compare postoperative outcomes of conventional multiport laparoscopic splenectomy (MLS) with SLS in patients with spleen sizes ≤15 cm.

METHODS

Demographic, intraoperative, and postoperative data were analyzed retrospectively and compared between patients who underwent MLS from June 20, 2006, to July 9, 2009 (MLS group, 18 patients) and those who underwent SLS from July 28, 2009, to November 2, 2010 (SLS group, 16 patients).

RESULTS

Blood loss was significantly greater in the SLS group than in the MLS group (206.25 ± 142.45 vs 111.11 ± 99.58 mL, respectively; P = .047). The Numeric Pain Rating Scale in the SLS group was significantly lower than in the MLS group (3.81 ± 0.91 vs 4.56 ± 1.29, respectively; P = .041). There were no significant differences between the groups for other variables.

CONCLUSIONS

SLS is a feasible method with good cosmetic benefit and equivalent clinical outcomes as compared with MLS.

Glove technique in single-port access laparoscopic surgery: results of an initial experience

Introduction. Single-incision laparoscopic surgery (SILS) is a virtually "scarless" technique. A retrospective analysis is performed to evaluate an initial experience of this surgical approach. Materials and Methods. From January 2010 to October 2011, SILS was considered as a minimally invasive approach to abdominal disease. The access was made by a standard wound protector and a size 6 glove. A series of little accesses were made on the tips of the glove-fingers to induce pneumoperitoneum and to create a working channel for the laparoscopic instruments. An analysis of costs of this technique was made too. Results. SILS was successfully completed with low cost in 34 patients: 20 appendectomy, 12 cholecystectomy, and 2 right colectomy were performed with a median operative time of 35, 45, and 67.5 minutes, respectively. In no patient any conversion to standard laparoscopy or to open surgery was needed. The postoperative course was uneventful in all patients. In right hemicolectomy, the oncological parameters were respected. Conclusions. In this paper the glove-port technique showed multiple advantages. The SILS is a feasible approach for some pathologies in selected patients. The glove-port is a simple, low-cost, reproducible, and sure method to perform SILS in a high-experienced laparoscopic surgical centre.

Prophylactic surgery prior to extended-duration space flight: is the benefit worth the risk?

This article explores the potential benefits and defined risks associated with prophylactic surgical procedures for astronauts before extended-duration space flight. This includes, but is not limited to, appendectomy and cholecystesctomy. Furthermore, discussion of treatment during space flight, potential impact of an acute illness on a defined mission and the ethical issues surrounding this concept are debated in detail.

Minilaparoscopic colorectal resections: technical note

Laparoscopic colorectal resections have been shown to provide short-term advantages in terms of postoperative pain, general morbidity, recovery, and quality of life. To date, long-term results have been proved to be comparable to open surgery irrefutably only for colon cancer. Recently, new trends keep arising in the direction of minimal invasiveness to reduce surgical trauma after colorectal surgery in order to improve morbidity and cosmetic results. The few reports available in the literature on single-port technique show promising results. Natural orifices endoscopic techniques still have very limited application. We focused our efforts in standardising a minilaparoscopic technique (using 3 to 5 mm instruments) for colorectal resections since it can provide excellent cosmetic results without changing the laparoscopic approach significantly. Thus, there is no need for a new learning curve as minilaparoscopy maintains the principle of instrument triangulation. This determines an undoubted advantage in terms of feasibility and reproducibility of the procedure without increasing operative time. Some preliminary experiences confirm that minilaparoscopic colorectal surgery provides acceptable results, comparable to those reported for laparoscopic surgery with regard to operative time, morbidity, and hospital stay. Randomized controlled studies should be conducted to confirm these early encouraging results.

Transumbilical single-port laparoscopic cholecystectomy using traditional laparoscopic instruments: a report of thirty-six cases

OBJECTIVE

To evaluate the feasibility and safety of the operation of transumbilical single-port laparoscopic cholecystectomy (TSPLC) by traditional laparoscopic instruments and summarize the initial experience.

METHODS

Sixty subjects with cholelithiasis were divided into two groups. One group (36 cases) underwent TSPLC and the control group (24 cases) underwent traditional three-port laparoscopic cholecystectomy (LC). Postoperative complications were observed and operation time, hospital days, visual analogue scale (VAS) after 6 and 24 h of operation, and subject satisfaction score were measured.

RESULTS

TSPLC and traditional LC were performed successfully in the two groups. The operation time in the TSPLC group was significantly longer than that in the control group. There was no statistically significant difference in hospital stay and VAS between the TSPLC and control groups. The subject satisfaction score in the TSPLC group was 91.2, significantly higher than that in the control group (P<0.01). All subjects recovered from the operation and no postoperative complication occurred during the period of two weeks after operation.

CONCLUSIONS

TSPLC is a feasible and safe method for cholecystectomy, although it may be more time-consuming. However, it is welcomed by patients who are more concerned with cosmetic outcomes. Future studies are needed to confirm its disadvantages and contraindications.

Liver and peritoneal biopsy by laparoscopy or notes in pigs: comparison of operative parameters and postoperative evolution

OBJECTIVE

To evaluate the impact of NOTES compared to laparoscopic surgery, through the analysis of physiological parameters as well as surgical complications and postoperative outcome, for liver biopsy.

METHODS

12 female pigs were divided into two groups: laparoscopy group (GLap) and NOTES group (GNote). The animals underwent liver biopsy by peritoneal laparoscopy or transvaginal endoscopy. The respiratory rate, heart rate, O2 saturation and expiratory concentrations of CO2 were recorded every 10 minutes. In the seventh postoperative day, the animals underwent laparotomy for evaluation of intra-abdominal complications.

RESULTS

Most of the animals showed weight loss after the procedure, however in no case more than 5%. There was no difference in percentage change in weight between the groups (p = 0.7535). Also, no differences were observed when comparing the averages of ETCO2 (p = 0.4762), and average heart rate (p = 0.6035). However, the GLap showed higher respiratory rate than the GNote (p = 0.0043), as well as the average O2 saturation (p = 0.0080). However, no animal showed SatO2 less than 87% and this difference was not considered clinically significant. Only one GNote animal presented with an operative complication.

CONCLUSION

NOTES is associated with physiological parameters similar to those found in operative laparoscopy. Performing transvaginal peritonioscopy is not associated with increased postoperative complications when compared to laparoscopy.

Laparoendoscopic single site in pelvic surgery

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