Transgastric cholecystectomy using a prototype endoscope with 2 deflecting working channels (with video)

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

LESS and NOTES instrumentation: future

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Flexible platforms for natural orifice transluminal and endoluminal surgery

The flexible endoscope is playing an increasingly pivotal role in minimally invasive transluminal and endoluminal surgery. Whilst the flexible nature of the platform is desirable in order to navigate through the abdominal cavity or through a lumen, there are a number of issues with using the platform for this purpose. The challenges associated with using flexible endoscopes such as a lack of triangulation of instruments and force transmission, which is often inadequate for endoscopic surgery are discussed in this review. As a result of these difficulties, a number of mechanically and robotically driven devices based upon the flexible endoscope are emerging. The design of these devices and potential problems are also reviewed. Finally, future robotic systems which are still in the development and validation stage are briefly discussed. The field of gastroenterology is diverging. The narrowing divide between minimally invasive and endoluminal surgery has led to a surge of innovative and novel devices which may in the future enable precise, seamless and scar less surgery.

Trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife: A pilot animal study

AIM: To investigate the feasibility and safety of Natural orifice trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife in a non-survival porcine model.

METHODS: Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy was performed on three non-survival pigs, by transumbilical approach, using a water-jet hybrid-knife. Under general anesthesia, the following steps detailed the procedure: (1) incision of the umbilicus followed by the passage of a double-channel flexible endsocope through an overtube into the peritoneal cavity; (2) establishment of pneumoperitoneum; (3) abdominal exploration; (4) endoscopic cholecystectomy: dissection of the gallbladder performed using water jet equipment, ligation of the cystic artery and duct conducted using nylon loops; and (5) necropsy with macroscopic evaluation.

RESULTS: Transumbilical endoscopic cholecystectomy was successfully completed in the first and third pig, with minor bleedings. The dissection times were 137 and 42 min, respectively. The total operation times were 167 and 69 min, respectively. And the lengths of resected specimen were 6.5 and 6.1 cm, respectively. Instillation of the fluid into the gallbladder bed produced edematous, distended tissue making separation safe and easy. Reliable ligation using double nylon loops insured the safety of cutting between the loops. There were no intraoperative complications or hemodynamic instability. Uncontrolled introperative bleeding occurred in the second case, leading to the operation failure.

CONCLUSION: Pure NOTES trans-umbilical cholecystectomy with a water-jet hybrid-knife appears to be feasible and safe. Further investigation of this technique with long-term follow-up in animals is needed to confirm the preliminary observation.

A technical review of flexible endoscopic multitasking platforms

BACKGROUND

Further development of advanced therapeutic endoscopic techniques and natural orifice translumenal endoscopic surgery (NOTES) requires a powerful flexible endoscopic multitasking platform.

METHODS

Medline search was performed to identify literature relating to flexible endoscopic multitasking platform from year 2004-2011 using keywords: Flexible endoscopic multitasking platform, NOTES, Instrumentation, Endoscopic robotic surgery, and specific names of various endoscopic multitasking platforms. Key articles from articles references were reviewed.

RESULTS

Flexible multitasking platforms can be classified as either mechanical or robotic. Purely mechanical systems include the dual channel endoscope (DCE) (Olympus), R-Scope (Olympus), the EndoSamurai (Olympus), the ANUBIScope (Karl-Storz), Incisionless Operating Platform (IOP) (USGI), and DDES system (Boston Scientific). Robotic systems include the MASTER system (Nanyang University, Singapore) and the Viacath (Hansen Medical). The DCE, the R-Scope, the EndoSamurai and the ANUBIScope have integrated visual function and instrument manipulation function. The IOP and DDES systems rely on the conventional flexible endoscope for visualization, and instrument manipulation is integrated through the use of a flexible, often lockable, multichannel access device. The advantage of the access device concept is that it allows optics and instrument dissociation. Due to the anatomical constrains of the pharynx, systems are designed to have a diameter of less than 20 mm. All systems are controlled by traction cable system actuated either by hand or by robotic machinery. In a flexible system, this method of actuation inevitably leads to significant hysteresis. This problem will be accentuated with a long endoscope such as that required in performing colonic procedures. Systems often require multiple operators. To date, the DCE, the R-Scope, the IOP, and the Viacath system have data published relating to their application in human.

CONCLUSION

Alternative forms of instrument actuation, camera control and master console ergonomics should be explored to improve instrument precision, sphere of action, size and minimize assistance required.

Hybrid NOTES transgastric cholecystectomy with reliable gastric closure: an animal survival study

Background

Secure transluminal closure remains the most fundamental barrier to safe translation of transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures to humans. Obtaining optimal critical view of safety (CVS) is a prerequisite to performing cholecystectomy avoiding common bile duct injury.

Objectives

(1) To evaluate feasibility and safety of hybrid transgastric NOTES cholecystectomy. (2) To evaluate feasibility and reliability of gastrotomy closure using a novel Over-The-Scope-Clip (OTSC; Ovesco) in survival porcine experiments.

Methods

Laparoscopic access to the abdominal cavity was obtained by two 2-mm and one umbilical optical trocar(s). Gastric access was created by balloon dilatation of a needle knife puncture up to 18 mm. Exposure of CVS was obtained and evaluated by aid of a 2-mm device. Subsequently the cystic duct and artery were clipped endoscopically. After laparoscopic dissection the specimen was extracted via the stomach. The gastrotomy was closed endoscopically using the OTSC. Necropsy was performed after 10 days with inspection of gastrotomy and peritoneal cavity for complications. Experiments were planned in 3 acute and 16 survival pigs. Main outcome parameters were documented exposure of CVS, successful cholecystectomy and closure, uncomplicated survival and histology-confirmed full-thickness closure.

Results

In all 16 survival experiments CVS was obtained satisfactorily and hybrid cholecystectomy was successfully performed [100%; 95% confidence interval (CI): 81–100%]. Transgastric closure was endoscopically successful in all experiments in mean time of 7 min [standard deviation (SD) 3 min]. At necropsy 10 days after surgery there were no signs of (infectious) complications. Histology confirmed full-thickness healing with 100% success (95% CI: 81–100%).

Conclusion

Hybrid transgastric NOTES cholecystectomy is feasible, safe and results in optimal CVS. Use of OTSC for gastrotomy closure is feasible, reliable and results in histology-proven full-thickness closure in survival porcine experiments.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-010-1242-4) contains supplementary material, which is available to authorized users.

Transgastric organ resection solely with the prototype R-scope and the self-approximating transluminal access technique

BACKGROUND

The self-approximating transluminal access technique (STAT) has been demonstrated to provide safe transluminal access and in-line endoscope positioning to target abdominal organs during natural orifice transluminal endoscopic surgery (NOTES). To date, organ resection with NOTES has typically required percutaneous assistance. We hypothesized that the in-line positioning and partial stability provided by STAT would allow single-access NOTES procedures if a multiarticulated endoscope could be used.

OBJECTIVE

Assessment of single-site NOTES, using STAT and a prototype, multi-articulated endoscope.

DESIGN

Animal survival study.

SETTING

Penn State Hershey Medical Center Research Laboratories.

INTERVENTIONS

Thirteen pigs underwent NOTES using a prototype endoscope with 2 articulated channels, a grasping forceps, and an insulated-tip needle-knife. The gallbladder was dissected using a fundus down technique, and hemoclips and a detachable loop were placed on the cystic duct and artery before removal. After a 2- to 3-week observation period, animals were euthanized and necropsy performed.

RESULTS

All target organs were successfully resected without laparoscopic assistance. Significant complications were 2 perforations (1 caused by a prototype duodenal occlusion device and 1 caused by enterotomy during cholecystectomy) and 1 entrapment of the small bowel with an endoloop. Postoperatively, all animals gained weight appropriately with 1 killed on postoperative day 12 because of lethargy (cystic duct leak/biloma).

LIMITATIONS

This is a limited animal survival study without control arm.

CONCLUSIONS

The combination of the R-scope and STAT does allow effective, single-site NOTES procedures; however, although the R-scope provides improved tissue manipulation and visibility, the complications incurred here suggest that further improvements in devices and technique will be required for safe and effective single-site NOTES procedures.

Natural orifice translumenal surgery: Flexible platform review

Natural orifice translumenal surgery (NOTES) has garnished significant attention from surgeons and gastroenterologists, due to the fusion of flexible endoscopy and operative technique. Preliminary efforts suggest that NOTES holds potential for a less invasive approach with certain surgical conditions. Many of the hurdles encountered during the shift from open to laparoscopic surgery are now being revisited in the development of NOTES. Physician directed efforts, coupled with industry support, have brought about several NOTES specific devices and platforms to help address limitations with current instrumentation. This review addresses current flexible platforms and their attributes, advantages, disadvantages and limitations.

Endoscopic transgastric pure NOTES cholecystectomy with naso-gallbladder drainage tube placement and injection of a hyaluronic acid mixture (with Video)

BACKGROUND

Endoscopic transgastric pure natural orifice translumenal endoscopic surgery (NOTES) cholecystectomy is a difficult procedure, and most human female cases are performed as hybrid NOTES, using a transvaginal route. We tried a transgastric pure NOTES procedure without laparoscopic procedure in an animal study after placing an endoscopic naso-gallbladder drainage (ENGBD) tube and injecting a hyaluronic acid (HA) mixture.

METHODS

We performed the method in four pigs, using a standard single-channel endoscope. The ENGBD tube was placed first and the HA mixture was injected between the gallbladder (GB) serosa and liver bed.

RESULTS

We determined the gastrotomy site using an ENGBD tube, which made the GB approach easy under fluoroscopic guidance. The scope was not retroflexed, but was rotated at the stomach fornix. The connecting tissues between the GB serosa and liver bed expanded following the injection of the HA mixture, facilitating GB removal with a Hook knife. The GB wall, liver, and vessels were observed clearly during the procedure, and there were no incorrect cuts.

CONCLUSION

We successfully performed a transgastric pure NOTES cholecystectomy in pigs. An ENGBD tube was useful as a guide to the GB, and for recognizing the cystic duct, and injecting the HA mixture facilitated the GB dissection.