Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for advanced reconstruction: initial experience

Gallbladder-preserving polypectomy for gallbladder polyp by embryonic-natural orifice transumbilical endoscopic surgery with a gastric endoscopy

BACKGROUND AND AIMS

Cholecystectomy is performed for most gallbladder polyps (GPs). However, cholecystectomy results concerning complications in some patients. For benign GPs, adoption of gallbladder-preserving surgery is worth to recommend. We describe our experiences performing gallbladder-preserving polypectomy for GPs by embryonic-natural orifice transumbilical endoscopic surgery (E-NOTES) with a gastric endoscopy.

METHODS

This is a retrospective study of patients with GPs who underwent gallbladder-preserving polypectomy by E-NOTES with a gastric endoscopy from April 2018 to September 2019 in our hospital. The operative time, intraoperative hemorrhage, intraoperative and postoperative complications, gallbladder emptying function were obtained and analyzed.

RESULTS

The procedure was performed successfully in all 12 patients with 5 cases of single polyp and 7 cases of multiple polyps. The range of GPs size was 2 mm to 15 mm. The mean operation time was (95.33 ± 23.08) minutes (55-135 min). There were no adverse events including heavy bleeding, mortality and conversion to open surgery during operation. All patients were discharged in 4-5 days after surgery without postoperative complications such as delayed bleeding, fever, peritonitis, intra-abdominal abscess and abdominal wall incisional hernia. All patients were followed up at 1, 3, 6, and 12 months postoperation who had almost no visible incision on the umbilical region, no recurrent GPs. The gallbladder emptying function decreased one month after surgery, and gradually improved 3, 6 and 12 months after surgery.

CONCLUSION

E-NOTES gallbladder-preserving polypectomy is a safe and effective option for patients with GPs and is close to scar-free surgery which can be performed in routine clinical practice.

Minimally invasive ileal ureter replacement: Comparative analysis of robot-assisted laparoscopic versus conventional laparoscopic surgery

BACKGROUND

This study is an initial comparative analysis of perioperative and intermediate-term functional outcomes between patients who underwent robot-assisted laparoscopic (RALS) or conventional laparoscopic surgery (LS).

MATERIALS AND METHODS

A total of 25 patients who underwent ileal ureter replacement (10 RALS and 15 LS) were followed by functional cine magnetic resonance urography (MRU) combined with a modified Whitaker test. Also, the characteristics, perioperative data and functional outcomes of the patients were compared.

RESULTS

The estimated blood loss, postoperative hospital stay and time to oral intake were significantly lower in the RALS group. At the median 14-month follow-up, all the patients showed improved renal function and were symptom-free, with no signs of leakage or stenosis observed by cine MRU combined with a modified Whitaker test.

CONCLUSIONS

RALS with an extracorporeal bowel resection is feasible and appears to be safe, with quick postoperative recovery and encouraging outcomes.

Anticipation of umbistoma in laparoscopic anterior rectal resection: Ileostomy and ostomy closure

Objective: The use of laparoscopic surgery for rectal disease is expected to provide good cosmetic benefits for patients postoperatively. However, this expectation is significantly reduced when a diverting ileostomy is created. We present a new technique that reduces the size of the skin wound by constructing a diverting ileostomy in the umbilicus. This procedure, diverting umbilical ileostomy (umbistoma) does not require special tools for its construction and closure. Methods: Twenty-nine patients underwent treatment with umbilical diverting stoma, including five women and 24 men, with a mean age of 70 years (range: 40-88 years). At the time of ostomy closure, a new umbilicus was formed by subcutaneously suturing the wound to the fascia. In addition, we did not close the new umbilical upper and lower spaces, so as to allow open drainage of the healing wound. Results: All procedures were completed successfully without any perioperative complications. Conclusions: Our findings suggest that the umbilical diverting stoma could provide improved safety and cosmetic advantages in laparoscopic rectal resection.

Postoperative Pain After Single-Site Versus Multiport Hysterectomy

Background and Objectives:

With advances in laparoscopic surgery, the goal of surgeons and patients is to minimize pain to allow for faster recovery and return to normal daily activities. One of these advances is single-site surgery. In this study, we compared postoperative pain in laparoendoscopic single-site surgery (LESS) to that in traditional multiple-incision hysterectomy.

Methods:

Seventy patients were selected for this prospective cohort study, with 35 undergoing multiple-incision and 35 undergoing LESS hysterectomy. All patients were included who were undergoing hysterectomy with the primary surgeon. All multiport hysterectomies were performed laparoscopically. Six patients underwent LESS hysterectomy and 29 underwent robotic single-site surgery (rLESS). Patients recorded pain levels for 3 weeks after surgery on a variety of measures, including overall and incisional pain. Linear mixed effects models for repeated measures were used for all multivariate analyses, with an unstructured covariance matrix accounting for correlation between time points.

Results:

Overall, across all time points, there was an average reduction in pain by 1.26 (SD 0.69) points in the single-site group (P = .06). Days 3 and 14 had a marginally significant reduction in pain (P = .06 and 0.058, respectively). On days 4 and 7 there was a significant reduction in overall pain (P = .04 and .04, respectively).

Conclusion:

Based on the results, it is likely that single-site hysterectomy leads to less postoperative pain and achieves a lower pain score faster than multiport surgery. A randomized control trial is necessary to confirm these results before accepting them in clinical practice.

Laparoscopic ureteroneocystostomy for mid and lower ureteric strictures: Experience from a tertiary center

Purpose:

The purpose of this study is to evaluate our experience of laparoscopic ureteroneocystostomy for mid and lower ureteral stricture in a tertiary center in North India.

Materials and Methods:

A total of 20 laparoscopic ureteroneocystostomy were performed with or without bladder flap procedures in 20 patients (13 females and 7 males) with various etiologies such as ureteric stricture, ureterovaginal fistula, endometriosis, and distal ureteric tumor at our hospital in a time frame from August 2013 to January 2017. Eight cases each presented after laparoscopic/open hysterectomy and postureterorenoscopic stone removal while two cases each presented secondary to endometriosis and distal ureteric tumor. Simple laparoscopic ureteroneocystostomy in 4, psoas hitch in 9, and Boari flap was done in 7 cases.

Results:

The mean patient age was 44.2 years (range 19–65), mean surgical time was 184.25 min (115–250 min.), mean amount of bleeding was 153.25 mL (90–250 mL), and mean hospital stay was 3.05 days (2–7 days). Female-to-male ratio was 1.3:0.7. There was one conversion to open during laparoscopic Boari reimplant because of inadvertent injury to external iliac vein. The mean follow-up was 22.35 months (6–45). All the patients were asymptomatic with the resolution of hydronephrosis on ultrasound and without any significant obstruction on renal scan.

Conclusions:

Laparoscopic ureteroneocystostomy with or without bladder flap (Boari) provides good functional outcomes with excellent success rates and minimal morbidity comparable to open surgery in patients with ureteric stricture.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

Transumbilical abdominal incision for laparoscopic colorectal surgery does not increase the risk of postoperative surgical site infection

PURPOSE

Besides antibiotic prophylaxis, antiseptic skin preparation is an important measure to prevent surgical site infection (SSI). No reports have detailed the relationship between SSI and umbilical microflora following laparoscopic colorectal cancer with a transumbilical longitudinal incision.

METHODS

Risk factors and the rate of SSI were investigated in 453 patients who underwent laparoscopic colorectal resection over a 3-year period. Microbiological samples were collected from the umbilicus and SSI areas.

RESULTS

After laparoscopic procedure, we observed SSIs in approximately 5% of cases, with superficial SSI in 15 (3.3%) patients and organ/space SSIs 7 (1.5%). In univariate analysis, preoperative albumin (Alb) value and anastomosis of enterocolostomy were significantly associated with superficial SSI development. Also, age, blood loss, stoma, tumor site (rectum), and Hartmann/abdominal perineal resection (APR) were significant risk factors for organ/space SSI. In multivariate analysis, the preoperative Alb value was the most significant factor associated with a predisposition to superficial SSI. The bacteria detected in SSI were mostly different from those at wound closure. Antibiotic-resistant bacteria were included in organ/space SSI all cases.

CONCLUSIONS

SSI development with laparoscopic surgery reportedly occurs in about 3-15% cases. The SSI rate in this study and other reports was comparable. Using small transumbilical longitudinal incision in laparoscopic colorectal surgery is less likely to cause SSI when sufficient control measures are enacted, even though the umbilicus contains resident bacteria in abundance.

Comparison of Laparoscopic Approaches for Dismembered Pyeloplasty in Children With Ureteropelvic Junction Obstruction: Critical Analysis of 11-Year Experiences in a Single Surgeon

OBJECTIVE

The choice of different laparoscopic approaches of laparoscopic pyeloplasty (LP) in children remains controversial. We present a comparison of different approaches of LP in children and a critical analysis of 11-year experiences in a single surgeon.

MATERIALS AND METHODS

There were 1750 patients (1889 sides) who underwent LP between 2003 and 2014 reviewed. The diagnosis and outcomes of ureteropelvic junction obstruction (UPJO) were reviewed based on clinical and imaging data. Retroperitoneal laparoscopic pyeloplasty (RPLP) were performed in 451 cases (RPLP group), conventional transperitoneal laparoscopic pyeloplasty (CTLP) were performed in 311 cases (CTLP group), transumbilical single-site laparoscopic pyeloplasty (TSLP) were performed in 322 cases (TSLP group), and transumbilical multiport laparoscopic pyeloplasty (TMLP) were performed in 805 cases (TMLP group). We assessed preoperative clinical data and outcomes, and analyzed the transition experience. Data are expressed as medians for continuous variables.

RESULTS

The start of oral feeding, hospital stay, and the operative time of RPLP group were 1.10 ± 0.10 days, 5.22 ± 1.32 days, and 138.2 ± 20.1 minutes, respectively. Compared with the other 3 groups, the start of oral feeding was the soonest, hospital stay was the shortest, and the operative time was the longest in the RPLP group (P < .01 or .05). The cosmetic result of the TMLP group was 7.07 ± 1.20 scores, and there are significant differences in cosmetic results between the TMLP group and the other 3 groups (P < .05).

CONCLUSION

Although the 4 laparoscopic approaches for LP in children with UPJO are safe and efficient procedures with equivalent success rates, we recommend RPLP or TMLP as a treatment option for children with UPJO.

Initial Series of Four-Arm Robotic Completely Intracorporeal Ileal Ureter

Ileal ureter formation has been found to be a suitable treatment option for long, chronic ureteral strictures not amendable to less invasive forms of repair. Minimally invasive surgical techniques for this condition have been investigated. We report the first series of robotic completely intracorporeal ileal ureter using a four-arm robotic technique. Three patients underwent this procedure, including one patient with a solitary kidney. All procedures were performed effectively with a median operative time of 450 minutes (range: 420-540) and median estimated blood loss of 100 mL (range: 50-200). Postoperatively, one patient suffered volvulus and subsequent necrosis of small bowel and ileal ureter, which required re-operation and small bowel resection, including the ileal ureter. The other two patients report no surgical complications to date. This early series represents preliminary technical procedure feasibility. Further experience is necessary.

Laparo-endoscopic single site surgery in pediatrics: Feasibility and surgical outcomes from a preliminary prospective Canadian experience

INTRODUCTION

Laparo-endoscopic single-site surgery (LESS) is becoming an alternative to standard laparoscopic surgery. Proposed advantages include enhanced cosmesis and faster recovery. We assessed the early post-operative surgical outcomes of LESS surgery utilizing different instruments in the pediatric urological population in Canada.

METHODS

We prospectively captured data on all patients undergoing LESS at our institution between February 2011 and August 2012. This included patient age, operative time, length of stay, complications and short-term surgical outcomes. Different instruments/devices were used to perform the procedures. Access was achieved through a transumbilical incision.

RESULTS

A total of 16 LESS procedures were performed, including seven pyeloplasties, four unilateral and one bilateral varicocelectomies, two simple nephrectomies, one renal cyst decortication and one pyelolithotomy. There was no statistical difference in the operative times, hospital length of stay and cost (pyeloplasty only) in patients undergoing pyeloplasty and varicocelectomy using the LESS technique when compared to an age matched cohort of patients managed with the traditional laparoscopic approach. One pyeloplasty in the LESS group required conversion to open due to a small intra-renal pelvis. There were no immediate or short term post-operative complications; however, one patient experienced a decrease in renal function status post LESS pyeloplasty. Since all procedures were performed by a vastly experienced surgeon at a tertiary center, the generalizability of the results cannot be assessed.

CONCLUSIONS

There are only a few series that have assessed the role of LESS in pediatric urological surgery. Although our experience is limited by a heterogeneous group of patients with a short follow-up period, the present cohort demonstrates the safety and feasibility of LESS. Further evaluation with randomized studies is required to better assess the role of LESS in pediatric urology.

Robotic ileal ureter: a completely intracorporeal technique

INTRODUCTION

The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure.

TECHNICAL CONSIDERATIONS

A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m(2). Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m(2).

CONCLUSION

Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

Umbilical laparoendoscopic urological surgery with a novel reusable device

OBJECTIVE

The aims of this study were to present cumulative experience with umbilical laparoendoscopic urological surgery using a reusable device and to evaluate outcomes and complications in the first 100 patients.

MATERIAL AND METHODS

Patients undergoing umbilical surgery with the KeyPort system and DuoRotate instruments (Richard Wolf, Knittlingen, Germany) were evaluated prospectively. Demographic, intraoperative and postoperative data were assessed.

RESULTS

Between October 2011 and July 2012, 79 pelvic (66 radical prostatectomy, 10 radical cystectomy, one diverticulectomy, one bilateral orchiectomy, one ureter reimplantation) and 21 renal (seven radical nephrectomy, six partial nephrectomy, five nephroureterectomy, two pyeloplasty, one pyelolithotomy) surgeries were performed through the umbilicus using this platform. Follow-up was 56.7 ± 12.6 weeks (mean ± SD). Mean age was 64.3 ± 10.3 years, body mass index 29 ± 4.6 kg/m(2), operative time 232 ± 106 min and estimated blood loss 260 ± 95 ml. Conversion to standard multiport laparoscopy was not necessary. An accessory port was used in 87 cases to facilitate suturing and conduct drainage extraction. Postoperative complications occurred in 24 cases (six Clavien grade I, 12 grade II, one grade IIIa, two grade IIIb, two grade IVa, one grade IVb). Mean hospital stay was 4.2 ± 4 days. Total transfusion rate was 10%. Mean visual analogue pain scale at day 2 was 2.1 ± 1.3 (0-10). Visual analogue wound satisfaction scale at month 1 was 9.2 ± 0.6 (0-10). No cancer-related events occurred during follow-up. Late complications (4%) were not related to the surgical approach.

CONCLUSIONS

Umbilical KeyPort surgery is technically feasible for a great variety of procedures, both ablative and reconstructive. This access offers adequate surgical outcomes, scarce postoperative pain and security for the patient in the short term. Its reusable nature implies a noticeable economic advantage.

Laparoendoscopic single-site surgery with the second-generation single port instrument delivery extended reach surgical system in a porcine model

Purpose

To describe our initial experience with the second-generation Single Port Instrument Delivery Extended Reach (SPIDER) laparoendoscopic single-site surgical system in a porcine model.

Materials and Methods

In four swine weighing approximately 32 to 35 kg, five nephrectomies, four adrenalectomies, three pyeloplasties, and three partial cystectomies and closures were performed by a single surgeon. The swine were placed in the lateral flank position under general anesthesia. The SPIDER surgical system was introduced through a single incision and the various urological procures were performed by use of flexible instrumentation.

Results

All five nephrectomies, four adrenalectomies, three pyeloplasties, and three partial cystectomies and closures were performed successfully without additional skin incisions. The mean time to set up the SPIDER platform was 3.5 minutes. The mean operative time for the right and left nephrectomies was 45.4 minutes and 47.8 minutes, respectively. The mean operative time for the right and left adrenalectomies was 37.6 minutes and 35.4 minutes, respectively. The mean operative time for the pyeloplasties for one right and two left ureters was 45.6 minutes and 47.3 minutes, respectively. The mean operative time for the partial cystectomies and closures was 18.6 minutes. There were no noticeable intraoperative complications except for minimal urine leakage in the first pyeloplasty.

Conclusions

In this initial pilot evaluation, the second-generation SPIDER surgical system offered intuitive instrument maneuverability and restored triangulation. However, retraction was challenging because of the lack of strength and the limited ability for precise manipulation of the tip. Future refinements of the technology and prospective studies are needed to optimize the application of this technology in urology.

Feasibility of endoscopic transumbilical thoracic sympathectomy in a porcine model

OBJECTIVES

Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. Current methods are associated with risks of chronic neuropathic pain and a visible chest scar. We developed a novel surgical technique for the performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery with a flexible endoscope in a porcine model.

METHODS

Transumbilical flexible endoscopic thoracic sympathectomies were performed in seven farm pigs (three acute and four 4-week survivals). Under general anaesthesia, animals were intubated and mechanically ventilated with a dual lumen endotracheal tube through tracheostomy. A newly developed long transabdominal trocar was placed through the umbilicus. After insertion of a gastroscope through this trocar, a small incision was created on both sides of the diaphragm by a needle-knife. Then the gastroscope was inserted into the thoracic cavity, and the sympathetic chain was identified at the desired thoracic level and ablated. Operation time, safety and feasibility were recorded in all animals.

RESULTS

The transumbilical thoracic sympathectomies were successfully completed in all pigs with a mean operation time of 66.7 ± 9.4 min. Intraoperative bleeding occurred in one pig during the electrosurgical incision of diaphragm tissue, which was successfully controlled by hot biopsy forceps. No other acute intraoperative complications were observed in any cases. In the acute group, the length of the diaphragm incision ranged from 4 to 5 mm in three pigs. In the survival group, the animals recovered promptly from surgery. In three pigs, a small pneumothorax was found in the postoperative chest X-ray, but all of them were completely resolved with conservative treatment. Autopsy showed all bilateral T3 sympathetic chains were successfully ablated and no evidence of vital structure injury or diaphragmatic hernia.

CONCLUSIONS

Transumbilical flexible endoscopic thoracic sympathectomy is technically feasible, simple and safe in a porcine model. This technique can be used as a novel experimental platform for studies of natural orifice transluminal endoscopic surgery (NOTES) for intrathoracic surgery.

[Current state of single-port transumbilical surgery in urology: challenges and applications]

CONTEXT

Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology.

ACQUISITION OF EVIDENCE

A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described.

SYNTHESIS OF EVIDENCE

LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach.

CONCLUSIONS

Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

Interim report: a randomized controlled trial comparing postoperative pain in single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) is increasingly practiced, but there have been no well-powered randomized trials investigating the technique. This non-inferiority trial aims to compare SILC with conventional four-port laparoscopic cholecystectomy (LC) with postoperative pain as the primary endpoint.

METHODS

We aim to randomize 100 patients into equal arms of SILC or LC. Exclusion criteria were: (i) acute cholecystitis; (ii) an ASA score of 3 or above; (iii) bleeding disorders; or (iv) previous upper abdominal surgery. Patients and postoperative assessors were blinded to the procedure received. The site and severity of pain was compared based on the visual analogue scale at 4 hours, 24 hours and 14 days postoperatively; non-inferiority was assumed when the lower boundary of the 95% confidence interval of the difference was above -1, and superiority when P ≤ 0.05.

RESULTS

We recruited 24 SILC and 26 LC patients. There were no conversions to open cholecystectomy or from SILC to LC. SILC was non-inferior for pain at umbilical sites at rest and at extra-umbilical sites at all times. At 24 hours postoperatively, SILC was associated with significantly less pain at extra-umbilical sites (rest: P = 0.002; movement: P = 0.004). There were no incidents of biliary injury or retained gallstones. Of the 24 SILC patients, 12.5% had postoperative complications (vomiting, mild fluid overload, wound infection) compared with 0% of LC patients (P = 0.110); all complications resolved with conservative management. Operating time, analgesic use, return to function, and overall satisfaction did not differ significantly between the two groups.

CONCLUSION

SILC is associated with reduced pain and is feasible in routine surgical practice.

Feasibility of a novel extraperitoneal two-port laparoendoscopic approach for radical prostatectomy: an initial study

The aim of this study was to describe the surgical technique and to report the early outcomes of an original extraperitoneal two-port laparoendoscopic approach for radical prostatectomy. A total of 22 consecutive patients diagnosed with early-stage prostate cancer (cT1c, cT2N0) were operated on and included in this analysis. A multichannel port with three 5-mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5-cm lower umbilical "U" incision. An additional 12-mm port was inserted into the left fossa to allow an adequate working angle to facilitate the most critical steps of the surgical procedures. The operation was successfully completed in all patients; one patient required an additional 5-mm port to control bleeding. The median operation time was 259 min (range 207-453 min), and the fluid loss, including urine and blood, was 946 mL (range 257-1821 mL). The median Foley catheter indwelling period was 6 days (range 3-11 days) after surgery. No intraoperative complications occurred. Judging from this initial trial, this procedure can be safely carried out if the surgeon is familiar with conventional five-port laparoscopic radical prostatectomy.

Single-access laparoscopic adjustable gastric band removal: technique and initial experience

BACKGROUND

Single-access laparoscopy (SAL) has gained significant interest in recent years. Potential benefits, beyond cosmetic outcomes, could be reduction of abdominal trauma, decreased risk of incisional hernia and diminished postoperative pain. Technique and initial experience in patients submitted to laparoscopic adjustable gastric band removal (LAGBR) through SAL is reported here.

METHODS

Between December 2009 and March 2012, 14 patients (9 females, 5 males) underwent LAGBR through SAL. Indications for operation were band intolerance (11), pouch dilatation (2) and insufficient weight loss (1). The mean age was 40.3 ± 9.1 years (range 26-57), and the mean interval time between LAGB placement and removal was 94.7 ± 41.9 months (range 37-157). The mean weight and the mean body mass index at the time of LAGBR were 89.3 ± 17.6 kg (range 65-119) and 30.6 ± 4.5 kg/m(2) (range 25.3-36.7), respectively. Technically, the previous port site scar was used as the single-access site to the abdominal cavity. An 11-mm reusable trocar was adopted for a 10-mm regular scope, besides curved reusable instruments.

RESULTS

No patients required conversion to open surgery and none necessitated additional trocars. The mean laparoscopic time was 24.6 ± 7.9 min (range 13-37), and the mean final scar length was 3.6 ± 0.3 cm (range 3-4). Two patients experienced early postoperative complications. The mean hospital stay was 1.3 ± 1.1 days (range 1-5). The mean follow-up time was of 18 ± 9.8 months (range 3-30), and there were no late complications.

CONCLUSIONS

LAGBR can be safely performed through SAL. Thanks to this technique, the laparoscopic working triangulation is established as well as the ergonomic positions of the surgeon. Due the use of only reusable material, the cost of this SAL remains similar to multiport laparoscopy.

Renaissance of Minilaparoscopy in the NOTES and single port era

The authors suggest that minilaparoscopy should be considered as the most sophisticated evolution of laparoscopic surgery at the present time.

Current status of laparoendoscopic single-site surgery in urologic surgery

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML)

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches.

OBJECTIVE

To present LESS and NOTES in its historical context and to clarify the associated terminology.

METHOD

Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT).

RESULTS

The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4 years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that 'laparoendoscopic single-site surgery' (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy.

DISCUSSION

The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.

Laparoendoscopic single-site surgery (LESS) versus conventional laparoscopic surgery for adnexal preservation: a randomized controlled study

Objective

To compare the operative outcomes, postoperative pain, and subsequent convalescence after laparoendoscopic single-site surgery (LESS) or conventional laparoscopic surgery for adnexal preservation.

Study design

From December 2009 to September 2010, 63 patients underwent LESS (n = 33) or a conventional laparoscopic surgery (n = 30) for cyst enucleation. The overall operative outcomes including postoperative pain measurement using the visual analog scale (VAS) were evaluated (time points 6, 24, and 24 hours). The convalescence data included data obtained from questionnaires on the need for analgesics and on patient-reported time to recovery end points.

Results

The preoperative characteristics did not significantly differ between the two groups. The postoperative hemoglobin drop was higher in the LESS group than in the conventional laparoscopic surgery group (P = 0.048). Postoperative pain at each VAS time point, oral analgesic requirement, intramuscular analgesic requirement, and the number of days until return to work were similar in both groups.

Conclusion

In adnexa-preserving surgery performed in reproductive-age women, the operative outcomes, including satisfaction of the patients and convalescence after surgery, are comparable for LESS and conventional laparoscopy. LESS may be a feasible and a promising alternative method for scarless abdominal surgery in the treatment of young women with adnexal cysts

Transumbilical laparoendoscopic single-site pyeloplasty in infants and children: initial experience and short-term outcome

BACKGROUND

Scar-free abdominal wall surgery is a research hotspot in recent years. This study presented surgical skills of transumbilical laparoendoscopic single-site pyeloplasty (LESS-P) for pediatric patients with ureteropelvic junction obstruction (UPJO) and its clinical application.

METHODS

Twenty-four pediatric patients with UPJO had transumbilical LESS-P performed by the same surgeon from June to December 2010. Among them, 16 were males and 8 females aged from 2 to 62 months with average of 14 months. Eighteen patients had obstruction on the left ureteropelvic junction and six on the right. The renal pelvis and ureter were anastomosed using 5-0 absorbable sutures and a double-J ureteric stent was placed through the anastomotic stoma.

RESULTS

All operations were successful. None was converted to open surgery and no additional sheath tube or incision besides umbilicus was needed. No intraoperative complications occurred. Ectopic blood vessels were found in two cases during surgery. The mean operative time was 145 min, and the average blood loss about 10 ml. Abdominal drainage tubes were remained for 2-9 days after surgery. The mean postoperative hospital time was 7 days. Two patients had postoperative urinary fistula, which naturally disappeared at 4 and 7 days of postoperation, respectively. Ultrasound and diuretic renal scintigraphy in follow-up found 23 patients had significantly decreased renal pelvis diameter. Although the other one showed no obvious change, but diuretic renography showed significantly improved excretion as indicated by increased glomerular filtration rate from 29 ml/min before surgery to 46 ml/min 6 months after surgery.

CONCLUSION

Pediatric transumbilical LESS-P is not only safe and effective but also can well meet patient's aesthetic desire for scar-free abdominal wall.

Laparoendoscopic single-site surgery in urology: Evaluation of complications

Objective

To comprehensively review current reports on the complications of laparoendoscopic single-site surgery (LESS), introduced recently into urology as an option for treating various urological pathologies.

Methods

We reviewed previous reports to August 2011 using Medline, focusing on LESS in urology, with special interest in the complications, evaluating those during and after surgery, as well as conversions to reduced-port laparoscopy, conventional laparoscopy and open surgery.

Results

There are increasing reports of LESS in urology, with expanding indications. Complication rates both during and after surgery are low and related mostly to the technical difficulty and dexterity with the currently available instruments. Overall, intraoperative complications were reported by 11 published studies, while postoperative complications were reported by 15. Although the overall conversion rates to open surgery and conventional laparoscopy were low, the incidence of reduced-port laparoscopy was significantly higher.

Conclusions

Although there are expanding indications for LESS in urology, the risk of complications is low. This might be related to the fact that LESS is still restricted to experienced laparoscopic surgeons, and to the criteria for selecting patients.

The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer

OBJECTIVE

The aim of this study was to show the safety and feasibility of single-port laparoscopic surgery (SPLS) by comparing its short-term outcomes with those following conventional laparoscopic surgery.

SUMMARY BACKGROUND DATA

Single-port laparoscopic surgery maximizes the advantages of laparoscopic surgery, and therefore it can be an ultimate attainment of laparoscopic surgery. However, no comparative study has addressed its role in colorectal cancer.

METHODS

Prospectively collected data of patients who had undergone either conventional laparoscopic surgery (n = 106) or SPLS (n = 73) for colorectal cancer between March 2006 and May 2010 were analyzed retrospectively. The short-term outcomes of these 2 operative modalities were compared.

RESULTS

Of the 179 study subjects, 103 (57.5%) had colon cancer and 76 (42.5%) had rectal cancer. Various operative methods, from right hemicolectomy to abdominoperineal resection, were used according to location through either conventional laparoscopic or SPLS approach. In its comparison, mean surgical time was greater in the SPLS group (255 vs 276 minutes, P < 0.008). Acquired length of sufficient surgical margins and the number of harvested lymph nodes were comparable. Postoperative recovery was faster in the SPLS group, in terms of shorter time duration before first flatus (SPLS vs conventional laparoscopic surgery; 2.5 ± 1.2 vs 3.2 ± 1.8 days, P = 0.004), earlier initiation of free oral fluids (1.8 ± 2.2 vs 2.6 ± 1.7 days, P = 0.000) and of a solid diet (4.2 ± 2.9 vs 6.5 ± 2.7 days, P = 0.000), less frequent usage of parenteral narcotics (2.2 ± 3.2 vs 3.5 ± 4.0 times, P = 0.029), and shorter hospital stay (9.6 ± 9.6 vs 15.5 ± 9.8 days, P = 0.000).

CONCLUSION

This study shows that SPLS is both safe and feasible in colorectal cancer, and that it has equivalent or better short-term outcomes than conventional laparoscopic surgery. Accordingly, the authors conclude that SPLS can be an alternative to conventional laparoscopic surgery for colorectal cancer.

Laparoendoscopic single-site surgery in urology

BACKGROUND

Since its introduction, the role of laparoscopic surgery has grown and it has now become the standard approach for many surgical procedures. The benefits of smaller incisions, improved pain and convalescence, and shorter hospital stays have greatly improved patient care and satisfaction. In an effort to further minimize the morbidity of surgery, laparoendoscopic single-site (LESS) or single-incision laparoscopic surgery (SILS) has emerged. We review the collective experience with this novel technique and share our initial observations and early results.

METHODS

We performed a literature search to review the published experience with this new technique including the breadth of applications and perioperative outcomes associated with LESS in urology. We also analysed the experience with this emerging technique at our institution.

RESULTS

There are numerous variations with regards to nomenclature as well as types of access to the abdominal cavity as it pertains to LESS. Urologic procedures involving single-port access have acceptable operating room time, blood loss, and postoperative pain, which are in line with standard laparoscopic surgical outcomes with the added benefit of improved cosmesis and smaller incisions.

CONCLUSIONS

Further studies and larger cohorts are needed to assess the real benefit of LESS procedures. The additional learning curve needed to master these techniques may be a barrier to wider acceptance, although improvements in instrumentation are likely to bridge this gap.

Laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments--preliminary experience

PURPOSE

To confirm the feasibility of the laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments.

MATERIALS AND METHODS

Since March 2009, laparoscopic nephrectomy through a Pfannenstiel incision has been performed in selected patients in our service. The Veress needle was placed through the umbilicus which allowed carbon dioxide inflow. One 5 mm (or 10 mm) trocar was placed at the umbilicus for the laparoscope, to guide the placement of three trocars over the Pfannenstiel incision. Additional trocars were placed as follows: a 10 mm in the midline, a 10 mm ipsilateral to the kidney to be removed (2 cm away from the middle one), and a 5 mm contralateral to the kidney to be removed (2 cm away from the middle one). The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed and all three incisions were united into a single Pfannenstiel incision for specimen retrieval.

RESULTS

Five nephrectomies were performed following this technique: one atrophic kidney, one kidney donation, two renal cancers and one bilateral renal atrophy. Median operative time was 100 minutes and median intraoperative blood loss was 100 cc. No intraoperative complications occurred and no patients required blood transfusion. Median length of hospital stay was 1 day (range 1 to 2 days).

CONCLUSIONS

The use of the Pfannenstiel incision for laparoscopic nephrectomy seems to be feasible even when using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic nephrectomy.

Laparoscopic single port surgery in children using Triport: our early experience

Laparoscopy has become the gold standard technique for appendectomy and cholecystectomy. With the emergence of newer laparoscopic instruments which are roticulating and provide 7 degrees of freedom it is now possible to perform these operations through a single umbilical incision rather than the standard 3-4 incisions and thus lead to more desirable cosmetic results and less postoperative pain. The newer reticulating telescopes provide excellent exposure of the operating field and allow the operations to proceed routinely. Recently, ports [Triports (Olympus surgery)/SILS ports] especially designed for single incision laparoscopic surgery (SILS) have been developed. We herein describe our experience with laparoscopic single port appendectomies and cholecystectomies in children using the Triport. This is a retrospective cohort study of children who underwent single incision laparoscopic surgery between May 2009 and August 2010 at Texas Children's Hospital and Ben Taub General Hospital in Houston Texas by a single surgeon. Charts were reviewed for demographics, type of procedure, operative time, early or late complications, outcome and cosmetic results. Fifty-four patients underwent SILS. A total of 50 appendectomies (early or perforated) and 4 cholecystectomies were performed using this new minimally invasive approach. The average operative time for SILS/LESS appendectomy was 54 min with a range between 25 and 205 min, while operative time for SILS cholecystectomy was 156 min with a range of 75-196 min. Only small percentage (4%) of appendectomies (mostly complicated) were converted to standard laparoscopy, but none were converted to open procedure. All patients were followed up in the clinic after 3-4 weeks. No complications were noted and all patients had excellent cosmetic results. Parents were extremely satisfied with the cosmetic results. SILS/LESS is a safe, minimally invasive approach for appendectomy and cholecystectomy in children. This new approach is performed in an acceptable operative time with good outcomes and great cosmetic result.

Transvaginal assisted totally laparoscopic single-port right colectomy

Operative approach for right colectomy has progressed substantially in last decades, by the application of laparoscopy in colorectal surgery. Single-port (SP) laparoscopic surgery is one of the newest branches of advanced laparoscopy. A 29-year-old woman with ileocecal Crohn's disease underwent a totally laparoscopic transumbilical SP right colectomy, assisted by vaginal access. The operation time was 140 minutes. The blood loss was 20 mL. The patient was allowed to drink fluids and a soft oral diet on the first day postoperatively. Neither intraoperative nor postoperative complications were observed. The patient was discharged on postoperative day 4. The wound size was 2.5 cm. The umbilical scar was almost invisible on postoperative day 7. Totally laparoscopic transumbilical SP right colectomy with vaginal access is a feasible procedure, providing a scarless surgery, ensuring the preservation of the body image.

Urologic Laparoendoscopic Single-Site Surgery (LESS): current status

BACKGROUND

The evolution of minimally invasive surgery led to the development of laparo-endoscopic single-site surgery (LESS).

DISCUSSION

The feasibility of almost all types of urologic procedures has been shown. Comparative series between conventional laparoscopy and LESS for different kidney procedures suggest a non-inferiority of LESS over standard laparoscopy but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instruments clashing, lacks of true triangulation, in-line vision are the main concerns of LESS surgery. LESS pre-bent and articulating instruments have been designed but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Da Vinci® assisted LESS procedures have been performed. The available robotic platform remains bulky, but innovative instruments and platforms may facilitate the future unrestricted development of LESS.

CONCLUSIONS

A steep learning curve limits the application of LESS procedures to well trained and experienced surgeons. Nevertheless, the adoption of LESS principles and the clinical experience with LESS techniques have significantly grown in the past few years worldwide. Improvements in the instruments and platforms will expand the application of LESS surgery, allowing us to better assess its advantages and disadvantages compared to other minimally invasive procedures.

Single-incision laparoscopic adrenalectomy

BACKGROUND

The aim of this study was to compare outcome measures between conventional transabdominal laparoscopic adrenalectomy and single-incision laparoscopic adrenalectomy (SILA).

METHODS

Between January 2006 and April 2010, a total of 96 patients underwent laparoscopic adrenalectomy. Of these, 74 (77.1%) underwent conventional transabdominal laparoscopic adrenalectomy (group 1) and 22 (32.9%) underwent SILA (group 2). Age, sex ratio, tumor size, operating time, blood loss, postoperative visual analog pain scale (VAS) scores, and duration of hospitalization were compared between the two groups.

RESULTS

The mean ages of the patients in groups 1 and 2 were 43.4 ± 12.3 and 43.3 ± 10 years, respectively (P = 0.7). The female:male ratios in groups 1 and 2 were 1.6:1 and 4.5:1, respectively (P < 0.0001). The mean tumor size was significantly larger in group 1 than in group 2 (4.7 ± 1.5 vs. 3.34 ± 1.06 cm, respectively; P = 0.093). No significant difference was found between group 1 and group 2 with respect to the mean operating time (68.4 ± 20.8 vs. 63.9 ± 16.9 min, respectively; P = 0.36) or the level of intraoperative blood loss (38 ± 26.5 vs. 48.4 ± 62.4 ml, respectively; P = 0.26). The postoperative VAS score was significantly lower in group 2 than in group 1 (2.05 ± 0.57 and 3.28 ± 0.63, respectively; P < 0.0001). The length of hospital stay was significantly higher in group 1 than in group 2 (3.04 ± 1.2 and 2.45 ± 0.96 days, respectively; P = 0.04).

CONCLUSION

The findings of the present study suggest that SILA is as safe as conventional transabdominal laparoscopic adrenalectomy. Furthermore, SILA is associated with less pain and better cosmesis than the conventional laparoscopic procedure.

Single-incision total laparoscopic hysterectomy

Single-incision laparoscopic surgery is an alternative to conventional multiport laparoscopy. Single-access laparoscopy using a transumbilical port affords maximum cosmetic benefits because the surgical incision is hidden in the umbilicus. The advantages of single-access laparoscopic surgery may include less bleeding, infection, and hernia formation and better cosmetic outcome and less pain. The disadvantages and limitations include longer surgery time, difficulty in learning the technique, and the need for specialized instruments. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. We perform single-incision total laparoscopic hysterectomy using three ports in the single transumbilical incision.

Bilateral simultaneous single-port (LESS) laparoscopic nephrectomy (laparoendoscopic single site surgery)

Minimal access surgery is rapidly expanding and currently single-port surgery is at the forefront of laparoscopy. Operating through a single port is technically demanding but through advances in camera design and instrument design, it is now gaining popularity. It offers minimal scar surgery as well as decreased postoperative pain and swift recovery. Here we present a case of bilateral simultaneous single-port laparoscopic nephrectomy (LESS) laparoendoscopic single site surgery in a 51-year-old man. Illustrating that LESS can be used by surgeons with laparoscopic skills outside of a few major international centers.

Single-incision laparoscopic surgery - current status and controversies

Scarless surgery is the Holy Grail of surgery and the very raison d’etre of Minimal Access Surgery was the reduction of scars and thereby pain and suffering of the patients. The work of Muhe and Mouret in the late 80s, paved the way for mainstream laparoscopic procedures and it rapidly became the method of choice for many intra-abdominal procedures. Single-incision laparoscopic surgery is a very exciting new modality in the field of minimal access surgery which works for further reducing the scars of standard laparoscopy and towards scarless surgery. Natural orifice translumenal endoscopic surgery (NOTES) was developed for scarless surgery, but did not gain popularity due to a variety of reasons. NOTES stands for natural orifice translumenal endoscopic surgery, a term coined by a consortium in 2005. NOTES remains a research technique with only a few clinical cases having been reported. The lack of success of NOTES seems to have spurred on the interest in single-incision laparoscopy as an eminently doable technique in the present with minimum visible scarring, rendering a ‘scarless’ effect. Laparo-endoscopic single-site surgery (LESS) is, a term coined by a multidisciplinary consortium in 2008 for single-incision laparoscopic surgery. These are complementary technologies with similar difficulties of access, lack of triangulation and inadequate instrumentation as of date. LESS seems to offer an advantage to surgeons with its familiar field of view and instruments similar to those used in conventional laparoscopy. LESS remains a evolving special technique used successfully in many a centre, but with a significant way to go before it becomes mainstream. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery. This article outlines the development of LESS giving an overview of all the techniques and devices available and likely to be available in the future.

Current status of natural orifice trans-endoscopic surgery (NOTES) and laparoendoscopic single site surgery (LESS) in urologic surgery

Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) represent novel approaches in urological surgery. To perform a review of the literature in order describe the current status of LESS and NOTES in Urology. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-02 to 15-05-09. Search terms included single port, single site, NOTES, LESS and single incision. A total of 412 manuscripts were initially identified. Out of these, 64 manuscripts were selected based in their urological content. The manuscript features subheadings for experimental and clinical studies, as NOTES-LESS is a new surgical technique and its future evolution will probably rely in initial verified feasibility. A subheading for reviews presents information regarding common language and consensus for the techniques. The issue of complications published in clinical series and the future needs of NOTES-LESS, are also presented.

Natural orifice translumenal endoscopic surgery (NOTES(®)): a technical review

INTRODUCTION

The clinical NOTES literature continues to grow. This review quantifies the published human NOTES experience to date, examines instrument use in detail, and compiles available perioperative outcomes data.

METHODS

A PubMed search for all articles describing human NOTES cases was performed. All articles providing a technical description of procedures, excluding cases limited to diagnostic procedures, specimen extraction, fluid drainage or gynecological procedures, were reviewed. Two reviewers systematically cataloged the technical details of each procedure and performed a frequency analysis of instrument use in each type of case. Available outcomes data were also compiled.

RESULTS

Forty-three discrete articles were reviewed in detail, describing a total of 432 operations consisting of transvaginal (n = 355), transgastric (n = 58), transesophageal (n = 17), and transrectal (n = 2) procedures, with 90% of cases performed in hybrid fashion with laparoscopic assistance. Cholecystectomy (84% of cases) was the most common procedure. Analysis of key steps included choice of endoscope, establishment of peritoneal access, dissection, specimen extraction, and closure of the access site. Analysis of instrument use during transvaginal cholecystectomy revealed variation in the choice of endoscope and the technique for establishment of access. A majority of these procedures relied heavily on the use of rigid and transabdominal instrumentation. Closure of the vaginotomy site was found to be well standardized, performed with an open suturing technique. Similar analysis for transgastric procedures revealed consistency in the choice of flexible endoscope as well as access and closure techniques. Perioperative outcomes from NOTES procedures were reported, but the data are currently limited due to small case numbers.

CONCLUSIONS

NOTES is most commonly performed using a hybrid, transvaginal approach. Although some aspects of these procedures appear to be well standardized, there is still significant variability in technique. More outcomes data with standardized reporting are needed to determine the actual risks and benefits of NOTES.

Natural orifice translumenal endoscopic surgery (NOTES(®)): a technical review

INTRODUCTION

The clinical NOTES literature continues to grow. This review quantifies the published human NOTES experience to date, examines instrument use in detail, and compiles available perioperative outcomes data.

METHODS

A PubMed search for all articles describing human NOTES cases was performed. All articles providing a technical description of procedures, excluding cases limited to diagnostic procedures, specimen extraction, fluid drainage or gynecological procedures, were reviewed. Two reviewers systematically cataloged the technical details of each procedure and performed a frequency analysis of instrument use in each type of case. Available outcomes data were also compiled.

RESULTS

Forty-three discrete articles were reviewed in detail, describing a total of 432 operations consisting of transvaginal (n = 355), transgastric (n = 58), transesophageal (n = 17), and transrectal (n = 2) procedures, with 90% of cases performed in hybrid fashion with laparoscopic assistance. Cholecystectomy (84% of cases) was the most common procedure. Analysis of key steps included choice of endoscope, establishment of peritoneal access, dissection, specimen extraction, and closure of the access site. Analysis of instrument use during transvaginal cholecystectomy revealed variation in the choice of endoscope and the technique for establishment of access. A majority of these procedures relied heavily on the use of rigid and transabdominal instrumentation. Closure of the vaginotomy site was found to be well standardized, performed with an open suturing technique. Similar analysis for transgastric procedures revealed consistency in the choice of flexible endoscope as well as access and closure techniques. Perioperative outcomes from NOTES procedures were reported, but the data are currently limited due to small case numbers.

CONCLUSIONS

NOTES is most commonly performed using a hybrid, transvaginal approach. Although some aspects of these procedures appear to be well standardized, there is still significant variability in technique. More outcomes data with standardized reporting are needed to determine the actual risks and benefits of NOTES.