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Huang J, Du BR, Qiao WG, Huang SL, Xue LF, Deng L, Liang JM, Wang J, Li JY, Chen Y. Endoscopic submucosal dissection training: evaluation of an ex vivo training model with continuous perfusion (ETM-CP) for hands-on teaching and training in China. Surg Endosc 2023:10.1007/s00464-023-09940-9. [PMID: 36914780 DOI: 10.1007/s00464-023-09940-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/21/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND The existing ex vivo models of endoscopic submucosal dissection (ESD) cannot simulate intraoperative hemorrhage well. We aimed to establish an ESD training method by applying an ex vivo training model with continuous perfusion (ETM-CP). METHODS Four training sessions were conducted for 25 novices under the guidance of 2 experts. Eventually, 10 novices completed ESD operations on a total of 89 patients after the training. The resection effectiveness, resection speed, complication rate, and novice performance before and after the training were compared. The data regarding the effects of the training and the model were gathered through a questionnaire survey. RESULTS In terms of the simulation effect of the model, ETM-CP was evaluated as similar to the live pig in all aspects (P > 0.05). The questionnaire analysis revealed that the ESD theoretical knowledge, skill operation, and self-confidence of novices were improved after the training (P < 0.05). The resection time per unit area had a correlation with the number of training periods (rs = - 0.232). For novice performance, the resection time per unit area was shortened (P < 0.05). There was no difference in patient performance between the novice group and the expert group after the training in terms of en bloc resection, R0 resection, complication rate, endoscopic resection bleeding (ERB) score, muscularis propria injury (MPI) score, and resection time per unit area (P > 0.05). CONCLUSION The ETM-CP is effective for ESD training.
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Affiliation(s)
- Jun Huang
- Department of Gastroenterology, The Seventh Affiliated Hospital of Southern Medical University, No. 28, Liguan Road, Lishui Town, Nanhai District, Foshan, 528244, Guangdong, China
| | - Bing-Ran Du
- Department of Stomatology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Foshan, 528308, Guangdong, China
| | - Wei-Guang Qiao
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Si-Lin Huang
- Department of Gastroenterology, South China Hospital, Medical School, Shenzhen University, Shenzhen, 518116, China
| | - Lan-Feng Xue
- Department of Gastroenterology, The Seventh Affiliated Hospital of Southern Medical University, No. 28, Liguan Road, Lishui Town, Nanhai District, Foshan, 528244, Guangdong, China
| | - Liang Deng
- Department of Gastroenterology, LunJiao Hospital, Shunde District, Foshan, 528244, Guangdong, China
| | - Jun-Ming Liang
- Department of Gastroenterology, Xingtan Hospital Affiliated to Shunde Hospital of Southern Medical University, Foshan, 528325, China
| | - Jun Wang
- Department of Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jian-Yi Li
- The Third Affiliated Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.,Department of Anatomy, Guangdong Provincial Key Laboratory of Digital Medicine and Biomechanics, Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, School of Basic Medical Sciences, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Yu Chen
- Department of Gastroenterology, The Seventh Affiliated Hospital of Southern Medical University, No. 28, Liguan Road, Lishui Town, Nanhai District, Foshan, 528244, Guangdong, China.
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Becker V, Ostler D, Feussner H, Nennstiel S, Haller B, Schmid RM, Bajbouj M, Schneider A. Esophageal bougination: a novel ex vivo endoscopic training model correlated with clinical data. Surg Endosc 2016; 31:2566-2572. [PMID: 27670649 DOI: 10.1007/s00464-016-5262-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Esophageal bougination is a worldwide standard endoscopic procedure. Clinical methods and recommendations are based on clinical experiences only. Mechanical properties have never been described. Aim of the study was to establish a realistic ex vivo training model. Therefore, detailed assessment of relevant mechanical features of esophageal bougination should be evaluated ex vivo and in patient setting and correlated against. PATIENTS AND METHODS A three-step concept was used to evaluate mechanical properties at stenosis level. First, insertion forces were evaluated in an ex vivo linear single stenosis model during steady mechanical insertion. Second, adding friction and properties of the pharynx and upper esophagus, the model was integrated in an artificial endoscopic training model (ELITE training model). Third, in vivo measurements were taken to correlate ex vivo data with parameters of a realistic patient setting. RESULTS With the presented setup, we were able to assess insertion force and pressure levels in an artificial stricture using different sizes of commercially available standard bougies. In all models, there was a relevant increase in insertion force with higher stricture pressure levels. Insertion force levels in the ELITE model show higher levels compared to the linear stenosis model. Having regard to the maximum forces in patients, there is also a constant increase in mean insertion force according to higher bougie sizes, but lower forces were measured as in the ELITE model. DISCUSSION The applied models are suitable to appraise mechanical properties of esophageal bougination in an ex vivo model and patient setting. Forces could be constituted reliable, significant increase was documented according to stenosis level and results were comparable to patient data. This was comparable to patient data. Further clinical evaluation in different kinds of stenosis is necessary.
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Affiliation(s)
- V Becker
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany.
| | - D Ostler
- MITI, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - H Feussner
- MITI, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - S Nennstiel
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - B Haller
- Institut für Medizinische Statistik und Epidemiologie, Technische Universität München, Munich, Germany
| | - R M Schmid
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - M Bajbouj
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - A Schneider
- MITI, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Korzeniowski P, Barrow A, Sodergren MH, Hald N, Bello F. NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator. Int J Comput Assist Radiol Surg 2016; 11:2303-2315. [PMID: 27314591 PMCID: PMC5110615 DOI: 10.1007/s11548-016-1401-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/23/2016] [Indexed: 12/13/2022]
Abstract
Purpose Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique in minimally invasive surgery whereby a flexible endoscope is inserted via a natural orifice to gain access to the abdominal cavity, leaving no external scars. This innovative use of flexible endoscopy creates many new challenges and is associated with a steep learning curve for clinicians. Methods We developed NOViSE—the first force-feedback-enabled virtual reality simulator for NOTES training supporting a flexible endoscope. The haptic device is custom-built, and the behaviour of the virtual flexible endoscope is based on an established theoretical framework—the Cosserat theory of elastic rods. Results We present the application of NOViSE to the simulation of a hybrid trans-gastric cholecystectomy procedure. Preliminary results of face, content and construct validation have previously shown that NOViSE delivers the required level of realism for training of endoscopic manipulation skills specific to NOTES. Conclusions VR simulation of NOTES procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. In the context of an experimental technique, NOViSE could potentially facilitate NOTES development and contribute to its wider use by keeping practitioners up to date with this novel surgical technique. NOViSE is a first prototype, and the initial results indicate that it provides promising foundations for further development. Electronic supplementary material The online version of this article (doi:10.1007/s11548-016-1401-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Przemyslaw Korzeniowski
- Centre for Engagement and Simulation Science, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, SW10 9NH, London, UK
| | - Alastair Barrow
- Centre for Engagement and Simulation Science, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, SW10 9NH, London, UK
| | | | - Niels Hald
- Centre for Engagement and Simulation Science, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, SW10 9NH, London, UK
| | - Fernando Bello
- Centre for Engagement and Simulation Science, Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, SW10 9NH, London, UK.
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Gromski MA, Ahn W, Matthes K, De S. Pre-clinical Training for New Notes Procedures: From Ex-vivo Models to Virtual Reality Simulators. Gastrointest Endosc Clin N Am 2016; 26:401-412. [PMID: 27036905 PMCID: PMC4990456 DOI: 10.1016/j.giec.2015.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) is a newer field of endoscopic surgery that allows for scarless treatment of pathologic entities, using novel transluminal approaches. There has been a shift of focus from a clinical and research standpoint from the development and dissemination of "first-generation" NOTES procedures to "new NOTES" procedures that traverse the mucosa of luminal structures, yet do not stray far into the peritoneal cavity. It has been a challenge to find appropriate and effective ways to train gastroenterologists and surgeons in these novel approaches. We review the importance of simulation in training and discuss available simulation options.
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Affiliation(s)
- Mark A. Gromski
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Woojin Ahn
- Center for Modeling, Simulation and Imaging in Medicine, Rennselaer Polytechnic Institute, Troy, NY, USA
| | - Kai Matthes
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Suvranu De
- Center for Modeling, Simulation and Imaging in Medicine, Rennselaer Polytechnic Institute, Troy, NY, USA
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Kenngott HG, Wünscher JJ, Wagner M, Preukschas A, Wekerle AL, Neher P, Suwelack S, Speidel S, Nickel F, Oladokun D, Albala L, Maier-Hein L, Dillmann R, Meinzer HP, Müller-Stich BP. OpenHELP (Heidelberg laparoscopy phantom): development of an open-source surgical evaluation and training tool. Surg Endosc 2015; 29:3338-47. [PMID: 25673345 PMCID: PMC4607709 DOI: 10.1007/s00464-015-4094-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 01/23/2015] [Indexed: 01/22/2023]
Abstract
Background Apart from animal testing and clinical trials, surgical research and laparoscopic training mainly rely on phantoms. The aim of this project was to design a phantom with realistic anatomy and haptic characteristics, modular design and easy reproducibility. The phantom was named open-source Heidelberg laparoscopic phantom (OpenHELP) and serves as an open-source platform.
Methods The phantom was based on an anonymized CT scan of a male patient. The anatomical structures were segmented to obtain digital three-dimensional models of the torso and the organs. The digital models were materialized via rapid prototyping. One flexible, using an elastic abdominal wall, and one rigid method, using a plastic shell, to simulate pneumoperitoneum were developed. Artificial organ production was carried out sequentially starting from raw gypsum models to silicone molds to final silicone casts. The reproduction accuracy was exemplarily evaluated for ten silicone rectum models by comparing the digital 3D surface of the original rectum with CT scan by calculating the root mean square error of surface variations. Haptic realism was also evaluated to find the most realistic silicone compositions on a visual analog scale (VAS, 0–10). Results The rigid and durable plastic torso and soft silicone organs of the abdominal cavity were successfully produced. A simulation of pneumoperitoneum could be created successfully by both methods. The reproduction accuracy of ten silicone rectum models showed an average root mean square error of 2.26 (0–11.48) mm. Haptic realism revealed an average value on a VAS of 7.25 (5.2–9.6) for the most realistic rectum. Conclusion The OpenHELP phantom proved to be feasible and accurate. The phantom was consecutively applied frequently in the field of computer-assisted surgery at our institutions and is accessible as an open-source project at www.open-cas.org for the academic community.
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Affiliation(s)
- H G Kenngott
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - J J Wünscher
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M Wagner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - A Preukschas
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - A L Wekerle
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - P Neher
- Division of Medical and Biological Informatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - S Suwelack
- Institute for Anthropomatics, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - S Speidel
- Institute for Anthropomatics, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - F Nickel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - D Oladokun
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Lorenzo Albala
- Ruprecht-Karls-University, Department of General Abdominal and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - L Maier-Hein
- Division of Medical and Biological Informatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - R Dillmann
- Institute for Anthropomatics, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - H P Meinzer
- Division of Medical and Biological Informatics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - B P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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A comparison of NOTES transvaginal and laparoscopic cholecystectomy procedures based upon task analysis. Surg Endosc 2014; 28:2443-51. [PMID: 24619331 DOI: 10.1007/s00464-014-3495-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 02/17/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND A virtual reality-based simulator for natural orifice translumenal endoscopic surgery (NOTES) procedures may be used for training and discovery of new tools and procedures. Our previous study (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013) shows that developing such a simulator for the transvaginal cholecystectomy procedure using a rigid endoscope will have the most impact on the field. However, prior to developing such a simulator, a thorough task analysis is necessary to determine the most important phases, tasks, and subtasks of this procedure. METHODS 19 rigid endoscope transvaginal hybrid NOTES cholecystectomy procedures and 11 traditional laparoscopic procedures have been recorded and de-identified prior to analysis. Hierarchical task analysis was conducted for the rigid endoscope transvaginal NOTES cholecystectomy. A time series analysis was conducted to evaluate the performance of the transvaginal NOTES and laparoscopic cholecystectomy procedures. Finally, a comparison of electrosurgery-based errors was performed by two independent qualified personnel. RESULTS The most time-consuming tasks for both laparoscopic and NOTES cholecystectomy are removing areolar and connective tissue surrounding the gallbladder, exposing Calot's triangle, and dissecting the gallbladder off the liver bed with electrosurgery. There is a positive correlation of performance time between the removal of areolar and connective tissue and electrosurgery dissection tasks in NOTES (r = 0.415) and laparoscopic cholecystectomy (r = 0.684) with p < 0.10. During the electrosurgery task, the NOTES procedures had fewer errors related to lack of progress in gallbladder removal. Contrarily, laparoscopic procedures had fewer errors due to the instrument being out of the camera view. CONCLUSION A thorough task analysis and video-based quantification of NOTES cholecystectomy has identified the most time-consuming tasks. A comparison of the surgical errors during electrosurgery gallbladder dissection establishes that the NOTES procedure, while still new, is not inferior to the established laparoscopic procedure.
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Natural-orifice translumenal endoscopic surgery (NOTES): minimally invasive evolution or revolution? Surg Laparosc Endosc Percutan Tech 2014; 23:244-50. [PMID: 23751986 DOI: 10.1097/sle.0b013e31828b8b7b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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A systematic review on low-cost box models to achieve basic and advanced laparoscopic skills during modern surgical training. Surg Laparosc Endosc Percutan Tech 2013; 23:109-20. [PMID: 23579503 DOI: 10.1097/sle.0b013e3182827c29] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Low-cost box models (BMs) are a valuable tool alternative to virtual-reality simulators. We aim to provide surgical trainees with a description of most common BMs and to present their validity to achieve basic and advanced laparoscopic skills. MATERIALS AND METHODS A literature search was undertaken for all studies focusing on BMs, excluded were those presenting data on virtual-reality simulators only. Databases were screened up to December 2011. RESULTS Numerous studies focused on various BMs to improve generic tasks (ie, instrument navigation, coordination, and cutting). Only fewer articles described models specific for peculiar operations. All studies showed a significant improvement of basic laparoscopic skills after training with BMs. Furthermore, their low costs make them easily available to most surgical trainees. CONCLUSIONS BMs should be developed by all surgical trainees during their training. Fields for future improvement regard endoscopy and complex laparoscopic operations for which ad hoc BMs are not available.
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Sodergren MH, Warren A, Nehme J, Clark J, Gillen S, Feussner H, Teare J, Darzi A, Yang GZ. Endoscopic horizon stabilization in natural orifice translumenal endoscopic surgery: a randomized controlled trial. Surg Innov 2013; 21:74-9. [PMID: 23686394 DOI: 10.1177/1553350613489187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spatial orientation in natural orifice translumenal endoscopic surgery (NOTES) has been identified as a potential barrier to clinical application. We aim to evaluate a triaxial inertial sensor and software that automatically corrects any movements on the roll axis of the flexible endoscope, allowing for stabilization of the image horizon during NOTES operations in a randomized controlled trial. METHODS A total of 18 participants (11 surgeons/7 gastroenterologists) performed a transgastric task in the ELITE simulator, which included navigation to the appendix and gallbladder, diathermy of the appendix base and gallbladder fossa, and clipping of the cystic duct using a single-channel gastroscope. Each participant performed the task twice with randomization to horizon stabilization occurring at the second attempt. The primary end point was change in overall performance (time taken and errors made) between the first and second attempt, and secondary end points were absolute performances in the second attempt and subjective evaluation. RESULTS Without horizon stabilization, there was a median improvement of 42.4% in time taken and 38% in number of errors made from the first to the second attempt; however, with the software turned on, there was a statistically significant deterioration of 4.9% (P = .038) in time taken and an increase in errors made of 183% (P = ns). CONCLUSIONS Although the software corrects the view to that preferred during surgery, the endoscopic control mechanism as well as the exit point of the instrument are altered in this process, leading to a deterioration of overall performance. Potential solutions include deploying intermittent horizon stabilization or using a robotic interface to achieve fully aligned perceptual-motor control.
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Nehme J, Sodergren MH, Sugden C, Aggarwal R, Gillen S, Feussner H, Yang GZ, Darzi A. A randomized controlled trial evaluating endoscopic and laparoscopic training in skills transfer for novices performing a simulated NOTES task. Surg Innov 2013; 20:631-8. [PMID: 23493565 DOI: 10.1177/1553350613480854] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task. METHODS A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors. RESULTS The endoscopy group was significantly faster than the control group at accessing the peritoneal cavity through the gastric incision (median 27 vs 78 s; P = .015), applying diathermy to the base of the appendix (median 103.5 vs 173 s; P = .014), and navigating to the gallbladder (median 76 vs 169.5 s; P = .049). Endoscopy participants completed the full NOTES procedure in a shorter time than the laparoscopy group (median 863 vs 2074 s; P < .001). CONCLUSION This study highlights the importance of endoscopic training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.
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de Montbrun S, MacRae H. Simulation and Minimally Invasive Colorectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Moghul MR, Sodergren MH, Clark J, Teare J, Yang GZ, Darzi A. Education and training in NOTES: a systematic review. Surg Innov 2013; 20:282-91. [PMID: 23355422 DOI: 10.1177/1553350612474495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Since the first published work on natural orifice translumenal endoscopic surgery (NOTES) a decade ago, progress has been made in the domain of education and training, although questions posed by the original White Paper remain. This article aims to review the current status of education and training in NOTES. METHODS A review of the literature was conducted to evaluate the following: (1) What are the current training methods/modalities used for NOTES; what is the level of evidence to support their use? (2) How has NOTES clinical training been quantified; what is the evidence relating to performance of different NOTES operators? (3) What clinical NOTES training programs have been established and what are the wider training needs? RESULTS A total of 25 studies were included: 11 nonanimal studies, 8 animal studies, and 6 descriptions of education programs. Several animal and simulator models demonstrated construct validity, but no study showed human predictive validity. Logarithmic learning curves in animal models demonstrate 10 to 15 cases achieving a proficiency level. Current trends are that gastroenterologists prefer it for diagnostic and basic procedures, whereas surgeons prefer it for complex therapeutic cases. CONCLUSION The development of a new specialty is intriguing but currently unviable. Training programs have been initiated, but information is limited; the common theme is surgeons receiving endoscopic training. Despite the research done, our knowledge of training and educating in NOTES procedures is limited, preventing a meta-analysis or formal review from being performed. Further research is needed to integrate NOTES into routine clinical procedure.
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Affiliation(s)
- Masood R Moghul
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London, UK
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Needs analysis for developing a virtual-reality NOTES simulator. Surg Endosc 2012; 27:1607-16. [PMID: 23247736 DOI: 10.1007/s00464-012-2637-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 09/21/2012] [Indexed: 02/07/2023]
Abstract
UNLABELLED INTRODUCTION AND STUDY AIM: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical technique that requires a cautious adoption approach to ensure patient safety. High-fidelity virtual-reality-based simulators allow development of new surgical procedures and tools and train medical personnel without risk to human patients. As part of a project funded by the National Institutes of Health, we are developing the virtual transluminal endoscopic surgery trainer (VTEST) for this purpose. The objective of this study is to conduct a structured needs analysis to identify the design parameters for such a virtual-reality-based simulator for NOTES. METHODS A 30-point questionnaire was distributed at the 2011 National Orifice Surgery Consortium for Assessment and Research meeting to obtain responses from experts. Ordinal logistic regression and the Wilcoxon rank-sum test were used for analysis. RESULTS A total of 22 NOTES experts participated in the study. Cholecystectomy (CE, 68 %) followed by appendectomy (AE, 63 %) (CE vs AE, p = 0.0521) was selected as the first choice for simulation. Flexible (FL, 47 %) and hybrid (HY, 47 %) approaches were equally favorable compared with rigid (RI, 6 %) with p < 0.001 for both FL versus RI and HY versus RI. The transvaginal approach was preferred 3 to 1 to the transgastric. Most participants preferred two-channel (2C) scopes (65 %) compared with single (1C) or three (3C) or more channels with p < 0.001 for both 2C versus 1C and 2C versus 3C. The importance of force feedback and the utility of a virtual NOTES simulator in training and testing new tools for NOTES were rated very high by the participants. CONCLUSION Our study reinforces the importance of developing a virtual NOTES simulator and clearly presents expert preferences. The results of this analysis will direct our initial development of the VTEST platform.
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Kranzfelder M, Staub C, Fiolka A, Schneider A, Gillen S, Wilhelm D, Friess H, Knoll A, Feussner H. Toward increased autonomy in the surgical OR: needs, requests, and expectations. Surg Endosc 2012; 27:1681-8. [PMID: 23239307 DOI: 10.1007/s00464-012-2656-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 10/10/2012] [Indexed: 11/24/2022]
Affiliation(s)
- Michael Kranzfelder
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, 81675 München, Germany.
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McConnell RA, Kim S, Ahmad NA, Falk GW, Forde KA, Ginsberg GG, Jaffe DL, Makar GA, Long WB, Panganamamula KV, Kochman ML. Poor discriminatory function for endoscopic skills on a computer-based simulator. Gastrointest Endosc 2012; 76:993-1002. [PMID: 22968094 DOI: 10.1016/j.gie.2012.07.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 07/12/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes. OBJECTIVE To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills. DESIGN Prospective, observational, non-randomized, parallel cohort study. SETTING Single academic center with accredited gastroenterology training program. PARTICIPANTS Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians. INTERVENTION Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys. MAIN OUTCOME MEASUREMENTS The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed. RESULTS Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy. LIMITATIONS Small sample size. CONCLUSION The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.
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Affiliation(s)
- Ryan A McConnell
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Abstract
The pedagogical approach to surgical training has changed significantly over the past few decades. No longer are surgical skills solely acquired through a traditional apprenticeship model of training. The acquisition of many technical and nontechnical skills is moving from the operating room to the surgical skills laboratory through the use of simulation. Many platforms exist for the learning and assessment of surgical skills. In this article, the authors provide a broad overview of some of the currently available surgical simulation modalities including bench-top models, laparoscopic simulators, simulation for new surgical technologies, and simulation for nontechnical surgical skills.
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Affiliation(s)
| | - Helen MacRae
- Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, Toronto, Ontario, Canada
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Clark J, Orihuela-Espina F, Sodergren M, James DR, Karimyan V, Teare J, Darzi A, Yang GZ. A quantitative scale to define endoscopic torque control during natural orifice surgery. MINIM INVASIV THER 2012; 22:17-25. [PMID: 22657573 DOI: 10.3109/13645706.2012.691638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The drive to perform procedures with the least impact on the patient has meant that interest in natural orifice translumenal endoscopic surgery (NOTES) continues to proliferate. However, endoscope control within the extralumenal environment remains a significant challenge. This study aims to define a method to quantitatively assess endoscopic torque control as an indication of performance. MATERIAL AND METHODS Fourteen endoscopists performed a ten-target navigational task within a simulated NOTES environment whilst wrist movements were tracked with an optical motion tracker. Patterns of wrist movements were translated to a binary form enabling differentiation of the specified movement from no movement. Three patterns were discernable suggesting the discrimination of purposeful over random manipulations. Three independent assessors scored 140 patterns on a scale of 1 to 3 determined by which pattern was the most appropriate fit. RESULTS Mean score for novices was 16 (± 3) and for clinicians 22 (± 7). Inter-rater reliability (kappa statistic function) between the assessors ranged from 0.637 to 0.751 p < 0.001 referred to as a substantial assessment tool. The internal consistency between all variables using Chronbach's alpha function was 0.948 (p < 0.001). CONCLUSIONS Pattern of movements extrapolated from the wrist can be used as a method of measuring endoscope torque control during a translumenal navigation task.
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Affiliation(s)
- James Clark
- Hamlyn Centre for Robotic Surgery, Imperial College London, London, UK.
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Real-Time Monitoring for Detection of Retained Surgical Sponges and Team Motion in the Surgical Operation Room Using Radio-Frequency-Identification (RFID) Technology: A Preclinical Evaluation. J Surg Res 2012; 175:191-8. [DOI: 10.1016/j.jss.2011.03.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 01/16/2011] [Accepted: 03/11/2011] [Indexed: 01/01/2023]
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Educational and training aspects of new surgical techniques: experience with the endoscopic–laparoscopic interdisciplinary training entity (ELITE) model in training for a natural orifice translumenal endoscopic surgery (NOTES) approach to appendectomy. Surg Endosc 2012; 26:2376-82. [DOI: 10.1007/s00464-012-2165-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 01/05/2012] [Indexed: 11/26/2022]
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Feussner H, Fiolka A, Schneider A, Gillen S, Kranzfelder M, Friess H, Wilhelm D. Safe sigmoid access for natural orifice transluminal endoscopic surgery (NOTES). Colorectal Dis 2011; 13 Suppl 7:55-8. [PMID: 22098520 DOI: 10.1111/j.1463-1318.2011.02782.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
One of the main challenges in transluminal surgery is sterile and safe access. For many interventions, a transanal approach would be ideal but it is considered too risky because of contamination and the danger of secondary leakage. A new safe and sterile transanal access was developed, combining four basic principles: (i) the creation of a decontaminating hydroperitoneum, (ii) the use of an overtube, (iii) defining the entry point with ultrasound and (iv) dedicated closure technique. Applicability and reliability was first proven in extensive animal experiments. Feasibility of the concept in humans was subsequently demonstrated in cadavers.
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Affiliation(s)
- H Feussner
- Chirurgische Klinik, Klinikum rechts der Isar der TUM, Ismaninger Str. 22, München, Germany.
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Gromski MA, Matthes K. Simulation in advanced endoscopy: state of the art and the next generation. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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22
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The European experience—current use of simulator training in Europe. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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23
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Simulation and training in transluminal endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Clark J, Gillen S, James DRC, Fiolka A, Karimyan V, Sodergren M, Orihuela-Espina F, Friess H, Darzi A, Feussner HD, Yang GZ. Transgastric or trans-sigmoidal? The impact of the choice of access on task performance in target natural orifice translumenal endoscopic surgery procedures. J Laparoendosc Adv Surg Tech A 2011; 21:237-42. [PMID: 21366439 DOI: 10.1089/lap.2010.0360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The effect of the choice of access upon endoscope control during a navigational task is explored within a simulator model. MATERIALS AND METHODS The study was conducted within the endoscopic-laparoscopic interdisciplinary training entity (ELITE) model (Minimally Invasive Therapy and Intervention Research Group [MITI], Technische Universität, Germany)--a validated natural orifice translumenal endoscopic surgery (NOTES) simulator. Seventeen subjects, 15 with no endoscopic experience, navigated the endoscope from predefined trans-sigmoidal and transgastric access points to the appendix and the gallbladder. A previously defined and validated quantitative analysis of endoscope control, in addition to time taken to complete the task, was used to evaluate overall performance. The quantitative analysis extrapolated the movements of the subject's wrist in control of the endoscope and rated the movements using a scoring system of 0-3 based upon the smoothness of the movements recorded. RESULTS Although no significant difference in terms of performance time was demonstrated between the two approaches to the appendix (36.6 ± 14.7 seconds TG and 29.8 ± 16 seconds TS) (P = .214), when the endoscope control score was compared, a significant difference was confirmed (3 TG and 7 TS) (P < .001). With regard to the approach to the gallbladder, a significant difference in terms of both the performance time (19.8 seconds TG and 35.6 seconds TS) (P < .001) and the quality of endoscope control (7 TG and 5 TS) (P = .001) was demonstrated. CONCLUSION The choice of access route impacts directly on the ease with which the endoscopist navigates to the target. Within this study, the trans-sigmoidal appears the most appropriate to access the appendix and the transgastric for the gallbladder.
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Affiliation(s)
- James Clark
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
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Nugent E, Traynor O, Neary P. Technical skill set training in natural orifice transluminal endoscopic surgery: how should we approach it? J Laparoendosc Adv Surg Tech A 2011; 21:107-11. [PMID: 21288127 DOI: 10.1089/lap.2010.0297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The boundaries in minimally invasive techniques are continually being pushed further. Recent years have brought new and exciting changes with the advent of natural orifice transluminal endoscopic surgery. With the evolution of this field of surgery come challenges in the development of new instruments and the actual steps of the procedure. Included in these challenges is the idea of developing a proficiency-based curriculum for training. METHODS A review of the currently available literature was performed to support the points discussed. RESULTS In this article we address and discuss the issues of who, when, where, and how to teach suitable trainees in the technique of natural orifice transluminal endoscopic surgery. CONCLUSION What comes to the fore is the importance of providing safe and structured training in these techniques.
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Affiliation(s)
- Emmeline Nugent
- National Surgical Training Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Fiolka A, Gillen S, Meining A, Feussner H. ELITE -Theex vivotraining unit for NOTES: Development and Validation. MINIM INVASIV THER 2010; 19:281-6. [DOI: 10.3109/13645706.2010.510673] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Maiss J, Zopf Y, Hahn EG. Entrance barriers and integration obstacles of NOTES. MINIM INVASIV THER 2010; 19:287-91. [DOI: 10.3109/13645706.2010.510671] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
PURPOSE OF REVIEW Since its introduction in 2000, natural orifice translumenal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world. In this article, we will review the progress in the field of NOTES and present the latest publications that provide some answers and solutions to the barriers suggested by the Natural Orifice Surgery Consortium for Assessment and Research white paper. RECENT FINDINGS Because of the first human NOTES procedure by Rao and Reddy, more pioneering procedures, including transgastric and transvaginal cholecystectomies, appendectomies, and hernia repairs, have been performed. Although NOTES researchers continue to experiment with new innovative equipment and procedures in the lab, more structured work, including randomized controlled trials, has been published. SUMMARY In the last several years, there has been growing interest in NOTES, which has translated into exciting animal research work and publication of randomized controlled trials. Additionally, preliminary NOTES human procedures have been successfully performed. When suitable instruments become available, the subsequent step should be comparing NOTES with current laparoscopic approaches. Superiority or even equality of NOTES to laparoscopic surgery would be the best argument for advancing and integrating implementation into clinical practice.
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Gillen S, Kleeff J, Kranzfelder M, Shrikhande SV, Friess H, Feussner H. Natural orifice transluminal endoscopic surgery in pancreatic diseases. World J Gastroenterol 2010; 16:3859-64. [PMID: 20712045 PMCID: PMC2923758 DOI: 10.3748/wjg.v16.i31.3859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diagnostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.
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Kranzfelder M, Schneider A, Gillen S, Feussner H. New technologies for information retrieval to achieve situational awareness and higher patient safety in the surgical operating room: the MRI institutional approach and review of the literature. Surg Endosc 2010; 25:696-705. [DOI: 10.1007/s00464-010-1239-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Accepted: 07/01/2010] [Indexed: 11/28/2022]
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