Endoluminal surgery: past, present and future

A foldable manipulator with tunable stiffness based on braided structure

Minimally invasive surgery (MIS) has recently seen a surge in clinical applications due to its potential benefits over open surgery. In MIS, a long manipulator is placed through a tortuous human orifice to create a channel for surgical tools and provide support when they are operated. Currently the relative large profile and low stiffness of the manipulators limit the effectiveness and accuracy of MIS. Here we propose a new foldable manipulator with tunable stiffness. The manipulator takes a braided skeleton to enable radial folding, whereas membrane is used to seal the skeleton so as to adjust stiffness through creating negative pressure. We demonstrated experimentally, numerically, and analytically that, a flexible and a rigid state were obtained, and the ratio of bending stiffness in the rigid state to that in the flexible state reached 6.85. In addition, the manipulator achieved a radial folding ratio of 1.95. The proposed manipulator shows great potential in the design of surgical robots for MIS. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B, 2019.

Hydraulic Robotic Surgical Tool Changing Manipulator

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique to perform "scarless" abdominal operations. Robotic technology has been exploited to improve NOTES and circumvent its limitations. Lack of a multitasking platform is a major limitation. Manual tool exchange can be time consuming and may lead to complications such as bleeding. Previous multifunctional manipulator designs use electric motors. These designs are bulky, slow, and expensive. This paper presents design, prototyping, and testing of a hydraulic robotic tool changing manipulator. The manipulator is small, fast, low-cost, and capable of carrying four different types of laparoscopic instruments.

The Future of Teaching Surgical Endoscopy

Gastrointestinal surgery, with its emphasis on endoscopy, has renewed interest in teaching surgical endoscopy. The field is rapidly evolving, with innovative techniques emanating from the laboratory to the operating room and endoscopy suite. To ensure that surgeons spearhead the field of endoscopic surgery, a new strategy for teaching surgical endoscopy to residents and practicing surgeons must be developed.

NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator

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.

Development of a Variable Stiffness Over Tube Based on Low-Melting-Point-Alloy for Endoscopic Surgery

Instruments used in endoscopic surgery (colonoscopy surgery or natural orifice transluminal endoscopic surgery (NOTES)) are flexible to be advanced in human body. However, when the end of the instrument reaches the target, the instrument should be rigid enough to hold its shape against external forces for better surgical accuracy. In order to obtain these two properties, a variable stiffness over tube based on low-melting-point-alloy (LMPA) is proposed in this paper. The structure exploits the phase transformation property of the LMPA which enables the stiffness change of the over tube by heating and cooling. A prototype was fabricated using a special molding method, and experiments were carried out to evaluate its variable stiffness property and response characteristics. According to experimental results, it costs 17 s to make the over tube transform from rigid state to flexible state and 18 s to make the over tube transform from flexible state to rigid state. The experimental results also indicated that the over tube is very rigid in rigid state and flexible in compliant state. A heat insulation layer was assembled to prevent human tissue from thermal damage. The temperature of the outer wall of the over tube was 42.5 °C when hot water of 80 °C was pumped into the over tube continually with the help of the heat insulation layer.

Magnetic microrobot and its application in a microfluidic system

This paper researches the design and control method of a microrobot in a microfluidic system by electromagnetic field. The microrobot can move along the microchannel to a required position, and by changing the magnetic torque, the microrobot can also rotate in the microfluidic chip. As an application of the microrobot, it is used as a mobile micromixer to mix two solutions in the microfluidic chip, and the experimental results verify its effectiveness.

Safety and effectiveness of an endoscopic suturing device in a human colonic treat-and-resect model

BACKGROUND

Despite advances in many areas of therapeutic endoscopy, the development of an effective endoscopic suturing device has been elusive. The purpose of this trial was to evaluate the safety and effectiveness of a suturing device to place and secure sutures within normal, in vivo human colonic tissue prior to surgical resection.

METHODS

Patients undergoing elective colectomy were enrolled in this treat-and-resect model. The Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, TX) was used to place sutures in healthy colonic tissue during a 15-minute, time-limited period. Following colectomy, the explanted tissue was evaluated to determine the depth of suture penetration and the effectiveness of the suture/cinch element. Clinical and operative data were recorded.

RESULTS

Four patients (50% female) were enrolled. Seven sutures were successfully placed, incorporating a total of 10 tissue bites in a mean of 13.5 minutes. On inspection of the explanted tissue, all sutures were found to be located subserosal (no full thickness bites were taken). The suture and cinch elements were judged to be effective in the majority of cases. One device-related issue did not inhibit the ability to oppose tissue or place the cinch. There were no intraoperative or postoperative complications.

CONCLUSIONS

The Overstitch permitted safe and effective suturing in an in vivo human colon model. The sutures were placed at a consistent subserosal depth and at no point risked iatrogenic injury to adjacent structures. Technical issues with the device were infrequent and did not inhibit the ability to place sutures effectively.

Preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones: system review and meta-analysis. Surg Endosc. 2013;27:2454-2465. [PMID: 23355158 DOI: 10.1007/s00464-012-2757-7]

BACKGROUND

Conducting preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones remains controversial. We conducted a meta-analysis to evaluate the outcomes of preoperative endoscopic sphincterotomy (POES) versus intraoperative endoscopic sphincterotomy (IOES).

METHODS

We searched multiple electronic databases for prospective, randomized, controlled trials related to safety and effectiveness of POES versus IOES. Relative risk ratios (RRs) were estimated with 95 % confidence intervals (CI) based on an intention-to-treat analysis. We considered the following outcomes: clearance rate, postprocedural complications, and hospital stay.

RESULTS

Five trials with 631 patients (318 with POES, 313 with IOES) were analyzed. Although the overall rates of common bile duct stone clearance were similar between POES and IOES (RR 0.96, 95 % CI 0.91-1.01; p = 0.13), the failure rate of common bile duct cannulation during endoscopic retrograde cholangiopancreatography (ERCP) was significantly higher for IOES (RR 2.54, 95 % CI 1.23-5.26; p = 0.01). The pooled RR after POES for overall complication rates was similar to that for IOES (RR 1.56, 95 % CI 0.94-2.59; p = 0.09). However, compared with IOES, the RR risk of ERCP-related complications was significantly higher for POES (RR 2.27, 95 % CI 1.18-4.40, p = 0.01), especially in the patients at high risk of developing post-ERCP pancreatitis. There was no significant difference in morbidity after laparoscopic cholecystectomy or required subsequent open surgery between the two groups. In the subgroup analyses, the RR risks of post-ERCP pancreatitis were significantly higher for POES (RR 4.85, 95 % CI 1.41-16.66, p = 0.01), and mean hospital stay was longer in the POES group (RR 2.22, 95 % CI 1.98-246; p < 0.01). However, the rates of bleeding, perforation, cholangitis, cholecystitis, and gastric ulceration did not differ significantly between POES and IOES.

CONCLUSIONS

With regard to the stone clearance and overall complication rates, POES is equal to IOES in patients with gallbladder and common bile duct stones. However, IOES is associated with a reduced incidence of ERCP-related pancreatitis and results in a shorter hospital stay.

Emerging robotic platforms for minimally invasive surgery

Recent technological advances in surgery have resulted in the development of a range of new techniques that have reduced patient trauma, shortened hospitalization, and improved diagnostic accuracy and therapeutic outcome. Despite the many appreciated benefits of minimally invasive surgery (MIS) compared to traditional approaches, there are still significant drawbacks associated with conventional MIS including poor instrument control and ergonomics caused by rigid instrumentation and its associated fulcrum effect. The use of robot assistance has helped to realize the full potential of MIS with improved consistency, safety and accuracy. The development of articulated, precision tools to enhance the surgeon's dexterity has evolved in parallel with advances in imaging and human-robot interaction. This has improved hand-eye coordination and manual precision down to micron scales, with the capability of navigating through complex anatomical pathways. In this review paper, clinical requirements and technical challenges related to the design of robotic platforms for flexible access surgery are discussed. Allied technical approaches and engineering challenges related to instrument design, intraoperative guidance, and intelligent human-robot interaction are reviewed. We also highlight emerging designs and research opportunities in the field by assessing the current limitations and open technical challenges for the wider clinical uptake of robotic platforms in MIS.

Laparoscopic assisted transvaginal cholecystectomy: single centre preliminary experience

BACKGROUND

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a new approach that allows abdominal surgery to be performed through a natural orifice such as the oral cavity, vagina or rectum. We present our preliminary experience of laparoscopic assisted transvaginal cholecystectomy (LATC).

METHODS

Women affected by cholelithiasis, age below 65 years, BMI under 30, ASA I or II, previous full-term pregnancies, and without previous abdominal surgery underwent LATC. Patients' biographic data, operative time, intraoperative and postoperative complications were collected.

RESULTS

We performed 21 LATCs. Median operative time was 58 min. There were no intraoperative complications. The postoperative course was uneventful in all patients. At 1 year there were no complications and no impaired sexual activity.

CONCLUSIONS

The results of NOTES are promising, but currently only hybrid NOTES can be safely performed. LATC seems to guarantee better cosmetic results, less postoperative pain, faster mobilization and shorter hospitalization than laparoscopic cholecystectomy.

Development of tasks and evaluation of a prototype forceps for NOTES

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Current progress on natural orifice transluminal endoscopic surgery (NOTES)

Natural orifice transluminal endoscopic surgery (NOTES) has received considerable interest in recent years as a novel surgical technique. Here, we aim to review the current progress on NOTES, particularly focusing on the advantages and complications related to NOTES, the recent advances of surgical approaches, new instruments for closure of the natural orifice incision, and the newly developed platform for NOTES. Finally, we make a prediction of the conceivable applications of NOTES on human subjects.

Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy?

In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.

Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital

BACKGROUND

The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP.

PATIENTS AND METHODS

This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique.

RESULTS

Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days).

CONCLUSIONS

Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.

Technical skill set training in natural orifice transluminal endoscopic surgery: how should we approach it?

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.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

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.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BACKGROUND

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).

METHODS

A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.

RESULTS

Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.

CONCLUSIONS

There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Evaluation of a manually driven, multitasking platform for complex endoluminal and natural orifice transluminal endoscopic surgery applications (with video)

BACKGROUND

The Direct Drive Endoscopic System (DDES) is a multitasking platform developed to overcome the limitations of the currently available rigid and flexible endoscopic systems in application to natural orifice transluminal endoscopic surgery (NOTES), single-port laparoscopy, and advanced endoluminal procedures. The system consists of a 3-channel, steerable guide sheath accepting a 6-mm endoscope and two 4-mm articulating instruments. The system's overall design enables the interventionalist to operate instruments bimanually from a stable platform, conveying a laparoscopic paradigm to the functional working space at the distal end of the flexible guide sheath.

OBJECTIVE

To assess the basic functionality of the DDES device in a series of defined exercises by using ex vivo porcine stomachs and 1 in vivo animal model.

DESIGN

Ex vivo calibration and training exercises, including EMR, full-thickness suturing, and knot tying.

SETTING

Animal laboratory.

INTERVENTIONS

EMR, full-thickness suturing, and knot tying.

MAIN OUTCOME MEASUREMENTS

Successful completion of specified tasks.

RESULTS

Independent instrument movement with a wide range of motion allowed the interventionalist to perform several complex tasks efficiently. The DDES was able to (1) grasp tissue and hold it under tension, (2) cut through layers of porcine stomach in a controlled fashion, (3) suture, and (4) tie knots.

LIMITATION

Ex vivo study.

CONCLUSIONS

This novel multitasking platform demonstrated surgical functionality including triangulation, cutting, grasping, suturing, and knot tying. Preliminary results suggest that the DDES can perform complex endosurgical tasks that have traditionally been challenging or impossible with the standard endoscopic paradigm, and may enable NOTES, single-port laparoscopy, and complex endoluminal procedures.

Oophorectomy by natural orifice transluminal endoscopic surgery: feasibility study in dogs

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) represents a potentially less-invasive alternative to conventional or laparoscopic surgery.

OBJECTIVE

Our purpose was to develop a canine oophorectomy model for prospective evaluation of intraoperative complications, surgical stress, and postoperative pain and recovery with NOTES.

DESIGN

Feasibility study.

SETTING

Academic preclinical research.

PATIENTS

Ten healthy female dogs.

INTERVENTIONS

NOTES procedures were performed through gastric access with an electrocautery snare to resect and retrieve the ovaries. The gastrotomy was closed with prototype T-fasteners.

MAIN OUTCOME MEASUREMENTS

Operative time; complications; postoperative pain scores, and nociceptive threshold; surgical stress markers (interleukin-6 [IL-6], C-reactive protein); systemic stress parameters (cortisol, glucose); necropsy evaluation at 10 to 14 days.

RESULTS

The mean operative time was 154 minutes (SD +/- 58 minutes) and no animals died as a result of complications from the procedure. The primary difficulty was incomplete ovarian excision and conversion to an open procedure in 1 dog. Serum glucose concentrations increased after surgery and remained elevated for at least 36 hours. The serum cortisol concentration was transiently increased from baseline at 2 hours after surgery. The serum IL-6 concentration peaked at 2 hours after surgery and returned to the baseline value by 18 hours. The serum C-reactive protein concentration increased significantly from baseline, peaked at 12 hours after surgery, and then slowly declined toward baseline but remained elevated at 72 hours after surgery. Nociceptive threshold measurements indicated increased sensitivity to pain for 2 to 24 hours after surgery. At necropsy, surgical sites were healing uneventfully with no significant damage to surrounding organs, no significant growth on bacterial cultures, and no evidence of peritonitis.

LIMITATIONS

Small number of animals, single center.

CONCLUSIONS

The NOTES approach to oophorectomy in dogs appears to be a reasonable alternative to traditional surgery. Attention must be paid to ensure complete excision of the ovaries.

Laparoscopic intraluminal surgery for gastrointestinal malignancies

INTRODUCTION

Intraluminal surgery began with the advent of endoscopy. Endoscopic endoluminal surgery has limitations; and its failure results in conventional open or laparoscopic interventions with increased morbidity. Laparoscopy-assisted intraluminal surgery is a novel alternative to open or laparoscopic surgery for a failed endoscopic endoluminal technique, minimizing the associated complications. Endoscopic resection of early gastric and duodenal cancers is restricted by the limited view of the endoscope, insufficient number of instrument channels, and inability to have adequate margins of resection without risking perforation. These cancers potentially can be treated by laparoscopy-assisted intraluminal surgery without resorting to major gastric or duodenal resection. This procedure is relatively easy to perform and oncologically effective. We present the experience of the Texas Endosurgery Institute (TEI) in treating early gastric and duodenal cancers, including large malignant polyps and carcinoid tumors, with laparoscopy-assisted endoluminal surgery.

MATERIALS AND METHODS

The data for all patients with early gastric and duodenal cancers who underwent laparoscopy-assisted endoluminal surgery at TEI between 1996 and 2007 were prospectively recorded. All of the patients had been referred by the endoscopist as noncandidates for endoscopic resection. We prospectively collected data on preoperative diagnosis, operating time, estimated blood loss, postoperative complications, histopathology, and recurrence rate. All patients underwent endoluminal port placement under direct visualization after a pneumoperitoneum was established. Operations were performed in conjunction with upper endoscopy for assistance with port placement under endoluminal visualization, insufflation, and specimen retrieval. After the intraluminal portion of the operation was completed, the endoluminal port sites were closed with laparoscopic intracorporeal suturing.

RESULTS

From 1996 to 2007, a total of 12 patients underwent laparoscopic endoluminal surgery. All cases were completed successfully, including 5 resections of early gastric cancer (stage I), 3 wedge resections of carcinoid tumor, 2 resections of duodenal adenocarcinoma, and 2 resections of a malignant polyp at the gastroesophagic junction; all the cases were completed with disease-free margins. No recurrence of the original pathology have been reported, and the complications were minimal.

CONCLUSION

Laparoscopic intraluminal surgery for early gastric and duodenal cancer is a feasible alternative to open conventional therapies; and it is associated with a lower incidence of incisional hernia formation and a lower infection rate.

Who should do NOTES? Initial endoscopic performance of laparoscopic surgeons compared to gastroenterologists and untrained individuals

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) is a multidisciplinary surgical technique. If conventional endoscopic instrumentation can be easily mastered, surgeons with laparoscopic experience could head NOTES interventions.

MATERIALS AND METHODS

Thirty individuals were tested for endoscopic dexterity. Group 1 included seven gastroenterologists, group 2 included 12 laparoscopically experienced surgeons lacking endoscopic experience, and group 3 included 11 interns who had no hands-on endoscopic or surgical experience. Each individual repeated an easy (T1), medium (T2), and difficult (T3) task ten times with endoscopic equipment on a NOTES skills-box.

RESULTS

Group 3 had significantly poorer performances for all three tasks compared to the other groups. No significant differences were seen between groups 1 and 2 for T1 and T2. The initial T3 performance of group 1 was better than that of group 2, but their performance after repetition was not statistically different. Groups 2 and 3 improved significantly with repetition, and group 2 eventually performed as well as group 1.

CONCLUSIONS

The data indicate that laparoscopic surgeons quickly learned to handle the endoscopic equipment. This suggests that a lack of endoscopic experience does not handicap laparoscopic surgeons when performing endoscopic tasks. Based on their knowledge of anatomy and the complication management acquired during surgical education, surgeons are well equipped to take the lead in interdisciplinary NOTES collaborations.

NOTES--third generation surgery. Vain hopes or the reality of tomorrow?

BACKGROUND

Laparoscopic approach has made many procedures less invasive; however, it seems like this is not enough. The newest challenge for the medical environment is applying the scarless surgery in humans. In this article, we review the origin, current state of art, and future of natural orifice transluminal endoscopic surgery (NOTES). The registered base of research in humans is yet scarce; however, the porcine model experimental studies hold a great promise. In NOTES, peritoneal cavity can be easily achieved, and some procedures are feasible through the natural orifices like digestive tract, vagina, or urinary bladder. If safety and advantages of these approaches will be proven beyond question, NOTES procedures are likely to be adapted in humans after overcoming the critical obstacles, like reliable closure methods, indispensable equipment invention, the multidisciplinary specialists training, etc. The aim of this article was to review available literature to provide current state of art in NOTES surgery.

MATERIALS AND METHODS

Medical databases were searched for animal and human experience with NOTES to give an overview of history, current state of art, and future of this technique.

RESULTS

NOTES is currently the subject of the intensive research. It seems like this is only the matter of time when a transluminal access to the abdominal or even thoracic cavity will become the reality. Moreover, this will enable the management of some diseases in a possibly minimally invasive pattern, nearly painless and leaving no scar at all.

Natural orifice translumenal endoscopic surgery (NOTES)

Surgery has rapidly evolved as new technologies are adopted. With the introduction of laparoscopic surgery, patient outcomes have improved, with faster recovery from smaller incisions. In an effort to continually improve these outcomes and offer alternative options to higher risk patients, a number of investigators have proposed the concept of operating in the peritoneal space through natural orifices, obviating the need for any abdominal skin incisions. Natural orifice translumenal endoscopic surgery (NOTES) offers the same advantages as laparoscopic surgery without skin incisions, and possibly without general anesthesia. This article gives a conceptual and technical description of NOTES, discusses its challenges and potential pitfalls, reviews the early efforts at NOTES-specific device development, and predicts potential future directions of this exciting new area of surgery.