Hybrid Natural Orifice Transluminal Endoscopic Surgery Research Articles

Effectiveness of NOTES versus traditional techniques on surgical outcomes in adults with diverticulitis: a systematic review protocol.

This review will evaluate the effectiveness of natural orifice transluminal endoscopic surgery (NOTES)/hybrid NOTES versus traditional surgical techniques in the management of diverticular disease. Diverticular disease can have a significant impact on a patient's quality of life, especially the changes affecting bowel function. Recurrent/severe symptoms may require surgery. Resections are invasive and can have significant operative complications. There has been a shift from an open resection to a more minimally invasive technique such as laparoscopy. Furthermore, the use of natural orifice transluminal endoscopic resection, using a transanal/transvaginal approach, has begun to be used in colorectal resections. Eligible studies will include patients who underwent surgical resection for diverticular disease or diverticulitis. The review will consider studies that evaluate NOTES in the management of diverticular disease or diverticulitis. This will include hybrid procedures involving both NOTES and natural orifice specimen extraction (NOSE), with the aid of laparoscopy/endoscopy/robotic equipment. Studies on participants under 18 years of age and presenting with non-diverticular pathologies will be excluded. This review will follow the JBI methodology for systematic reviews of effectiveness and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Databases to be searched will include PubMed, MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane Library, Web of Science, Scopus, ProQuest, ClinicalTrials.gov, and ANZCTR, with no language limitations. The reference lists of included studies will be screened for additional studies. This review will preferentially consider experimental and quasi-experimental study designs. Two reviewers will conduct critical appraisal and data extraction. Studies will, where possible, be pooled in statistical meta-analyses. PROSPERO CRD42023420771.

Comparative analysis of postoperative pain after transvaginal hybrid NOTES versus traditional laparoscopic cholecystectomy in obese patients

PurposeEven though obesity is a known risk factor for needing cholecystectomy, most research excludes patients with higher degrees of obesity. The aim of this retrospective study was to compare postoperative pain and analgesic consumption in obese patients, who underwent either transvaginal hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy (NC) or traditional laparoscopic cholecystectomy (LC).MethodsBetween 12/2008 and 01/2017, 237 NC were performed, of which 35 (14.8%) showed a body mass index (BMI) of 35 kg/m2 or more (obesity II and III according to the World Health Organization). Of these, procedural time, postoperative pain, analgesic requirements, and other early postoperative parameters were collected and compared with 35 matched LC patients from the same time period.ResultsThere were no differences in the baseline characteristics between the two groups, but we found significant benefits for the hybrid NOTES technique in terms of less pain (P = 0.006), coherent with significantly less intake of peripheral (paracetamol; P = 0.005), and of centrally acting analgesics (piritramide; P = 0.047) within the first two-day post-surgery. We also found that those in the NC group had shorter hospital stays (P < 0.001). The postoperative complication rates and the procedural time did not differ between the two groups.ConclusionWith regard to postoperative pain and analgesic requirements and without an increase in postoperative complications, obese patients experience short-term benefits from the hybrid NOTES technique compared to traditional laparoscopic cholecystectomy.

Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies.

Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

Transvaginal laparoscopic appendectomy using innovative submucosal tunnels: a conducive modification for improving hybrid NOTES access and its critical appraisal.

Currently, transvaginal natural orifice transluminal endoscopic surgery (NOTES), the most minimally invasive option for laparoscopic surgery, suffers various technological restraints limiting its implementation. We discuss a simple modification for vaginal access to improve the existing hybrid NOTES technique. We retrospectively studied 18 women at our rural hospital in central India, who, under defined criteria, underwent transvaginal appendicectomy using innovative strategically designed submucosal tunnels. The procedure was successfully completed in all but the first three cases. None required additional abdominal trocar or analgesia beyond the first 6 h. The mean operative and hospitalisation times were 27.5 min and 18.5 h, respectively. We had no intraoperative complications and only one patient experienced postoperative self-limiting vaginal spotting. All patients were very pleased with the cosmetic results and sexual life as assessed by locally devised scales. On regular follow-up, all were progressing well. We recommend the method presented, as it is not only feasible and safe but has the potential to improve overall results. Clearly, a larger volume randomised trial would be optimal to confirm our conclusion.

The feasibility of natural orifice transluminal endoscopic surgery in gynecology practice: Single-surgeon experience

Objectives:Natural orifice transluminal endoscopic surgery (NOTES) has been performed in gynecology practice for the surgical treatment of ovarian cysts, uterine fibroids, ectopic pregnancies, adnexal masses, and pelvic organ prolapse. The aim of this study is to evaluate the intraoperative and postoperative outcomes of patients who underwent NOTES for gynecological diseases.Materials and Methods:This study was a retrospective clinical study. The data of 50 patients who had been treated via NOTES procedure for benign gynecological indications such as ectopic pregnancy, adnexal mass, uterine fibroid, and treatment-resistant heavy menstrual bleeding during the time period between January 2016 and 2019 were included. All procedures were performed by a single surgeon (C.K.) using a self-constructed glove port, and a sealing device in addition to conventional laparoscopic (CL) equipment. Descriptive analysis of the patients' data was performed.Results:The initial two of the adnexectomy procedures were performed via hybrid NOTES technic and four of them were performed via total vaginal NOTES technic. The remaining procedures, namely hysterectomies, adnexectomies, salpingectomies, and myomectomy were performed via vaginally assisted NOTES (VaNOTES) technic. The mean operation time for the hysterectomy ± bilateral salpingo-oophorectomy (BSO) and salpingo-oophorectomy patients was 85.25 min and 53.15 min, respectively. For those patients who underwent VaNOTES procedure, the median postoperative visual analog scale pain score at the 6thh was six and at the 24thh was two. The mean length of the hospital stay was 2.07 days in the hysterectomy ± BSO patients and 1.63 days in the salpingo-oophorectomy patients.Conclusion:The NOTES procedure is a feasible technic in regards to the duration of surgery, postoperative pain scores, and cosmetic outcomes.

Transvaginal laparoscopic right colectomy for colon neoplasia.

The laparoscopic technique has been used for colorectal surgery for decades. Minimally invasive surgery is executed differently in operations on the right colon, left colon, and the rectum [1]. Sometimes, the abdominal incision is critical for rectal surgery, which can be used for extraction of the resected specimen and for creation of the diverting stoma. However, for right or left colectomy, once the anastomosis is performed intra-corporeally, then the specimen can be extracted through any incision (abdominal wall or vaginal) to enhance post-operative recovery. The natural-orifice transluminal endoscopic surgery (NOTES) approach has been used in operations on the colon and rectum to minimize abdominal trauma, as, for example, in transanal total mesorectal excision (taTME) [2], laparoscopic colectomies with transanal [3] or transvaginal specimen extraction [4]. Up to now, transabdominal assistant with the laparoscopic technique is critical for accomplishing colorectal NOTES operations, so it is called the hybrid NOTES technique [5, 6]. Pure NOTES has not been reported for colonic resection. Recently, we successfully performed a laparoscopic right colectomy via the transvaginal approach. Here we describe the procedure.

TRANSANAL TOTAL MESORECTAL EXCISION OF RECTAL CANCER TREATMENT

Purpose: To evaluate the early results of the feasibility and safety on technology and oncologic transanal total mesorectal excision (down to up). Materils and method: Prospective study from 2012 to 2018. Patients: 23 rectum adenocarcinoma staging T ≤ 3, N ≤ 1, M0 were operated using one of two modalities Hybrid NOTES (A) and NOTES (B). Results: Twenty three patients with Rectal cancer were sucessfully in total mesorectal excision performed by Hybrid NOTES and NOTES procedures. Three cases in group NOTES had per-operative complications such as bleeding or urethra injury required one or two trocarts for assistance, no conversion to open surgery and no mortality. The operation time: group A (Hybrid NOTES): 190 ± 47 (120-280) mins; group B (NOTES): 258 ± 40 (190-300) mins. The hospital stay: 9 ± 2.7 (4-19) day. Conclusions: transanal total mesorectal excision (down to up) endoscopic surgery (NOTES) and Hybrid NOTES is feasible and safe.However, a study in a large number of patient and long follow-up is necessary. Key words: Mesorectum, Natural orifice transluminal endoscopic surgery (NOTES), Hybrid NOTES, rectal cancer

Canine ovariectomy by hybrid or total natural orifice transluminal endoscopic surgery: technical feasibility study and pain assessment.

To compare technical feasibility, surgical time, surgical complications, and postoperative pain in ovariectomy (OVE) by hybrid and total natural orifice transluminal endoscopic surgery (NOTES). Prospective randomized clinical trial. Sixteen healthy and sexually intact bitches. Dogs were randomly assigned to the hybrid NOTES group (HNG; n = 8) and the total NOTES group (TNG; n = 8) to compare surgical time, pain scores and complications. Pain was assessed by using the visual analog scale (VAS) and the Melbourne pain scale (MPS). Surgical time did not differ between the experimental groups (HNG = 46.3 ± 18.5 minutes, TNG = 54.6 ± 31.1 minutes). Exteriorization of the ovaries through the vaginal wound was the major difficulty. Complications were minor in both groups and occurred intraoperatively only in the HNG, and in both groups post operatively. No dogs required rescue analgesia in the intraoperative or postoperative period. There were no differences in VAS or MPS scores between the groups for any surgical times except for the VAS assessment at 72 hours after extubation (HNG = 1.1 ± 0.3, TNG = 0.7 ± 0.4, P = .0221). Both NOTES techniques were comparable for canine OVE, with no requirement for additional analgesia in the postoperative periods. It was not possible to determine whether there was a clear advantage of one technique rather than the other. The minimally invasive techniques proposed for laparoscopic OVE are feasible for dogs with low pain scores and low rates of complications for both groups.

Clinical outcomes of minimally invasive treatment for early gastric cancer in patients beyond the indications of endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) with laparoscopic sentinel lymph node dissection (ESN) and endoscopic full-thickness gastric resection with laparoscopic sentinel lymph node dissection (Hybrid-natural orifice transluminal endoscopic surgery, Hybrid-NOTES) are minimally invasive treatment options for early gastric cancer (EGC) beyond the indications of ESD. This study aimed to evaluate the short- and long-term clinical outcomes of ESN and Hybrid-NOTES. We retrospectively analyzed patients who had undergone ESN or Hybrid-NOTES for EGC from January 2009 to March 2013. A total of 48 patients, including 21 undergoing ESN and 27 undergoing Hybrid-NOTES, were enrolled. All patients had cancer stage T1N0M0, EGC less than 5cm in size, and suspected submucosal invasion according to imaging or biopsy-proven diffuse-type histology. In ESN and Hybrid-NOTES, the curative resection rates were 76.5% and 90.9% of patients, respectively. In the ESN group, 5 patients underwent an additional gastrectomy (1 for lymph node metastasis (LNM), 3 for surgical complications, and 1 for noncurative resection). In the Hybrid-NOTES group, 6 patients underwent additional gastrectomy, (1 for LNM, 3 for surgical complications, and 2 for noncurative resection). Of the 37 patients who were followed up in the long-term (a median follow-up of 59.8months), one was found to have liver metastasis after ESN and received palliative chemotherapy. ESN and Hybrid-NOTES have shown favorable long-term outcomes despite their technical limitations. These methods may be utilized as a bridge between ESD and gastrectomy in cases of EGC with a high risk of LNM beyond the ESD indications.

Transvaginal natural orifice transluminal endoscopic surgery in female urologic diseases

Objective To describe our experience with the transvaginal natural orifice transluminal endoscopic surgery (NOTES) in female patients, and to evaluate its clinical value. Methods Between May 2010 and April 2017, a total of 289 female patients underwent transvaginal NOTES in our center, including 31cases of adrenal tumors, 46 cases of renal tumors, 188 cases of non-functional kidneys, 5 cases of renal cysts, 4 cases of duplex kidney, 7 cases of renal tuberculosis and 8 cases of renal pelvis tumors. Among them, 146 cases were on the left side, 142 cases on the right side, and 1 case on both sides (renal cysts). The median age was 39.4 (range 23 to 76) years, and the median body mass index was 21.8(range 15.4 to 32.6)kg/m2. After general anesthesia, the patients were positioned in lithotomy with ipsilateral lumbar at 30°-60° angle to the floor. Hybrid and pure transvaginal NOTES were performed. The specimen was removed through an extended incision at the posterior vaginal fornix. Results Transvaginal NOTES was successfully completed in 281 patients. Two patients required conversion to suprapubic-assisted laparoendoscopic single-site surgery because of the rectal injury in pure transvaginal NOTES nephrectomy. Six patients underwent open conversion. The various transvaginal hybrid NOTES procedures included adrenalectomy (31 cases), nephrectomy (206 cases; simple 174 cases, radical 32 cases), partial nephrectomy (13 cases), heminephroureterctomy for duplex kidney (4 cases) and hybrid endoscopy for nephroureterectomy (7 cases). The mean operative time was 105 min (45-310 min), the mean estimated blood loss was 87 ml (20-800 ml), the mean visual analogue score (VAS) of 48 hours after operation was 2.5 (1-4) points and the mean hospitalization was 7.3 d (4-13 d) for transvaginal hybrid NOTES. The various pure transvaginal NOTES procedures included nephrectomy (22 cases; simple 21, radical 1), renal cyst excision (5 cases). The mean operative time was 170 min (60-320 min), the mean estimated blood loss was 140 ml (20-500 ml), the mean VAS of 48 hours after operation was 1.7 (1-3) points and the mean hospitalization was 5.5 d (3-10 d) for transvaginal pure NOTES. Complications occurred in 56 cases (19.38%), including 20 cases (6.92%) of severe complications, and no death occurred. After a mean follow-up of 51 (range 3 to 86) months, umbilicus scar was hidden. The incision in the vagina healed well. No infection in the abdominal or pelvic cavity or celiocele occurred. The umbilicus scar is not obvious after surgery, and 3 months after surgery.The median Patient Scar Assessment Questionnaire (PSAQ) score was 38 (31-58) and the median Female Sexual Function Index (FSFI) score was 28.2 (22.5-32.2), and the quality of life index was significantly higher than that of preoperation. Conclusions Transvaginal NOTES could treat variousprimary diseases, and improve the postoperative quality of life. It does not increase the incidence of related complications, or cause negative effect on the female sexual function, pregnancy or fertility. It can lead to good cosmetic outcome and less pain, which is worth applying in clinical practice. Key words: Natural orifice transluminal endoscopic surgery (NOTES); Transvaginal approach; Female; Urologic diseases

Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery

Hybrid natural-orifice transluminal endoscopic surgery (NOTES), combining access through a natural orifice with small-sized abdominal trocars, aims to reduce pain and enhance recovery. The objective of this systematic review and meta-analysis was to compare pain and morbidity in hybrid NOTES and standard laparoscopy. A systematic literature search was performed to identify RCTs and non-RCTs comparing hybrid NOTES and standard laparoscopy. The main outcome was pain on postoperative day (POD) 1. Secondary outcomes were pain during the further postsurgical course, rescue analgesia, complications, and satisfaction with the cosmetic result. The results of meta-analysis in a random-effects model were presented as odds ratio (ORs) or standard mean differences (MDs) with 95 per cent confidence intervals. Six RCTs and 21 non-randomized trials including 2186 patients were identified. In hybrid NOTES the score on the numerical pain scale was lower on POD 1 (-0·75, 95 per cent c.i. -1·09 to -0·42; P = 0·001) and on POD 2-4 (-0·58, -0·91 to -0·26; P < 0·001) than that for standard laparoscopy. The need for rescue analgesia was reduced in hybrid NOTES (OR 0·36, 0·24 to 0·54; P < 0·001). The reduction in complications found for hybrid NOTES compared with standard laparoscopy (OR 0·52, 0·38 to 0·71; P < 0·001) was not significant when only RCTs were considered (OR 0·83, 0·43 to 1·60; P = 0·570). The score for cosmetic satisfaction was higher after NOTES (MD 1·14, 0·57 to 1·71; P < 0·001). Hybrid NOTES reduces postoperative pain and is associated with greater cosmetic satisfaction in selected patients.

Natural orifice transluminal endoscopic surgery (hybrid) cholecystectomy: The Dhillon technique.

INTRODUCTION:This study presents a novel technique to perform cholecystectomy and assess its outcome and feasibility.PATIENTS AND METHODS:This study presents the novel Dhillon technique and experience of hybrid natural orifice transluminal endoscopic surgery (NOTES) technique, that is, laparoscopic-assisted transvaginal cholecystectomy. We have evaluated the outcomes in terms of cosmesis, post-operative recovery and analgesic requirement. The study included 257 patients who underwent hybrid NOTES cholecystectomy at single tertiary hospital. The biographical data, surgical time, pain score on day 1 and 2, need of analgesia, intra- and post-operative complication and aesthetic assessment on day 7 were recorded.RESULTS:Out of a total of 1100 cases of laparoscopic cholecystectomy 257 had hybrid NOTES cholecystectomy. Only two of these cases were converted to standard laparoscopic cholecystectomy. The mean operative time was 31.5 ± 5.1 (25–40) min. None of the patients had any complication or biliary leakage. The mean pain score on day 1 and 2 was 3.6 ± 0.4 (3–4) and 1.0 ± 0.06 (1–2), respectively. The mean paracetamol (analgesic) dose requirement was 6.1 ± 0.6 (4–6.9) g. The aesthetic score was excellent in all the cases.CONCLUSIONS:Using the present technique of hybrid NOTES is beneficial in terms of cosmetic results, lesser need of analgesic and shorter hospital stay.

Feasibility and Technique for Transvaginal Natural Orifice Transluminal Endoscopic Surgery Liver Resection: A Porcine Model.

Introduction:Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR).Materials and Methods:Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures.Results:Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver.Conclusions:Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.

Hybrid natural orifice transluminal endoscopic surgery colectomy versus conventional laparoscopic colectomy for left-sided colonic tumors: intermediate follow up of a randomized trial

Background: In 2009, we have described a novel technique of laparoscopic colectomy without abdominal incision [hybrid natural orifice transluminal endoscopic surgery (NOTES) colectomy] where laparoscopic dissection and intra-corporeal anastomosis were performed as usual but the specimen was delivered through the anus with the use of transanal endoscopic operation (TEO) device set-up without mini-laparotomy. We have completed a randomized trial comparing this technique with conventional laparoscopic colectomy (CL) for left sided colonic tumors, and early short term results had showed that in selected group of patients, they can enjoy the full benefit of minimally invasive surgery with significant lesser wound pain as well as a lower wound infection rate. This study is a follow up of previous trial, and aims to report immediate outcome between the two groups. Method: All 70 patients including 35 patients in the hybrid NOTES group and 35 patients in conventional colectomy group were continued to follow up in our outpatient clinic with regular surveillance. Patients were compared for clinicopathological variables, disease recurrence and survival rates. Results: Clinicopathological details were comparable between the two groups. Within median follow up of 37–45 months in the two groups, no statistically significant difference was observed in disease recurrence rate (conventional: 8.57%; hybrid: 5.71%; P value: 0.22) and 3-year disease free survival rates (conventional: 42%; hybrid: 62%; P value: 0.144). While the overall 3-year survival rate is statistically shorter in the conventional group (conventional: 54%; hybrid: 71%; P value Conclusions: It is safe for us to offer hybrid colectomy for selected patients with left sided colonic cancer, without adversely affect their oncological outcome and survival, while at the same time, benefit of minimally invasive surgery can be fully expressed.

Safety Outcomes of NOTES Cholecystectomy Versus Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis.

Objective:Natural orifice transluminal endoscopic surgery (NOTES) is an endoscopic technique whereby surgical interventions can be performed with a flexible endoscope passed through a natural orifice (mouth, vulva, urethra, anus) then through a transluminal opening of the stomach, vagina, bladder, or colon. Although in the early stage of research and development, NOTES has been clinically applied across the globe, above all the transvaginal cholecystectomy is among the most frequently performed procedures. In the existing 2 types of transvaginal routes, the hybrid NOTES cholecystectomy (NC) is more likely to be accepted. However, there has been controversy regarding the safety outcomes of hybrid NC in comparison with classical laparoscopic cholecystectomy (LC). The primary objective of this meta-analysis is to compare the characteristics between NC and classical LC.Materials and Methods:A meta-analysis of eligible studies comparing NC with classical LC was performed to evaluate the safety outcomes including wound complications, other postoperative complications and intraoperative conversion between the 2 groups.Results:Pooling 3 randomized controlled trials (n=157) and 7 nonrandomized trial (n=593) demonstrated that the rates of wound complications and other postoperative complications in NC group did not significantly differ from those of classical LC group [wound complications: ratio difference (RD)=−0.02, 95% confidence interval (CI) −0.04to 0.01, P=0.23; other postoperative complication: RD=−0.01; 95% CI, −0.03 to 0.02; P=0.6]. The intraoperative conversion rate in NC groups was higher than that of LC groups (RD=0.03; 95% CI, 0.01-0.06; P=0.02).Conclusions:There is no significate difference between the safety of NC and laparoscope cholecystectomy. NC is associated with a higher rate of intraoperative conversion when compared with LC. It is worthy of further promotion and validation in clinical settings.

RETRACTED: Graphic and haptic simulation for transvaginal cholecystectomy training in NOTES

Natural Orifice Transluminal Endoscopic Surgery (NOTES) provides an emerging surgical technique which usually needs a long learning curve for surgeons. Virtual reality (VR) medical simulators with vision and haptic feedback can usually offer an efficient and cost-effective alternative without risk to the traditional training approaches. Under this motivation, we developed the first virtual reality simulator for transvaginal cholecystectomy in NOTES (VTEST™). This VR-based surgical simulator aims to simulate the hybrid NOTES of cholecystectomy. We use a 6DOF haptic device and a tracking sensor to construct the core hardware component of simulator. For software, an innovative approach based on the inner-spheres is presented to deform the organs in real time. To handle the frequent collision between soft tissue and surgical instruments, an adaptive collision detection method based on GPU is designed and implemented. To give a realistic visual performance of gallbladder fat tissue removal by cautery hook, a multi-layer hexahedral model is presented to simulate the electric dissection of fat tissue. From the experimental results, trainees can operate in real time with high degree of stability and fidelity. A preliminary study was also performed to evaluate the realism and the usefulness of this hybrid NOTES simulator. This prototyped simulation system has been verified by surgeons through a pilot study. Some items of its visual performance and the utility were rated fairly high by the participants during testing. It exhibits the potential to improve the surgical skills of trainee and effectively shorten their learning curve.

Duodenal web resection via hybrid natural orifice transluminal endoscopic surgery (NOTES)

Congenital duodenal atresia, stenosis, and webs are a common cause of proximal obstruction in the newborn period. A variety of surgical techniques have been described for the treatment of duodenal webs. Open and laparoscopic duodenotomy with web resection have been well described; endoscopic resection has also shown to have promising success. We describe a case of a 2-year-old male with a duodenal web, which was resected via an existing gastrostomy site utilizing a modified hybrid natural orifice transluminal endoscopic surgery (NOTES). • Duodenal webs are a common cause of neonatal duodenal obstruction. • High index of suspicion is needed to diagnose duodenal webs after infancy. • Hybrid NOTES is a safe and effective approach for the excision of duodenal webs. • Approach can be performed without an endoscope.

Hybrid Transvaginal Nephrectomy: Development of Our Technique

To evaluate the development of natural orifice transluminal endoscopic surgery (NOTES) transvaginal nephrectomy and present the initial experience. Thirty-eight female patients were submitted to hybrid NOTES transvaginal nephrectomy for tumor (n=23) and nonfunctioning renal unit (n=15) in 2 academic medical centers. Patients underwent surgery from July 2010 to June 2012 and none of them were candidates for partial nephrectomy (clinical stage T1b or higher). The procedure was performed by the use of multi-instrument ports or flexible cannulas inserted through umbilical and vaginal incisions. A 30° lens extra-long camera and combinations of conventional laparoscopic and prebent instruments were used. Specially designed extra-long, prebent straight instruments were found to be particularly useful for transvaginal manipulations. Prospective data regarding patient demographics, intraoperative and postoperative course of the patients, and pathology results were collected. Average tumor diameter was 6 cm (range, 4.9-7.5 cm). Average operative time was 114.1 minutes (range, 90-190 minutes). Estimated blood loss ranged between 50 and 150 mL (average, 80 mL). Intraoperatively, 2 bladder perforations occurred and were treated by suturing. Postoperatively, 2 patients suffered from fever of unknown origin and 2 patients required transfusions due to bleeding. Average hospital stay was 3.3 days (range, 3-5 days). Positive surgical margins were not detected. Hybrid NOTES transvaginal nephrectomy is a feasible and safe alternative to standard laparoscopic nephrectomy in selected patients. Difficulties arising from limitations in current instrumentation have been addressed by the use of specially designed instruments. Further clinical studies are required to ascertain this approaches' place among nephrectomy techniques.

Biomarcadores inflamatórios e indicadores de estresse oxidativo em cadelas submetidas à ovariossalpingohisterectomia convencional, por NOTES híbrida e NOTES total

Objetivou-se comparar a resposta inflamatória e o perfil oxidativo da técnica de ovariossalpingohisterectomia (OSH) convencional com duas técnicas de Cirurgia Endoscópica por Orifícios Naturais (NOTES). Foram utilizados 15 fêmeas, alocadas em três grupos de cinco animais. No primeiro grupo, a OSH foi realizada por celiotomia convencional, no segundo, por NOTES total e, no terceiro, por NOTES híbrida. Foram realizadas as coletas sanguíneas antes do procedimento cirúrgico (basal), 3, 6, 12, 24, 48 e 72h pós-operatórias. A atividade da catalase manteve-se alta nos três grupos estudados, entretanto a peroxidação lipídica, medida pelos níveis dos produtos de reação com o ácido tiobarbitúrico (TBARS), ocorreu mais acentuadamente no grupo convencional e foi quase que imperceptível no grupo de NOTES total. Nos três grupos estudados, ocorreu elevação na atividade da butirilcolinesterase e acetilcolinesterases, bem como aumento leucocitário neutrofílico nas primeiras horas pós-cirúrgicas. Conclui-se que a inflamação sistêmica acontece de forma similar nas três técnicas operatórias, com ressalva para as realizadas por NOTES total que mantiveram as mais baixas taxas oxidativas.

Postoperative pain after transvaginal cholecystectomy: single-center, double-blind, randomized controlled trial

Natural orifice transluminal endoscopic surgery (NOTES) has the potential to reduce postoperative pain. We compared postoperative pain in the hybrid NOTES procedure transvaginal video-assisted cholecystectomy (TVC) with standard conventional laparoscopic cholecystectomy (CLC). Single-center, double-blind, randomized controlled trial in a level II hospital between June 2008 and June 2012. Female patients, older than 18 years of age with symptomatic cholecystolithiasis were randomized to receive either TVC or CLC. The follow-up period was 7 days and the primary outcome of the study was postoperative pain. We hypothesized that there is no reduction of pain (Visual Rating Scale ≥1) while resting or coughing over a 48-h period after the operation. Secondary outcome included wound infections, complications, and patient reported outcomes. Sealed envelopes with computer-generated randomization information were kept for allocation in theater. All patients received opaque wound dressing, as in standard four-trocar cholecystectomy and a vaginal tamponade. Theater protocol and surgical notes were kept separate after the procedure. Overall, 97 of 426 patients assessed for participation were randomized for either TVC or CLC. A total of 41 patients had a TVC and 51 had a CLC. Five patients were excluded from the analysis. There was no difference in age, body mass index, American Society of Anesthesiologists (ASA) grade, or hospital stay, but anesthetic and surgical times were significantly longer in TVC (p < 0.001). There was no statistical difference in postoperative pain between the two groups while resting or coughing. Complications included conversion to laparotomy, bleeding, wound infections, and re-admission. No difference in the rate of complications between the two groups was seen. Overall, 86 and 93% of CLC and TVC patients, respectively, would recommend the procedure to other patients. In this study, no significant difference in pain on days 1 and 2 postoperatively between the two methods was found. The safety profile of TVC is comparable to CLC, and TVC patients would generally recommend this procedure to other patients.