Natural Orifice Transluminal Endoscopic Surgery Procedures Research Articles

Natural orifice transluminal endoscopic surgery for intra-abdominal emergency conditions

Patient benefits from natural orifice transluminal endoscopic surgery (NOTES) are of interest in acute-care surgery. This review provides an overview of the historical development of NOTES procedures, and addresses their current uses and limitations for intra-abdominal emergency conditions. A PubMed search was carried out for articles describing NOTES approaches for appendicectomy, percutaneous gastrostomy, hollow viscus perforation and pancreatic necrosectomy. Pertinent articles were reviewed and data on available outcomes synthesized. Emergency conditions in surgery tax the patient's cardiovascular and respiratory systems, and fluid and electrolyte balance. The operative intervention itself leads to an inflammatory response and blood loss, thus adding to the physiological stress. NOTES provides a minimally invasive alternative access to the peritoneal cavity, avoiding abdominal wall incisions. A clear advantage to the patient is evident with the implementation of an endoscopic approach to deal with inadvertently displaced percutaneous endoscopic gastrostomy tubes and perforated gastroduodenal ulcer. The NOTES approach appears less invasive for patients with infected pancreatic necrosis, in whom it allows surgical debridement and avoidance of open necrosectomy. Transvaginal appendicectomy is the second most frequently performed NOTES procedure after cholecystectomy. The NOTES concept has provided a change in perspective for intramural and transmural endoscopic approaches to iatrogenic perforations during endoscopy. NOTES approaches have been implemented in clinical practice over the past decade. Selected techniques offer reduced invasiveness for patients with intra-abdominal emergencies, and may improve outcomes. Steady future development and adoption of NOTES are likely to follow as technology improves and surgeons become comfortable with the approaches.

Transvaginal Hybrid NOTES Cholecystectomy: Current Techniques and Advantages

Laparoscopic cholecystectomy has proven to be a safe and effective procedure, with low rates of complications and mortality since its introduction in the late 1980s. However, surgeons have been working to develop alternatives to this technique to improve clinical outcomes and the level of patient satisfaction. Natural orifice transluminal endoscopic surgery (NOTES) is one such alternative. NOTES has potential benefits compared to conventional laparoscopic and open surgery, including reduced abdominal wall trauma and trocar site complications, lower infection rates, less postoperative pain, decreased hospital stays, and excellent cosmetic results. Transvaginal hybrid NOTES cholecystectomy is the most common NOTES procedure performed. The objective of this article is to review this surgical technique and its clinical outcomes based on the current scientific evidence available in the literature.

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra‐abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra-abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES-related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES-related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.

Mo1675 Learning Curve of Direct PerOral Cholangioscopy Using Ultra Slim Gastroscopes

Mo1675 Learning Curve of Direct PerOral Cholangioscopy Using Ultra Slim Gastroscopes Jochen Weigt*, Arne Kandulski, Peter Malfertheiner Gastroenterology, Hepatology and Infectious Diseases, University Magdeburg, Magdeburg, Germany Direct peroral cholangioscopy (POCS) is an emerging technique complementing ERCP. Unless several data show the feasibility and clinical relevance of POCS, only few data about the learning process of this technique are available. Aim: To investigate the technical success rate and learning process of POCS in a tertiary center. Methods: All patients were investigated with standard ERCP and biliary sphincterotomy directly prior to cholangioscopy. After removal of the duodenoscope, an ultra slim gastroscope was directly advanced to the duodenum. The common bile duct was intubated using the balloon anchor technique. All POCS procedures were performed with water irrigation. Histology was taken from suspicious lesions. The investigation times and the success rates were calculated. Special caution was given to the time from oral intubation until visualization of the bile ducts, that served as a key technical parameter. Results: A total of 28 POCS were performed. Intubation was successful in 24/28 (86%). Reasons for failed intubation were small caliber bile ducts, duodenal diverticulum and papillary adenoma. The mean intubation time was 9.5 min (3-23 min). The average intubation time did not change significantly over time (R*2 -0.05). The variance of intubation times changed over time and was 35,7 min in the first half of investigations and 13,5 min in the second half. Complications did not occur. Conclusions: The technique of direct peroral cholangioscopy using the balloon anchor technique in combination with ultra-slim gastroscopes is technically demanding but learning does not show a long learning period at last in a tertiary center. However the technical measures present signs of adaptation and learning of the technique.Nevertheless, as POCS is not yet a standard technique, we suggest that POCS may only be performed by experienced endoscopists. Mo1676 Evaluated Experimental Model of Gallstone Cholecystitis Available for Miniinvasive Surgical Procedures Ondrej Ryska*, Zuzana Serclova, Jan Martinek, Radek Dolezel, Stefan Juhas, Jana Juhasova, Bohus Bunganic, Miroslav Ryska Department of Surgery and 2nd Medical Faculty, Central Military Hospital, Prague 6, Czech Republic; Hepatogastroenterology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Internal Medicine, Central Military Hospital, Prague, Czech Republic; Institute of Animal Physiology and Genetics, Academy of Sciences, Libechov, Czech Republic Background: Natural orifice transluminal endoscopic surgery (NOTES), single port laparoscopy (SILS) and other miniinvasive surgical techniques are recently under the experimental investigation. Cholecystectomy as a most frequent laparoscopic procedure is usually the subject of evaluation where the clear benefits of new approaches should be proved. Experimental studies using healthy animals with physiological finding on gallbladder are lacking for the clinical relevance. The aim of the experimental study was to create and evaluate surgical model of gallstone cholecystitis in large animal. Material And Method: Model creation: 14 pigs weighing 40.3 10.0 kg were included. Laparoscopy (3 ports) was performed under general anesthesia. Bile from the gallbladder was aspirated and cholecystotomy was done. Three to five gallstones obtained by human cholecystectomy were inserted and incision was closed. Evaluation: 11 pigs with artificial cholelithiasis the laparoscopic cholecystectomy (3-port access) was performed. This group was compared to 10 cholecystemies in pigs without lithiasis. All pigs were euthanized 30th postoperative day (POD) and the autopsy performed. The protocol was approved by committee for the protection of the animals. Results: All animals survived without severe complications. Model procedure took 42 (35-150) minutes. White blood cells (WBC) count increased 1.POD and 2.POD markedly; 18.7 (10.4-23.7)x109/l and 16.7 (8.3-27.8)x109/l); and remained slightly higher till 7.POD 15.4 (9.2-22.8)x109/l. CRP levels were higher on 1st, 2nd and 3rd POD 12.4 (6.9-21.4, 13.3 (1.4-35.7) and 13.0 (8.117.8)mg/l) and decreased to normal levels till 7.POD. Levels of interleukin 6 were the highest 2 hours after surgery 472.7 (50.9-1286) and decreased the 1.POD 80.8 (36.4-153) and the 2.POD 35.6 (8.257.2) pg/ml. The ultrasound signs of chronic gallstone cholecystitis were observed 4 weeks after intervention, which was also confirmed by histology. Laparoscopic cholecystectomy in gallstone model took longer time compare to healthy animals: 63 (42-91) minutes vs. 46 (31-62) minutes (p 0,0182). The perioperative gallbladder perforation was significantly less more frequent in healthy pigs 1/10 vs. 8/11 (RR: 7,27; CI95%: 1,09-48,3; p 0,04) as well as postoperative complications rate nonsignificantly lower 0/10 vs. 2/11 (2 abscesses in gallbladder bed) at autopsy (RR: 4,58; Cl95%: 0,25-85,3; p 0,307). Conclusion: Simple surgical model of gallstone cholecystitis was created as a reliable tool for accurate evaluation of NOTES and other miniinvasive procedures. Sonographic and histological signs of inflammation with no elevation of inflammatory markers were observed 4 weeks after intervention. The laparoscopic cholecystectomy was technically more difficult in cholecystitis model than in healthy animals. Supported by a grant from IGA NT12250-4

Euro-NOTES Status Paper: from the concept to clinical practice

The concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures. After the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed. The statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections. NOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.

The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report

The EURO-NOTES Clinical Registry (ECR) was established as a European database to allow the monitoring and safe introduction of Natural Orifice Transluminal Endoscopic Surgery (NOTES). The aim of this study was to analyze different techniques applied and relative results during the first 2 years of the ECR. The ECR was designed as a voluntary database with online access. All members of the European Society for Gastrointestinal Endoscopy and the European Association for Endoscopic Surgery were requested to participate in the registry. Demographic and therapy data as well as data on the postoperative course are recorded in the ECR in an anonymous way. A total of 533 patients who underwent NOTES procedures were included in the study. Four different hybrid techniques for 435 cholecystectomies were described, registering postoperative complications in 2.8% of patients, addition of a single trocar in 5.3%, and conversions to laparoscopy in 0.5%. Both flexible endoscopic and rigid laparoscopic cholecystectomy techniques proved to be safe and effective with minor differences. There was a shorter operative time in the rigid laparoscopic group. Thirty-three appendectomies were reported by transgastric and transvaginal techniques, with transvaginal techniques scoring shorter operative time and hospital stay, but with a frequent need to add more trocars. Overall complications occurred in 14.7% of patients but they did not differ significantly among the different techniques. One transvaginal and 31 transanal sigmoidectomies were included for prolapse and diverticulitis, with four postoperative complications (12.5%), but none needing further treatment. Twenty peroral esophageal myotomies were included with three postoperative complications (15.0%), but none needing further treatment. Five years since the introduction of NOTES into clinical practice, hybrid techniques have gained considerable clinical application. Several NOTES hybrid cholecystectomy and appendectomy techniques are practicable and safe alternatives to laparoscopic procedures. Also, sigmoidectomies and peroral esophageal myotomies were described, proving feasibility and safety. Nevertheless, the real benefit of NOTES for patients still needs to be assessed.

Broad clinical utilization of NOTES: is it safe?

Natural orifice transluminal endoscopic surgery (NOTES) has been the focus of several studies as a less invasive alternative to conventional laparoscopy to access and treat intracavitary organs. For the last 5 years, much has been accomplished with animal studies, yet the clinical utilization of this novel technique is still modest. After 2 years of experience in the laboratory, we started our clinical experience. We report our experience with clinical utilization of NOTES procedures from 2007 to 2010. Under UCSD institutional review board-approved trials, 104 patients were enrolled under seven different NOTES protocols from 2007 to 2010, where a NOTES procedure was offered as an alternative to conventional treatments. The treated pathologies were cholelithiasis, biliary dyskinesia, acute and chronic appendicitis, ventral hernias, morbid obesity, and achalasia. The access routes included transgastric (TG), transvaginal (TV), transesophageal (TE), and perirectal (PR). Among the 104 patients enrolled, 103 underwent a surgical procedure starting with diagnostic laparoscopy, and 94 cases were deemed appropriate to proceed via a NOTES approach. There were 9 aborted NOTES procedures at the time of the initial peritoneoscopy before creating a NOTES access route. The reasons to not proceed with a NOTES procedure in the TV cholecystectomy group (n = 5) were a large amount of pelvic adhesions in 4 patients and a severe inflammation of the gallbladder in 1 patient. In the TG cholecystectomy group (n = 1), it was severe inflammation of the gallbladder. In the TG appendectomy group (n = 1), it was the presence of localized peritonitis. In the TE endoscopic myotomy group (n = 2), it was the presence of megaesophagus with an inability to clean the esophagus of food debris. The NOTES procedures performed were 48 TV cholecystectomies, 4 TV appendectomies, 8 TG cholecystectomies, 2 PR peritoneoscopies, 3 TG appendectomies, 3 TV ventral hernia repairs, 5 TE endoscopic myotomies, 3 TV sleeve gastrectomies, and 18 TG sleeve gastrectomies. The average body mass indexes for those in the sleeve gastrectomy group was 42.1 kg/m(2) (TG route) and 40.6 kg/m(2) (TV route). There were no intraoperative complication and no conversions to standard laparoscopy during these procedures. The average hospital stay was 1-2 days. One patient who underwent TV cholecystectomy required an emergency department visit for nausea and vomiting. To date, 3 patients who underwent TV cholecystectomy have become pregnant and delivered normally. NOTES is safe, feasible, and reproducible with previous training in the laboratory and a consistent team at a high-volume center. Prospective randomized studies of a large patient population are necessary to assess long-term results.

Is the transvaginal route appropriate for intra-abdominal NOTES procedures? Experience and follow-up of 222 cases

Since 2007, natural orifice transluminal endoscopic surgery (NOTES) has been applied in humans. We performed this prospective study to evaluate the transvaginal route in terms of risks, complication rate, and long-term side effects such as dyspareunia. From June 2007 to September 2011, we performed 222 transvaginal hybrid NOTES procedures: 220 transvaginal cholecystectomies (TVC) and 2 transvaginal appendectomies (TVA). All patients were asked to present to our associated gynecologists within 1 week for an examination. After at least 3 months, the patients were interviewed using a standard questionnaire. All operations could be successfully performed in this technique except two cases, which were converted to conventional laparoscopic cholecystectomy. The only intraoperative complication was the puncture of the urine bladder. We observed two postoperative complications: one biliary fistula 3 days after TVC, and one abscess in the Douglas pouch 3 weeks after TVC. The gynecological examinations revealed no abnormalities. The interview (median postoperative time, 6 months) with a follow-up rate of 93 % revealed no pain in the pelvis, dyspareunia, or sexual dysfunction after TVC. The transvaginal route is appropriate for NOTES procedures; there is only a minor and acceptable rate of intra- and postoperative morbidity.

Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese

The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients. One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m(2). These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19-62 years) and average BMI of 38.9 kg/m(2) (range 35.2-44.9 kg/m(2)). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments. The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered. NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.

An Intestinal Occlusion Device for Prevention of Small Bowel Distention During Transgastric Natural Orifice Transluminal Endoscopic Surgery

Bowel distention from luminal gas insufflation reduces the peritoneal operative domain during natural orifice transluminal endoscopic surgery (NOTES) procedures, increases the risk for iatrogenic injury, and leads to postoperative patient discomfort. A prototype duodenal occlusion device was placed in the duodenum before NOTES in 28 female pigs. The occlusion balloon was inflated and left in place during the procedure, and small bowel distension was subjectively graded. One animal had no balloon occlusion, and 4 animals had a noncompliant balloon placed. The balloon maintained its position and duodenal occlusion in 22 animals (79%) in which the bowel distention was rated as none (15), minor (4), moderate (3), or severe (0). The intestinal occlusion catheter failed in 6 animals (21%) because of balloon leak (5) or back-migration into the stomach (1), with distention rated as severe in 5 of these 6 cases. The intestinal occlusion catheter that maintains duodenal occlusion significantly improves the intraabdominal working domain with enhanced visualization of the viscera during the NOTES procedure while requiring minimal time and expense.

Natural orifice transluminal endoscopic surgery (NOTES): where are we going? A bibliometric assessment

The aim of this study was to analyse natural orifice transluminal endoscopic surgery (NOTES)-related publications over the last 5 years. A systematic literature search was done to retrieve publications related to NOTES from 2006 to 2011. The following variables were recorded: year of publication; article type; study design; setting; Journal Citation Reports® journal category; authors area of surgical speciality; geographic area of origin; surgical procedure; NOTES technique; NOTES access route; number of clinical cases. A time-trend analysis was performed by comparing early (2006-2008) and late (2009-2011) study periods. Overall, 644 publications were included in the analysis and most papers were found in general surgery journals (50.9%). Studies were most frequently clinical series (43.9%) and animal experimental (48%), with the articles focusing primarily on cholecystectomy, access creation and closure, and peritoneoscopy. Pure NOTES techniques were performed in most of the published reports (85%) with the remaining cases being hybrid NOTES (7.4%) and NOTES-assisted procedures (6.1%). The access routes included transgastric (52.5%), transcolonic (12.3%), transvesical (12.5%), transvaginal (10.5%), and combined (12.3%). From the early to the late period, there was a significant increase in the number of randomised controlled trials (5.6% vs 7.2%) or non-randomised but comparative studies (5.6% vs 22.9%) (P < 0.001) and there was also a significant increase in the number of colorectal procedures and nephrectomies (P = 0.002). Pure NOTES remained the most studied approach over the years but with increased investigation in the field of NOTES-assisted techniques (P = 0.001). There was also a significant increase in the adoption of transvesical access (7% vs 15.6%) (P = 0.007). NOTES is in a developmental stage and much work is still needed to refine techniques, verify safety and document efficacy. Since the first description of the concept of NOTES, >2000 clinical cases, irrespective of specialty, have been reported. NOTES remains a field of intense clinical and experimental research in various surgical specialities.

Transanal hybrid colon resection: from laparoscopy to NOTES

Reducing access size and trauma are important issues in natural orifice transluminal endoscopic surgery (NOTES). The combination of experience with laparoscopic colorectal surgery and transanal endoscopic microsurgery has helped in the use of the transanal approach as a realistic option of NOTES techniques to introduce transanal hybrid laparoscopic-assisted colon resection into clinical practice. The purpose of this study was to assess the clinical introduction of transanal hybrid colon resection in terms of feasibility and patient safety. Patients with pelvic floor disorders, prolapse, and slow-transit constipation in whom a colon resection was indicated were recruited. Patients were followed prospectively with a postoperative well-being score, a pain score, and a quality-of-life score. All complications were prospectively documented. The essential change was the reduction of the number and size of ports by using the transanal route. A camera and two 5-mm ports for grasping forceps and delivering ultrasonic energy were the laparoscopic components. All tasks requiring a port diameter of >5 mm were applied via the transanal route, such as positioning of the proximal stapler anvil, application of linear stapling for resection, specimen retrieval, stapler anastomosis, and closing the bowel. Fifteen patients with benign colorectal disease underwent transanal hybrid colon resection, and 11 had additional rectopexy. All patients were women with a mean age of 61 (range, 28-86) years and a body mass index of 26 kg/m(2). One patient was converted to full laparoscopy. One complication--bleeding that required no reintervention--was recorded. The procedure lasted a mean of 131 (range, 55-184) min. The Gastrointestinal Quality of Life Index was 96 before surgery and 117 after surgery. From this initial experience, transanal hybrid colon resection seems a feasible and safe hybrid NOTES procedure that can be usefully introduced into clinical practice.

Assessment of Omentoplasty for Gastrotomy Closure after Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Purpose: Reliable and effective closure of gastrotomy during natural orifice transluminal endoscopic surgery (NOTES) procedures is extremely important, and novel methods to improve it are still under way. This study aims to evaluate the feasibility of omentoplasty in the closure of gastric defects in NOTES, and assess the efficacy of this procedure by testing for leakage and peritoneal bacterial load in a porcine model. Methods: Four farm pigs (Sus scrofa domesticus) were selected to undergo peritoneoscopy via a transgastric NOTES procedure. Omentoplasty was used for gastrotomy closure in all procedures. Pigs were subsequently euthanized and the gastrotomy site was examined for leakage using a practical novel leakage test. This technique was based on measuring the maximal intra-gastric pressure of a healthy water-filled porcine stomach and then filling the explanted stomachs with water to achieve this pressure. Positive leakage test was defined as the first sign of leakage before achieving the maximal pressure. Peritoneal samples were also taken for cultures. Results: All gastrotomy sites were adequately sealed at necropsy. No evidence of spontaneous leakage was noted. No leaks were observed even after applying manual pressure on the gastric wall. Leakage testing using our method was negative in all four explanted stomachs. On culture, the mean colony forming units (CFU) for the four pigs was 0.8 ±0.9 CFU/ml and the organism grown was coagulase-negative staphylococcus, probably the result of a cross-contamination from skin flora. Conclusion: Omentoplasty proved to be a feasible, effective and promising technique to seal transgastric access in NOTES procedures. It is associated with a negligible risk of leakage and peritoneal bacterial contamination. Larger future studies need to be conducted to confirm our findings.

Evaluation of sexual function in sexually active women 1 year after transvaginal NOTES: a prospective cohort study of 106 patients

The primary objective of this prospective cohort study was to investigate sexual function, quality of life and patient satisfaction in sexually active women 1 year after transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES). This prospective single-centre cohort study included sexually active female patients after transvaginal hybrid NOTES cholecystectomy or anterior resection. Sexual life impairment and quality of life were assessed by the Gastrointestinal Quality of Life Index (GIQLI) prior and 1 year after surgery. Patient satisfaction was assessed as well as the sexual function 1 year postoperatively using the validated German version of the Female Sexual Function Index (FSFI-D). Between September 2008 and December 2009, 106 sexually active women after transvaginal hybrid NOTES cholecystectomy or anterior resection were identified. Sexual life significantly improved (GIQLI scores 3.2 ± 1.0 preoperatively vs. 3.7 ± 0.7 1 year postoperatively, P < 0.001), and painful sexual intercourse (3.3 ± 1.0 vs. 3.6 ± 0.7, P = 0.008) decreased post-surgery. The mean FSFI-D total score after transvaginal NOTES was 28.1 ± 4.6, exceeding the cutoff for sexual dysfunction defined as 26. Four (4.5 %) out of 88 patients who answered this question were not satisfied with the transvaginal hybrid NOTES procedure. This prospective cohort study of female sexual function after transvaginal NOTES provides compelling evidence that the transvaginal access is safe and associated with high satisfaction rate.

Specialized Instrumentation Facilitates Stable Peritoneal Access, Gastric Decompression, and Visualization During Transgastric Endoscopic Peritoneoscopy

The lack of high-fidelity instrumentation has impeded the development and implementation of natural orifice transluminal endoscopic surgery (NOTES). A steerable flexible trocar (SFT), a rotary access needle (RAN), and an articulating needle knife were developed as components of a flexible instrument set to facilitate transgastric peritoneal access and transluminal abdominal procedures. This cohort study aimed to assess the safety, feasibility, and efficacy of these devices during transgastric peritoneoscopy. Ten morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Following laparoscopic access, transgastric peritoneal access was established using the SFT and RAN, and transgastric peritoneoscopy performed. NOTES adhesiolysis was performed in 2 patients with significant intra-abdominal adhesions due to prior surgery. Outcome measures included time to enter the peritoneal cavity, ability to visualize each quadrant of the abdomen, ability to perform adhesiolysis, and complications. Ten patients with a median body mass index as stated in table 1 of 47.5 kg/m(2) were enrolled. Successful transgastric access was achieved in 8 of the 10 patients. One procedure was aborted because of difficulty creating the gastrotomy. Another procedure was aborted because of the difficult passage of the device through the oropharynx. An upper esophageal laceration occurred in one patient. Transgastric peritoneal access required 17.4 ± 5.5 minutes, and peritoneoscopy averaged 24.7 ± 7.6 minutes. The 4 abdominal quadrants were visualized and were accessible with the endoscope in all patients. The SFT and RAN facilitate transgastric peritoneal access and visualization of difficult-to-reach areas of the peritoneum. These devices provide advanced instrumentation for transgastric NOTES procedures; however, care must be taken during the transoral insertion to avoid complications.

On-demand endoscopic CO2 insufflation with feedback pressure regulation during natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy induces minimal hemodynamic and respiratory changes

Endoscopic insufflation has been associated with marked increase in intra-abdominal pressure (IAP) and hemodynamic and respiratory changes during transgastric surgery. To investigate the hemodynamic and respiratory effects during intraperitoneal cavity exploration through 3 different natural orifice transluminal endoscopic surgery (NOTES) access locations compared with laparoscopy. Survival experiments using 40 female pigs randomized to transgastric, transcolonic, transvaginal, and laparoscopic peritoneoscopy. On-demand endoscopic insufflation of CO(2) with feedback pressure regulation was used in NOTES with a maximum pressure of 14 mm Hg. In the laparoscopy group, the IAP was maintained at 14 mm Hg. NOTES procedures were performed by an endoscopist (with the assistance of a gynecologist in the transvaginal group and a second endoscopist in the transgastric and transrectal groups) and laparoscopy by 2 surgeons. Invasive hemodynamic and respiratory data. Blood samples were drawn for gas analyses. All experiments except one in the transrectal group were completed. The IAP was significantly lower in all NOTES groups compared with the laparoscopy group. A significant increase in mean systemic arterial blood pressure was observed in the laparoscopy group at 15 and 30 minutes of intraperitoneal cavity exploration, but it remained unchanged during all NOTES procedures. An increase in airway pressures was observed at 15 and 30 minutes of peritoneoscopy in the animals undergoing laparoscopy, whereas those parameters remained unchanged in the NOTES groups. The laparoscopy group showed a significant impairment in pulmonary gas exchange (decrease in Pao(2), increase in Paco(2), and decrease in arterial pH) after 30 minutes of peritoneoscopy, whereas only a slight increase in Paco(2) was observed in the transrectal and transvaginal groups. Healthy animal model. On-demand endoscopic insufflation of CO(2) with feedback pressure regulation can minimize the risk of hemodynamic and respiratory compromise caused by acute changes in IAP.

Analysis of the Anatomical Characteristics of the Pelvis in Koreans to Aid in Development of a NOTES Platform

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique affording full-thickness resection of rectal tumors and can also be used as a platform for transrectal access to the peritoneal cavity for NOTES (natural orifice transluminal endoscopic surgery) procedures. The authors investigated the anatomical characteristics of the pelvis in Koreans to develop an ergonomically designed NOTES platform. A total of 256 patients (156 men and 100 women) who underwent pelvic magnetic resonance imaging for evaluating rectal neoplasms were enrolled for analysis. The authors retrospectively reviewed and calculated anatomical lengths and angles on pelvic magnetic resonance images and analyzed differences in pelvic anatomy in terms of patient gender, age, and body mass index. Various angulations were noted from the anal canal to the sacral promontory, attributable to the shape of the sacral bone. Minimal difference in pelvic anatomy was evident between men and women. In conclusions, the authors expect that their data will be useful in the development of ergonomic TEM-NOTES platforms.

Su1264 Transgastric Peritoneoscopy Using a Forwarding-Viewing EUS: The Evaluation of Diagnostic and Therapeutic Potential for Notes

Su1264 Transgastric Peritoneoscopy Using a Forwarding-Viewing EUS: The Evaluation of Diagnostic and Therapeutic Potential for Notes

Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model. Cholecystectomies were attempted in five 88-130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route. Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present. NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.

A randomized trial comparing rates of abdominal contamination and postoperative infection among natural orifice transluminal endoscopic surgery, laparoscopic surgery, and open surgery in pigs

Bacterial contamination of the abdominal cavity and infectious complications have been debated concerning transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures. The aim of this study was to compare bacterial contamination of the abdominal cavity and clinically relevant infections after open, laparoscopic, and transgastric NOTES procedures. Randomized survival study in a porcine model. Animal laboratory at a university hospital. Thirty pigs were randomized to open, laparoscopic, or transgastric NOTES uterine horn resection under sterile conditions. Bacterial cultures were obtained from the pelvic area immediately at entry of the abdominal cavity and just before closure. The left uterine horn was dissected and ligated. The animals survived for 4 weeks. At necropsy, bacterial culture was obtained from the pelvic area. Perioperative: operation time and incision length, bacterial growth in abdominal samples. Postoperative: infections or complications, weight gain. Necropsy: signs of peritonitis or infection, abdominal bacterial growth. Procedure time was significantly longer for transgastric NOTES. At the start of the procedure, 4 of the NOTES animals showed positive cultures, but only 1 showed positive cultures at the end. No open surgery or laparoscopic surgery animals showed positive cultures at these time points. At necropsy, none of the animals in the NOTES group showed bacterial growth, whereas 4 open surgery animals and 3 laparoscopic surgery animals had positive cultures. Four of these animals (2 from each group) had concurrent wound infections. Small sample size and lack of power calculation. This study indicates that clinically relevant infections are rare after transgastric NOTES procedures despite evidence of bacterial contamination and longer operating times.