Rigid Scope Research Articles

Role of Flexible choledochoscopy in present era – for difficult billiary stones.

Introduction: Several studies have concluded that Laparoscopic Common bile duct exploration (LCBDE) procedures are superior to sequential endo-laparoscopic treatment in terms of both clinical and economical outcomes. Method: In all the cases of LCBDE Calot’s triangle was dissected and cystic duct & artery were clipped before Laparoscopic CBD exploration (Intra-operative Flexible choledochoscopy was done with help of a Olympus (6mm) Flexible Choledochoscope (CYF-5A) via Choledochotomy approach rather than transcystic appreoach). After removal of CBD stones with dormia basket, irrigation & ballon sweep, check completion choledochoscopy of both lower CBD & CHD was performed in all the cases. CBD was closed primarily in all the LCBDE cases over a stent in situ (Infant feeding tube No-7/8). Result: A total of 82 patients underwent LCBDE and 8 patients underwent open CBD exploration (criteria dilated CBDE >20mm with intrahepatic stones) between the periods of 2011 to 2018. Age of the patients ranged from 22 to 76 years. The mean age is about 42.30 years. Peroperatively 14(17.07%) cases had only choledocholithiasis (had previous history of cholecystectomy), 52(63.41%) cases had cholelithiasis with choledocholithiasis, 12(14.63%) cases had associated hepatolithiasis and 2(0.024%) cases had retained cystic duct stump stones with choledocholithiasis. Of eight open CBD exploration patients five and three patients underwent choledochoduodenostomy and Roux-en-Y hepaticojejunostomy respectively. In this series Mechanical lithotripsy with a rigid scope was used in 18 patients after failure to remove large stones by instrumental exploration and percentage of residual stone in this study was 0%. Two cases of LCBDE was converted to open procedure (due to presence of large impacted intrahepatic stones in one case and difficulty in defining Calot’s triangle in another case). Conclusion: Examination of the bile ducts under direct vision with a choledochoscope seems a certain method of ensuring that there are no residual stones.

Ideal and Reality: The Reform of Juvenile Sealed Criminal Records in China

Two-way protection is a special concept of juvenile justice. The connotation of this concept is to protect minors while taking the protection of social and public interests into account. Under this concept, the sealed criminal records system should balance the protection of minors and social defense effectively. However, the current system of juvenile sealed criminal records in China has some problems, such as improper disclosure of criminal information, rigid scope of sealed, hindering the employment of juveniles etc., which deviates from the concept of two-way protection principle. From the perspective of the principle of two-way protection, this paper explores the state-should-be of the system and analyzes the problems in judicial practice, and then perfects the current system from the aspects of concept correction and system docking, in order to make the system protect the interests of juvenile offenders to the greatest extent and take the protection of social interests into account.

How Much Loading Does Water Resistance Voice Therapy Impose on the Vocal Folds? An Experimental Human Study

Water resistance voice therapy applies phonation into water through a tube. This study investigates how strenuous this therapy can be for the vocal folds in terms of impact stress (IS). It further examines whether it is possible to estimate the IS using the contact quotient (CQ) and maximum derivative from an electroglottogram (EGG). Experimental study. A male participant sustained a rounded back vowel [u:] or [o:] at a comfortable speaking pitch and loudness, and phonated into a silicone "Lax Vox" tube submerged 2 cm in water. High-speed videolaryngoscopy was performed with a rigid scope. Oral air pressure (Poral) was registered in a mouthpiece through which an endoscope was inserted into the larynx. An EGG was recorded. The CQEGG from the EGG and the closed quotient from the glottal width (CQarea) increased, while the maximum glottal amplitude and absolute value of derivative minimum (dmin) and also the derivative maximum from the EGG decreased for phonation into water. Normalized amplitude quotient from the glottal width variation also decreased but the change was not significant. Based on the glottal area findings, water resistance therapy does not seem to increase vocal fold loading (in terms of increased IS) even if the increase of CQarea, and CQEGG suggest so. CQEGG may qualitatively correspond to that of area, but the reliability of CQ (from the glottal area or the EGG) and the maximum derivative from the EGG as estimates of IS in semiocclusion exercises warrant further studies.

Surprising cause of a hoarse voice

A 78-year-old woman presented to our otorhinolaryngology clinic with a 5-year history of gradually progressive, worsening dysphonia, associated with some recent weight loss. She denied any dysphagia, odynophagia, otalgia, dyspnoea...

AB002. Tracheal surgery

AB002. Tracheal surgery

Difficult airway intubation simulation using Bonfils fiberscope and rigid fiberscope for surgical training

IntroductionPediatric otolaryngologists are frequently called to assist in difficult airway management in newborns with Pierre Robin Sequence (PRS) who have microretrognathia, glossoptosis, and an anterior larynx. The Bonfils fiberscope (BF) is a curved rigid scope designed to provide superior visualization in the anterior larynx. Objective(1) to assess whether BF provides an improvement in intubation success rate, time to intubation, or airway visualization as compared to rigid fiberscope (RF) in a difficult airway simulation setting and (2) to determine whether a training program for BF can improve time to intubation through practice trials. MethodsSix right-handed trainees completed five trials on each of the three following airway models using the BF and RF: normal anatomy, anterior larynx and PRS. The normal larynx model was intubated only with RF. Main outcome measures were the time needed for tracheal intubation and Cormack–Lehane classification (1–4). ResultsThe majority of the intubation trials showed a statistically significant difference between first and last completion times (p < .05) suggesting construct validity. Only the anterior larynx trials with BF did not demonstrate an improvement in time to intubation between first and last attempts (p < .3125). For the PRS retrognathia model, there was no statistically significant difference in time to intubation between using the BF and the RF (p < .44); in the anterior larynx model, the RF yielded a faster time to intubation than the BF on the final trial attempts (p < .0313). By Cormack–Lehane classification measures, laryngeal visualization by the BF was better than RF in the PRS manikin (p < .0022) while there was no significant difference in grade scores for the anterior larynx manikin (p < .45). All six trainees reported an improved visualization of the larynx with the BF compared to the RF for both the anterior larynx and PRS manikins; at the end of the trial runs, all participants noted an improvement in comfort level using the BF. ConclusionThe difficult airway simulation model is feasible for surgical training. BF adds superior visualization of the anterior larynx in PRS. Otolaryngology training programs may include BF as a supplemental tool in addition to RF as a part of the airway equipment training since there is significant improvement in time to intubation with consecutive practice trials and superior laryngeal visualization.

P2.02-072 Reliability of Small Biopsy Samples for Tumor PD-L1 Expression in Non-Small-Cell Lung Cancer

Programmed death 1 immune checkpoint inhibitor antibody has been effective in patients with PD-L1 positive advanced NSCLC. However, surgically resected specimens or core-needle biopsy samples were used to estimate drug potency in past clinical trials. The aim of this study is to prospectively investigate small sample reliability for NSCLC to determine the PD-L1 expression status. We prospectively enrolled patients who underwent diagnostic biopsy by any procedures (under rigid bronchoscopy, flexible bronchoscopy, CT & US-guided core-needle, excisional method) from March 2017 to March 2018 (ongoing study). Pathologically confirmed non-small cell lung cancer (NSCLC), PD-L1 expression was evaluated in our institution using companion diagnostic PD-L1 immunohistochemistry：PD-L1 IHC 22C3 pharmDx (Daco) with autostainer Link 48, detecting a driver mutation in parallel. We evaluated: 1) the total number of tumor cells and sample size; 2) compared PD-L1 expression for each procedure using tumor proportion score: TPS (<1%, 1～49%, 50%≤), 3) the concordance rate of PD-L1 expression status by biopsy and surgical materials; and 4) the efficacy of administration for PD-1 immune checkpoint inhibitor antibody. During the first three months 44 cases of PD-L1 expression were evaluated. 33 cases were sampled by bronchoscopy (6 under rigid scope with BF 1T260, 17 TBBs using 1T260/P260F in 4/13 cases, 10 TBNAs), and 7 cases were CT-guided core-needle biopsy. The TPS (<1%, 1～49%, 50%≤) was 8/6/10 for TBB, 3/4/2 for TBNA, and 4/0/3 for CT-guided. Four cases harboring EGFR mutation showed a lower PD-L1 expression (<10%). Utilizing smaller samples to evaluate PD-L1 expression, and the frequency of TPS were comparable to past clinical trials using larger samples. Smaller samples might be an accurate alternative to assess PD-L1 expression. Current data will be updated at the conference.

Mini grasping basket forceps for endobronchial foreign body removal in pediatric patients.

Appropriate device selection is crucial for endobronchial foreign body removal using a bronchoscope. In pediatric patients, bronchoscopy requires the use of a thin device due to the narrow access to the airway, limiting the range of useful endobronchial devices. We herein review our experience in endobronchial foreign body removal with a focus on the type of bronchoscope and the instruments used in comparison with the literature, and investigate the utility of mini grasping basket forceps (FG-55D, Olympus® ; and Zero Tip™ , Airway Retrieval Basket, Boston Scientific). Between April 2008 and April 2016, foreign bodies were removed from the airway of 12 pediatric patients by bronchoscopy. These cases are reviewed in this study. The clinical presentation, location and characteristics of the foreign bodies, and the type of bronchoscope and instruments used were analyzed. A consecutive series of 12 pediatric patients was retrospectively reviewed, and the therapeutic characteristics investigated. Nuts were the most frequently observed foreign body. Seven of the 12 pediatric patients required an ultrathin bronchoscope (diameter, 2.8mm) for foreign body removal. Only one patient required a rigid scope in addition to flexible bronchoscopy. The most frequently used instrument was a mini grasping basket forceps (n=7; 58%), which was used with a 1.2mm instrument channel (n=4; 33%). The use of a mini grasping basket forceps in combination with an ultrathin flexible bronchoscope was useful for removing smooth, soft materials such as a nuts or beans in pediatric cases.

P.086 Endoscopic assisted ulnar nerve decompression: a technical note

Background: Cubital tunnel syndrome is the second most frequent upper extremity entrapment neuropathy. Various surgical approaches have been described in the literature for Ulnar nerve decompression, ranging from open In-situ decompression to endoscopic Ulnar nerve release. In this technical note we describe a new endoscopic approach for Ulnar nerve decompression. Methods: Four cadavers, a total of eight fresh arms were dissected using our new endoscopic technique. The technique involves a 2.5cm skin incision placed 2.5cm distal to the medial epicondyle, and perpendicular to the long nerve axis. Early identification of motor branches was achieved using this skin incision. Under endoscopic view using 30 degree rigid scope Ulnar nerves were decompressed Results: Early identification of motor branches was achieved using distally placed skin incision in all eight arms. Conclusions: The safety of identifying Ulnar nerve motor branches in the early steps of the procedure, and the avoidance of scar formation over the elbow joint are the proposed advantages of this approach. More clinical studies needed to validate this outcome.

Endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in non-small cell lung carcinoma

IntroductionLung cancer staging has recently evolved to include endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for nodal assessment. AimEvaluate the performance and safety of EBUS-TBNA as a key component of a staging algorithm for non-small cell lung carcinoma (NSCLC) and as a single investigation technique for diagnosis and staging of NSCLC. MethodsPatients undergoing EBUS-TBNA for NSCLC staging at our institution between April 1, 2010 and December 31, 2014 were consecutively included with prospective data collection. EBUS-TBNA was performed under general anesthesia through a rigid scope. ResultsA total of 122 patients, 84.4% males, mean age 64.2 years. Histological type: 78 (63.9%) adenocarcinoma, 33 (27.0%) squamous cell carcinoma, 11 (8.9%) undifferentiated/other NSCLC. A total of 435 lymph node stations were punctured. Median number of nodes per patient was 4. EBUS-TBNA nodal staging: 63 (51.6%) N0; 8 (6.5%) N1; 34 (27.9%) N2, and 17 (13.9%) N3. EBUS-TBNA was the primary diagnostic procedure in 27 (22.1%) patients. EBUS-TBNA NSCLC staging had a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate of 83.3, 100, 100, 86.1, and 91.8%, respectively. No complications were attributable to the procedure. ConclusionA comprehensive lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective. Our EBUS-TBNA performance and safety in this particular setting was in line with previously published reports. Additionally, our study showed that, in selected patients, lung cancer diagnosis and staging are achievable with a single endoscopic technique.

Three-dimensional measurement of small inner surface profiles using feature-based 3-D panoramic registration.

Rapid development in the performance of sophisticated optical components, digital image sensors, and computer abilities along with decreasing costs has enabled three-dimensional (3-D) optical measurement to replace more traditional methods in manufacturing and quality control. The advantages of 3-D optical measurement, such as noncontact, high accuracy, rapid operation, and the ability for automation, are extremely valuable for inline manufacturing. However, most of the current optical approaches are eligible for exterior instead of internal surfaces of machined parts. A 3-D optical measurement approach is proposed based on machine vision for the 3-D profile measurement of tiny complex internal surfaces, such as internally threaded holes. To capture the full topographic extent (peak to valley) of threads, a side-view commercial rigid scope is used to collect images at known camera positions and orientations. A 3-D point cloud is generated with multiview stereo vision using linear motion of the test piece, which is repeated by a rotation to form additional point clouds. Registration of these point clouds into a complete reconstruction uses a proposed automated feature-based 3-D registration algorithm. The resulting 3-D reconstruction is compared with x-ray computed tomography to validate the feasibility of our proposed method for future robotically driven industrial 3-D inspection.

The performance of rigid scopes for tracheal intubation: a randomised, controlled trial in patients with a simulated difficult airway.

We compared the Bonfils™ and SensaScope™ rigid fibreoptic scopes in 200 patients with a simulated difficult airway randomised to one of the two devices. A cervical collar inhibited neck movement and reduced mouth opening to a mean (SD) of 23 (3) mm. The primary outcome parameter was overall success of tracheal intubation; secondary outcomes included first-attempt success, intubation times, difficulty of intubation, fibreoptic view and side-effects. The mean (95% CI) overall success rate was 88 (80-94)% for the Bonfils and 89 (81-94)% for the SensaScope (p = 0.83). First-attempt intubation success rates were 63 (53-72)% for the Bonfils and 72 (62-81)% for the SensaScope (p = 0.17). Median (IQR [range]) intubation time was significantly shorter with the SensaScope (34 (20-84 [5-240]) s vs. 45 (25-134 [12-230]) s), and fibreoptic view was significantly better with the SensaScope (full view of the glottis in 79% with the SensaScope vs. 61% with the Bonfils). This might be explained by its steerable tip and the S-formed shape, contributing to better manoeuvrability. There were no differences in the difficulty of intubation or side-effects.

A multiport MR-compatible neuroendoscope: spanning the gap between rigid and flexible scopes.

OBJECTIVE Rigid endoscopes enable minimally invasive access to the ventricular system; however, the operative field is limited to the instrument tip, necessitating rotation of the entire instrument and causing consequent tissue compression while reaching around corners. Although flexible endoscopes offer tip steerability to address this limitation, they are more difficult to control and provide fewer and smaller working channels. A middle ground between these instruments-a rigid endoscope that possesses multiple instrument ports (for example, one at the tip and one on the side)-is proposed in this article, and a prototype device is evaluated in the context of a third ventricular colloid cyst resection combined with septostomy. METHODS A prototype neuroendoscope was designed and fabricated to include 2 optical ports, one located at the instrument tip and one located laterally. Each optical port includes its own complementary metal-oxide semiconductor (CMOS) chip camera, light-emitting diode (LED) illumination, and working channels. The tip port incorporates a clear silicone optical window that provides 2 additional features. First, for enhanced safety during tool insertion, instruments can be initially seen inside the window before they extend from the scope tip. Second, the compliant tip can be pressed against tissue to enable visualization even in a blood-filled field. These capabilities were tested in fresh porcine brains. The image quality of the multiport endoscope was evaluated using test targets positioned at clinically relevant distances from each imaging port, comparing it with those of clinical rigid and flexible neuroendoscopes. Human cadaver testing was used to demonstrate third ventricular colloid cyst phantom resection through the tip port and a septostomy performed through the lateral port. To extend its utility in the treatment of periventricular tumors using MR-guided laser therapy, the device was designed to be MR compatible. Its functionality and compatibility inside a 3-T clinical scanner were also tested in a brain from a freshly euthanized female pig. RESULTS Testing in porcine brains confirmed the multiport endoscope's ability to visualize tissue in a blood-filled field and to operate inside a 3-T MRI scanner. Cadaver testing confirmed the device's utility in operating through both of its ports and performing combined third ventricular colloid cyst resection and septostomy with an endoscope rotation of less than 5°. CONCLUSIONS The proposed design provides freedom in selecting both the number and orientation of imaging and instrument ports, which can be customized for each ventricular pathological entity. The lightweight, easily manipulated device can provide added steerability while reducing the potential for the serious brain distortion that happens with rigid endoscope navigation. This capability would be particularly valuable in treating hydrocephalus, both primary and secondary (due to tumors, cysts, and so forth). Magnetic resonance compatibility can aid in endoscope-assisted ventricular aqueductal plasty and stenting, the management of multiloculated complex hydrocephalus, and postinflammatory hydrocephalus in which scarring obscures the ventricular anatomy.

Open and endoscopic excision of calvarial dermoid and epidermoid cysts: a single center experience on 128 consecutive cases.

Dermoid and epidermoid cysts rank among the most common pediatric tumors. We analyzed the outcomes of surgical excision of dermal and epidermal inclusion cysts in a large consecutive series of children. We retrospectively reviewed 128 consecutive children who underwent calvarial inclusion cyst resection between 2000 and 2010 at NYU Langone Medical Center. Demographic information, neurological exam, lesion location, lesion diameter, type of treatment, extent of resection, time of follow-up, and recurrence were collected. The cohort includes 67 girls (52.3%) and 61 boys (47.7%). Age at diagnosis ranged from birth to 6.5years (mean of 1.2years) with surgical intervention between 1month and 20years of age (1.5±2.1). Of the 128 patients, 107 underwent open resection. Surgical approach was determined by the senior surgeon. Location, postoperative cosmesis, and family preference were the determining factors. Endoscopic resection was favored with supraorbital and glabellar lesions (75% endoscopic versus 25% open) using a rigid scope via a single incision. Erosion of the outer table and involvement of the inner table was noted in 20 patients (15%), 14 of which were reconstructed using a split thickness calvarial graft. These lesions were noted to be significantly larger than lesions where cranioplasty was not used (1.9±2.81cm versus 1.23±0.98cm, p=0.022). Gross total resection was achieved in all cases. Complete removal and cure from dermoid and epidermoid inclusion cysts are possible. Complications are few. Endoscopic approaches are useful to improve cosmesis and limit tissue damage for lesions near the orbits.

Modified Thoracoscopic Hepatectomy For Segment VIII

Although previous studies have reported the use of total thoracoscopic hepatectomy (TH) for malignant liver tumors, it is technically impossible to perform intraoperative ultrasonography (IUSO) to exclude intrahepatic metastasis for the whole liver via a thoracic approach. Therefore, total TH may be inappropriate for these patients. We here report the first case of modified TH for a malignant liver tumor in China.The patient was a 26-year-old man with a 10-year HBV infection. Preoperative CT showed a 1.2 cm × 0.9 cm mass located in segment VIII. His alpha-fetal protein level was 444 ng/mL. Child-Pugh was Grade (A, 6), whereas an ICG-15 test yielded 2.7%. HCC was diagnosed preoperatively. The indications for TH were difficult tumor location, HCC, and a young patient with good resilience.The modified TH included 2 steps: (1) the patient was placed in a supine position. IUSO was used to locate the tumor in segment VIII and determine that intrahepatic metastasis had not occurred. The hepatoduodenal ligament was hanged over using a Pringle maneuver; (2) patient was then placed in the left-lateral position with single-lung ventilation. Three trocars were placed into the right thoracic cavity. The intra-thoracic space was observed using a regular 10-mm rigid scope. The diaphragm was transected and retracted. IUSO was used again to confirm the tumor location. Under the Pringle maneuver (once every 10 min), the superficial portion of the liver was transected by ultrasonic shears, whereas the deeper tissue was transected by LigaSure. Bipolar was used for hemostasis. The specimen was put into a retrieval bag and removed from the abdominal trocar. The diaphragm was repaired by running suturing. The operation time was 260 minutes and estimated blood loss was 30 mL. The patient was discharged on postoperative day 5 with normal liver function. No complications arose.Total TH may be inappropriate for malignant liver tumors due to the limitation of IUSO for the whole liver. The 2-step modified TH is technically feasible and suitable for malignant liver tumors located in segments VII or VIII.Video abstract: http://links.lww.com/MD/B6.

The Utility of Thulium Laser in Neuroendoscopy

In the last years, neuroendoscopy has gained consensus as a minimally invasive surgical approach to ventricular lesions. The magnification of the endoscope has become wonderful, but the bleeding control and tumor ablation continue to be harmful by standard tools only through the working channel. Specially, in vascularized tumors and near vital structures the traditional electrosurgery can be ineffective and dangerous. Since 2009, we are using the Tu diode pumped solid state (DPSS) laser (Revolix, LISA laser products) to improve neuroendoscopic procedures. In the Tu DPSS laser the active material is thulium (Tu), emitting light at wavelength of 2,0 μ, through one microfiber large 0,2 mm in diameter introduced in the endoscope working channel. The Tu DPSS laser works very well in water solution, as in the CSF of the ventricles. This laser can hit the tumor by touching or targeting from short distance with low penetration. Tumor cutting and ablation is possible, too. We report our experience in 26 ventricular tumors, 16 in 3rd ventricle and 10 in the lateral ventricle. The histology was: 13 high grade glioma, 5 craniopharyngiomas, 2 PNET, 2 metastasis, 4 colloid cysts. A flexible or rigid scope was used. In 18 neuroendoscopic biopsies the Tu DPSS laser microfiber was used for hemostasis and partial ablation. In 5 craniopharyngiomas wall ablation was performed. In 4 colloid cysts complete removal was possible in one case 3rd ventricular nodule was totally removed by Tu laser ablation. The ETV or tumors cyst fenestration or septostomy through infiltrated septum was successfully performed. The Tu laser showed precise coagulation at low temperature without tissue sticking. In all surgical procedures bleeding control was easy and successful. During Tu laser activation endoscopic vision was always clear. No side effects due to this device were observed. We consider Tu DPSS laser extremely handle and safe. The Tu laser is very efficient for coagulation and ablation of vascularized tumors.

The Tools of the Trade — Uses of Flexible Bronchoscopy

Bronchoscopes have markedly improved the diagnosis as well as therapy in pediatric pulmonary disorders. Two types of bronchoscopes are available; flexible and rigid, with their own advantages and disadvantages. Depending on the clinical need and availability of skills, choice is made between the two. Typically, rigid scopes are largely used by the surgeons (pediatric or otolayngologists) while flexible bronchoscope stays in the domain of the pediatric pulmonologist and intensivists. Rigid scopes may be more versatile than flexible bronchoscopes in removing the foreign bodies from the airway. Flexible bronchoscopes on the other hand can even be introduced through an endotracheal tube. At times, use of both scopes may be required in a given patient for optimal results. Bronchoscopes give us a means to visualize the inside of the airway, which can be very informative for assessing various pathologies affecting the airways. Apart from the visualization of the parts of the airway tree and their structure as well as patency, it can also be used to take tissue biopsy specimens, collect secretions from the airways and bronchoalveolar lavage which can also get cellular elements from the distal alveoli. In the past few decades, more and more instruments are being used for expanding the utility of flexible bronchoscope for interventions ranging from bronchial toilet, foreign body removal, airway stenting and lasers or cryotherapy for airway lesions. The perinatologists have opened up more vistas and thrown newer challenges for using fiberoptic bronchoscopy (FB) for in utero tracheal occlusion in cases with diaphragmatic hernia. The vast applications of this tool makes it very relevant to pulmonary investigations and therapeutics.

Site of eustachian tube obstruction in chronic ear disease.

Assess the patency of the proximal and distal segments of the Eustachian tube in patients undergoing surgery for chronic ear disease. Case study with control group. All consecutive patients presenting for surgery for chronic ear disease in our practice over 14 months underwent preoperative Valsalva computed tomography (CT), and an attempt was made intraoperatively using angled rigid scopes to evaluate obstruction of the protympanic segment of the Eustachian tube. Endoscopic examination of the same segment in 19 cadaver ears served as a control group. Preoperative Valsalva CT showed patency of the distal one-third of the Eustachian tube in 51 of 53 ears. Intraoperative endoscopy allowed visualization of the protympanic opening of the Eustachian tube in 31 of 53 ears; 21 of 31 ears showed obstruction of the protympanic opening of the Eustachian tube. A clear obstruction was more likely to be present in the protympanic opening of the Eustachian tube in the patient population undergoing surgery for chronic ear disease than in the cadaver control group, and was equally likely to be present in the distal cartilaginous tube in patients as in the control population. 4.

Natural orifice translumenal endoscopic surgery (NOTES): emerging trends and specifications for a virtual simulator.

A virtual translumenal endoscopic surgical trainer (VTEST) is being developed to accelerate the development of natural orifice translumenal endoscopic surgery (NOTES) procedures and devices in a safe and risk-free environment. For a rapidly developing field such as NOTES, a needs analysis must be conducted regularly to discover emerging research trends and areas of potential high impact for a virtual simulator. This paper presents a survey-based study which follows a similar study conducted by this group in 2011 (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013). A 32-point questionnaire was distributed at the 2012 Natural Orifice Surgery Consortium for Assessment and Research annual meeting. These data were subsequently augmented by an identical online survey, targeted at the members of the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons, and analyzed. Twenty-eight NOTES experts participated in the 2012 study. Cholecystectomy (CE) procedure remained the most commonly performed NOTES technique, with 18 positive responses (64%). In contrast to 2011, the popularity of the NOTES appendectomy (AE) was significantly lower, with only 2 (7%) instances (CE vs. AE, p < 0.001), while the number of peroral endoscopic myotomy (POEM, PE) cases had increased significantly, with 11 (39%) positive responses, respectively (PE vs. AE, p = 0.013). Strong preference toward hybrid rather than pure NOTES techniques (82 vs. 11%, p < 0.001) was also expressed. Other responses were similar to those in the 2011 study, with the VTEST™ utility in developing and testing new techniques and instruments ranked particularly high. Based on the results of this study, a decision was made to focus exclusively on the transvaginal hybrid NOTES cholecystectomy procedure, including both rigid and flexible scope techniques. The importance of developing a virtual NOTES simulator was reaffirmed, with POEM identified as a promising candidate for future simulator development.

589 A multicenter evaluation of zero-fragment nephrolithotomy: Robotic pyelolithotomy and nephrolithotomy for treating large renal stones

CONCLUSIONS: The rate of upper calyx rigid scope approachability through the lower calyx is significant higher in supine PCNL compared to prone PCNL. The possible anatomical explanation for this finding is the thinner body wall and muscular layer, as well as the lower muscle/fat ratio along the supine position tract. In addition, the angle between the upper calyx axis and the lower calyx tract is significantly wider in the supine position compared to the prone position. These measurements and findings may help in preoperative planning of PCNL and in deciding optimal patient positioning.