Standard Endoscopic Instruments Research Articles

Upper gastrointestinal endoscopy in the surgically altered patient.

As management of upper gastrointestinal malignancies improves, and with popularization of bariatric surgery, endoscopists are likely to meet patients with altered upper gastrointestinal anatomy. Short-term, the surgery can cause complications like bleeding, leaks, and fistulas, and longer-term problems such as intestinal or biliary anastomotic strictures or biliary stones can arise, all necessitating endoscopy. In addition, the usual upper gastrointestinal pathologies can also still occur. These patients pose unique challenges. To proceed, understanding the new layout of the upper gastrointestinal tract is essential. The endoscopist, armed with a clear plan for navigation, can readily diagnose and manage most commonly occurring conditions, such as marginal ulcers and proximal anastomotic strictures with standard endoscopic instruments. With complex reconstructions involving long segments of small bowel, such as Roux-en-Y gastric bypass, utilization of balloon-assisted enteroscopy may be necessary, mandating modification of procedures such as endoscopic retrograde cholangiopancreatography. Successful endoscopic management of patients with altered anatomy will require prior planning and preparation to ensure the appropriate equipment, setting, and skill set is provided.

Endoscopy-assisted purely total outer wall excision for pediatric Sylvian arachnoid cysts

BackgroundTo present a novel endoscopy-assisted surgical strategy of Sylvian arachnoid cysts (ACs).Case presentationEndoscopy-assisted surgery was performed on 9 children (May 2019–December 2021). All patients were evaluated with CT and/or MRI and had regular follow-up examinations. The procedure consisted of performing a small temporal craniotomy (2 cm) behind the hairline. After dural opening, the surgery was performed with the assistance of a rigid 30-degree transcranial endoscope, self-irrigating bipolar forceps, and other standard endoscopic instruments. Steps included total excision of the AC outer wall and dissection of arachnoid adhesion around the cystic edge to communicate the residual cyst cavity with subdural space. Compared with the microscopical procedure, a 30-degree transcranial endoscope provides a wider view, especially for the lateral part exposure of the outer wall.The average age of the patients was 27.7 months (range 13–44 months). The Sylvian AC was in the right hemisphere in three patients and six in the left, respectively. 1 patient suffered transient postoperative epilepsy. There was no mortality or additional postoperative neurological deficit in this series. All of the patients achieved significant clinical improvement after surgery. Radiological examination after the operation showed a significant reduction in all cases (100%, 9/9) and disappearance in one case (11.1%, 1/9). Postoperative subdural fluid collection occurred in six cases and completely resolved spontaneously in 9 months.ConclusionThe study demonstrated the minimally invasive, safety, and effectivity of the endoscopy-assisted purely total outer wall excision.

A Contemporary Clinico-Anatomical Guide to Craniovertebral Junction Surgery.

Background Surgical treatment of ventral and ventrolateral lesions of the craniocervical junction are among the most challenging neurosurgical pathologies to treat. Three surgical techniques, the far lateral approach (and its variations), the anterolateral approach, and the endoscopic far medial approach can be used to approach and resect lesions in this area. Objective The aim of the study is to examine the surgical anatomy of three skull base approaches to the craniocervical junction and review surgical cases to better understand the indications and possible complications for each of these approaches. Methods Cadaveric dissections with standard microsurgical and endoscopic instruments were performed for each of the three surgical approaches, and key steps and surgically relevant anatomy were documented. Six patients with appropriate pre-, post-, and intraoperative imaging and video documentation are presented and discussed accordingly. Results Based on our institutional experience, all three approaches can be utilized to safely and effectively approach a wide variety of neoplastic and vascular pathology. Unique anatomical characteristics, lesion morphology and size, and tumor biology should all be considered when determining the optimal approach. Conclusion Preoperative assessment of surgical corridors with 3D illustrations helps to define the best surgical corridor. 360 degree knowledge of the anatomy of craniovertebral junction allows safe surgical approach and treatment of ventral and ventrolateral located lesions using one of the three approaches.

Snare-assisted flexible endoscope in trans-gastric endoscopic gallbladder-preserving surgery: A pilot animal study.

BACKGROUNDNatural orifice transluminal endoscopic surgery (NOTES) gallbladder-preserving surgery by flexible endoscopy is an emerging technology. However, the gallbladder fails to obtain traction and positioning functions during the operation.AIMTo evaluate the feasibility and safety of a new surgical method, “snare-assisted pure NOTES gallbladder-preserving surgery”.METHODSEight miniature pigs were randomly divided into the experimental group [NOTES gallbladder-preserving surgery using the snare device, snare assisted (SA)] and the control group (NOTES gallbladder-preserving surgery without using the snare device, NC), with four cases in each group. The differences between the two groups of animals in operating time, operating workload, complications, adverse events, white blood cells, and liver function were determined.RESULTSNo differences were found in the surgical success rate, gallbladder incision closure, white blood cell count, or liver function between the two groups. The total operating time, gallbladder incision blood loss, gallbladder disorientation time, gallbladder incision closure time, and workload scores on the National Aeronautics and Space Administration-Task Load Index were significantly reduced in the SA group (P < 0.05).CONCLUSIONThese results indicated that snare-assisted pure NOTES gallbladder-preservation surgery using standard endoscopic instruments reduced the difficulty of operation, shortened operation time, and did not increase complications in pigs. A new method for pure NOTES gallbladder-preservation surgery was provided.

Endoscopic approaches in head and neck endocrine surgery − introduction of TOETVA (TransOral Endoscopic Thyroidectomy by Vestibular Approach) into clinical use at the Department of Surgery of the University Hospital in Brno

Transoral endoscopic surgery of the thyroid and parathyroid glands is amodification of neck surgery using natural orifices. The classic approach in neck surgery is the gold standard, which we modified in 2007 by introducing Minimally Invasive Video-Assisted Thyroidectomy/Parathyroid-ectomy (MIVAT/P). We have been using TransOral Endoscopic Thyroidectomy/Parathyroidectomy by Vestibular Approach (TOETVA/TOEPVA) since the end of the last year and have operated on four patients. This method is more attractive for patients because it does not leave avisible scar on the neck, which is common in MIVAT/P. TOETVA is apromising procedure with many advantages, such as healing without visible scars, less pain, minimally invasive dissection and aclear operating field to both thyroid lobes and parathyroid glands. Presentation of the first case. Patients indicated for TOETVA must meet certain criteria - nodule(s) up to 3.5 cm, gland volume up to 30 ml, benign FNAB, papillary, follicular carcinoma not advanced, well differentiated, up to the nodule size of 10 mm with 1 lymph node up to 10 mm. The contraindications include alarge goiter, previous neck surgery, history of thyroiditis, lymphadenopathy of the neck, advanced thyroid cancer. Relative contraindications include previous radiotherapy to the throat, Grave´s disease, and obese patients with ashort neck. Intraoperative findings may result in amodification of the procedure. TOETVA is an excellent choice for selected patients who want to avoid aneck incision. This method provides the benefit of using standard endoscopic instruments and techniques. It is asafe and effective procedure that provides agood cosmetic result and considerable comfort in terms of clarity of the operating field by zooming in with an endoscopic camera.Longer operating times become shorter due to the learning curve effect.

Viscosity and degradation controlled injectable hydrogel for esophageal endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is a common procedure to treat early and precancerous gastrointestinal lesions. Via submucosal injection, a liquid cushion is created to lift and separate the lesion and malignant part from the muscular layer where the formed indispensable space is convenient for endoscopic incision. Saline is a most common submucosal injection liquid, but the formed liquid pad lasts only a short time, and thus repeated injections increase the potential risk of adverse events. Hydrogels with high osmotic pressure and high viscosity are used as an alternate; however, with some drawbacks such as tissue damage, excessive injection resistance, and high cost. Here, we reported a nature derived hydrogel of gelatin-oxidized alginate (G-OALG). Based on the rheological analysis and compare to commercial endoscopic mucosal resection (EMR) solution (0.25% hyaluronic acid, HA), a designed G-OALG hydrogel of desired concentration and composition showed higher performances in controllable gelation and injectability, higher viscosity and more stable structures. The G-OALG gel also showed lower propulsion resistance than 0.25% HA in the injection force assessment under standard endoscopic instruments, which eased the surgical operation. In addition, the G-OALG hydrogel showed good in vivo degradability biocompatibility. By comparing the results acquired via ESD to normal saline, the G-OALG shows great histocompatibility and excellent endoscopic injectability, and enables create a longer-lasting submucosal cushion. All the features have been confirmed in the living both pig and rat models. The G-OALG could be a promising submucosal injection agent for esophageal ESD.

A snare-assisted pure NOTES retrograde cholecystectomy using a single channel flexible endoscope: a pilot experiment in a porcine model.

Natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy is an emerging technology. Interest is ongoing and developments have been rapid but NOTES cholecystectomy has failed to gain traction. Here, we share our experience of snare-assisted pure NOTES retrograde cholecystectomy using porcine models. Under general anesthesia, an incision was created on the posterior vagina wall and an endoscope with a snare attached to the transparent cap was introduced into the pelvic cavity and then upward into peritoneal cavity. After locating the liver and gallbladder, the fundic wall of gallbladder was grasped using a biopsy forceps and the snare was released to ligate the fundus. The gallbladder was then carefully dissected from the gallbladder bed using hook/IT knives with the assistance of the snare. The cystic duct and cystic artery were identified, clipped twice and isolated from the gallbladder using the hook knife to cut between the clips. The specimen was then removed through the vagina using the snare. This procedure was successfully performed in 8 consecutive pigs. The average procedure time was 53min (range 40-60min). No severe bleeding or other complication was observed either during or after the procedure. Normal diets were given on the same day of the procedure. All animals recovered uneventfully. We successfully performed snare-assisted pure NOTES retrograde cholecystectomy in pigs using standard endoscopic instruments. In our experience, pure NOTES cholecystectomy using the retrograde approach performed with a single channel flexible endoscope proved safe and feasible with a short procedure time and quick recovery. The translation of this technique to human subjects seems straight forward and provides a new fitting path to pure NOTES.

Deployable, Variable Stiffness, Cable Driven Robot for Minimally Invasive Surgery.

Minimally Invasive Surgery (MIS) imposes a trade-off between non-invasive access and surgical capability. Treatment of early gastric cancers over 20 mm in diameter can be achieved by performing Endoscopic Submucosal Dissection (ESD) with a flexible endoscope; however, this procedure is technically challenging, suffers from extended operation times and requires extensive training. To facilitate the ESD procedure, we have created a deployable cable driven robot that increases the surgical capabilities of the flexible endoscope while attempting to minimize the impact on the access that they offer. Using a low-profile inflatable support structure in the shape of a hollow hexagonal prism, our robot can fold around the flexible endoscope and, when the target site has been reached, achieve a 73.16% increase in volume and increase its radial stiffness. A sheath around the variable stiffness structure delivers a series of force transmission cables that connect to two independent tubular end-effectors through which standard flexible endoscopic instruments can pass and be anchored. Using a simple control scheme based on the length of each cable, the pose of the two instruments can be controlled by haptic controllers in each hand of the user. The forces exerted by a single instrument were measured, and a maximum magnitude of 8.29 N observed along a single axis. The working channels and tip control of the flexible endoscope remain in use in conjunction with our robot and were used during a procedure imitating the demands of ESD was successfully carried out by a novice user. Not only does this robot facilitate difficult surgical techniques, but it can be easily customized and rapidly produced at low cost due to a programmatic design approach.

Transoral endoscopic thyroid surgery

To analyze own initial experience of transoral thyroid surgery. There were 7 patients thyroid nodules who underwent surgery for the period from March 2018 to May 2019. All patients signed an informed consent to be included in the study. Surgical approach was performed through three incisions in the lower arch of the vestibule of the mouth with deployment of 10 mm endoscope and two 5 mm tools. Gas insufflation was used. All patients were females aged 43.3±11.8 years. Thyroidectomy was performed in 2 cases, hemithyroidectomy - in 5 patients. Dimensions of nodules varied from 10 to 42 mm. Mean time of hemithyroidectomy and thyroidectomy was 206.4±63.8 and 232±37.5 min, respectively. Papillary carcinoma was histologically verified in 1 case. Injuries of recurrent laryngeal nerve, postoperative hypocalcemia and local complications were absent. Drainage was not applied. Postoperative hospital-stay was 3.7±1.1 days. Transoral approach to the thyroid gland is technically feasible with standard endoscopic instruments, safe for important anatomical structures and more precise due to the optical capabilities of endoscopic equipment. Any types of procedures are possible. Undoubtedly, aesthetic outcome is also favorable.

Feasibility of transumbilical anatomic Lung segmentectomy in a canine model

Transumbilical approach has been shown to be feasible to perform lung wedge resection and anatomic lobectomy. This study uses a canine model to assess the feasibility of transumbilical segmentectomy. Transumbilical segmentectomy was performed in 10 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. We evaluated the surgical outcomes, operative complications, physiologic changes, hemodynamic changes, and inflammatory changes of the procedures. Transumbilical segmentectomy was successfully completed in eight of ten animals. There was one mortality complication related to lung injury causing hemodynamic collapse. Another animal required conventional thoracotomy to complete the surgery due to limited working space. There were no notable events in the postoperative period for all eight dogs that completed the segmentectomy via the transumbilical approach. This animal study demonstrates that the pulmonary segmentectomy can be performed with current standard endoscopic instruments via a single transumbilical incision.We believe that advancing surgical innovation and good collaboration between multi-disciplinary research teams will further establish clearer roles for transumbilical segmentectomy in thoracic surgery.

Transvaginal natural orifice transluminal endoscopic surgery: a new approach to ovarian cystectomy

To demonstrate a new approach for performing an ovarian cystectomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as an alternative for a laparoscopic ovarian cystectomy. Stepwise explanation of the technique using original video footage. Hospital. Fourteen patients who provided informed consent and were treated transvaginally to remove a benign ovarian cyst. The patient was placed in the lithotomy position under general anaesthesia. A 2.5-cm posterior colpotomy was made. The pouch of Douglas was opened and a transvaginal natural orifice transluminal endoscopic surgery (vNOTES) port was inserted transvaginally. A pneumoperitoneum was created, and the ovarian cyst was identified. Conventional endoscopic instruments and a standard endoscope were inserted transvaginally through the vNOTES port. The ovarian cortex was incised over the cyst using cold scissors. The cyst was dissected from the ovarian cortex by a combination of blunt and sharp dissection. Ovarian hemostasis was achieved using bipolar forceps. The ovarian cyst was removed through the colpotomy in an endobag. The vNOTES port was removed, and the colpotomy was sutured using a resorbable suture. The following data were collected: age, body mass index, parity, number of previous abdominal procedures, ovarian cyst diameter, operating time, length of hospital stay, and visual analog scale score. Successful minimally invasive ovarian cystectomy via vNOTES without abdominal scars. An ovarian cystectomy was successfully completed in all patients without conversions to standard laparoscopy, and no complications occurred. A fertility sparing cystectomy was performed via vNOTES in all patients; no ovariectomies were performed. All patients were discharged within 30hours, and nine patients were discharged within 12hours. Benign ovarian cysts can be treated by vNOTES through a posterior colpotomy via the pouch of Douglas. In a low-resource setting, a self-constructed gloveport and standard reusable endoscopic instruments can be used. In a first-world setting the surgical time can be reduced using a commercially available vNOTES port. Transvaginal natural orifice transluminal endoscopic surgery provides a new, less invasive approach for performing an ovarian cystectomy. This first IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study confirms the feasibility of vNOTES ovarian cystectomy although it remains a novel approach that requires further investigation. It can provide improved patient comfort and better cosmetic results.

V9-04 ONE-STAGE TRANSVESICAL LAPAROENDOSCOPIC SINGLE-SITE SURGERY (T-LESS) FOR REMOVAL OF TWO BLADDER DIVERTICULA IN A FEMALE PATIENT.

You have accessJournal of UrologyInfertility, ED, and Reconstruction Lower Tract (II)1 Apr 2017V9-04 ONE-STAGE TRANSVESICAL LAPAROENDOSCOPIC SINGLE-SITE SURGERY (T-LESS) FOR REMOVAL OF TWO BLADDER DIVERTICULA IN A FEMALE PATIENT. Marek Roslan, Maciej Przudzik, Michal Borowik, and Miroslaw Lesiów Marek RoslanMarek Roslan More articles by this author , Maciej PrzudzikMaciej Przudzik More articles by this author , Michal BorowikMichal Borowik More articles by this author , and Miroslaw LesiówMiroslaw Lesiów More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2440AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bladder diverticula are usually encountered in males, and they are a rarity in women, especially in the absence of obstruction. Open surgery, as well as laparoscopic or robotic, or single-port surgery have been applied successfully to remove bladder diverticula. To the best of our knowledge, no single-port diverticulectomies have been performed in women. We present the case of using the transvesical laparoendoscopic single-port surgery (T-LESS) for excision of two bladder diverticula in a woman METHODS In August 2016, we carried out the T-LESS access on a 67-year old woman to remove two symptomatic bladder diverticula in one session. The patient was placed in the lithotomy position and was under general anesthesia.The procedure was performed transvesically (percutaneous intraluminal approach) with a single-port device (Tri-Port+) via a 1.5-cm incision made 3 cm above the pubic symphysis. Standard 10-mm optic and straight laparoscopic instruments were used. The diverticula were dissected and removed from the bladder with a combination of standard laparoscopic and endoscopic instruments introduced through the TriPort+ or the urethra. The bladder wall openings were closed by running absorbable 2/0 polyglactin sutures. An 18F Foley catheter was left in place for 6 days. RESULTS The operation lasted 120 minutes. Blood loss was minimal, and no complications were observed. The postoperative period was uneventful. The patient was discharged within 18 hours of surgery. During a nine-week follow-up, the patient reported the significant improvement in the severity of symptoms. Laboratory examination results were all within the normal range. CONCLUSIONS The T-LESS procedure can be considered as a valuable option for diverticulectomies in female patients because of its minimal invasiveness, short hospital stay and fast recovery time © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1057 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Marek Roslan More articles by this author Maciej Przudzik More articles by this author Michal Borowik More articles by this author Miroslaw Lesiów More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Modified approach for endoscopic harvest of the latissimus dorsi free flap with CO2 insufflation and standard laparoscopic equipment.

The latissimus dorsi (LD) muscle flap is frequently used for free tissue transfer to reconstruct large defects of the extremities. As a free flap, the LD also can be harvested as a muscle-sparing flap (MS-LD), preserving the innervation and insertion of the remaining muscle. Conventional harvesting of the LD flap, however, results in a long scar on the lateral back. Harvesting using an endoscopic approach minimizes donor site morbidity. We present our modified endoscopic technique with CO2 insufflation and standard endoscopic instruments for harvesting the LD or MS-LD muscle flap. Ten patients (mean age 43 years, range 22-66) underwent endoscopically harvested LD or MS-LD free-flap reconstruction for upper and lower extremity defects. Harvesting required only a short (3-5 cm) incision in the axilla for dissection of the vascular pedicle and the motor nerve, and the remainder of the dissection was performed endoscopically with CO2 insufflation. Dissection was achieved through three of four 5-mm ports and 30° view angle optics. Six of the flaps were MS-LD flaps. The largest flap size was 18 × 16 cm. Mean flap harvest time was 164 min (range 105-270 min). One total flap was lost 3 days postoperatively due to anastomotic thrombosis in a trauma patient who was later diagnosed with hypercoagulopathy. No donor site scar or wound complications were observed during the follow-up (20.1 months). Endoscopic harvesting of an LD muscle free flap with CO2 insufflation and standard laparoscopic equipment is a feasible option for free-flap reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery 37:383-387, 2017.

Endoscopy-assisted interhemispheric transcallosal hemispherotomy: preliminary description of a novel technique.

Various hemispherotomy techniques have been developed to reduce complication rates and achieve the best possible seizure control. To present a novel and minimally invasive endoscopy-assisted approach to perform this procedure. Endoscopy-assisted interhemispheric transcallosal hemispherotomy was performed in 5 children (April 2013-June 2014). The procedure consisted of performing a small craniotomy (4 × 3 cm) just lateral to midline using a transverse skin incision. After dural opening, the surgery was performed with the assistance of a rigid high-definition endoscope, and bayoneted self-irrigating bipolar forceps and other standard endoscopic instruments. Steps included a complete corpus callosotomy followed by the disconnection of the hemisphere at the level of the basal nuclei and thalamus. The surgeries were performed in a dedicated operating room with intraoperative magnetic resonance imaging and neuronavigation. Intraoperative magnetic resonance imaging confirmed a total disconnection. The pathologies for which surgeries were performed included sequelae of middle a cerebral artery infarct (n = 2), Rasmussen syndrome (n = 1), and hemimegalencephaly (2). Four patients had an Engel class I and 1 patient had a class II outcome at a mean follow-up of 10.2 months (range, 3-14 months). The mean blood loss was 80 mL, and mean operating time was 220 minutes. There were no complications in this study. This study describes a pilot novel technique and the feasibility of performing a minimally invasive, endoscopy-assisted hemispherotomy.

Endoscopic epilepsy surgery: Emergence of a new procedure.

The use of minimally invasive endoscopic surgery is fast emerging in many subspecialties of neurosurgery as an effective alternative to the open procedures. The author describe a novel technique of using an endoscope for performing a corpus callosotomy and hemispherotomy. A description of endoscopic disconnection for a hypothalamic hamartoma (HH) and a review of the literature is also presented. Thirty four patients underwent endoscopic procedures between January 2010 and March 2015. These included endoscopic-assisted inter-hemispheric trans-callosal hemispherotomy (EH; n = 11), endoscopic-assisted corpus callosotomy with anterior/posterior commissurotomy (CCWC; n = 16), and endoscopic disconnection for HH (n = 7). EH and CCWC were performed with the use of a small craniotomy (4 cm × 3 cm). The surgeries were performed using a rigid high-definition endoscope, bayonetted self-irrigating bipolar forceps, and other standard endoscopic instruments along with the guidance of intra-operative magnetic resonance imaging and neuronavigation. HH disconnection was performed using endoscopic neuronavigation through a burr hole. Hemispherotomy: Sequelae of middle cerebral artery infarct (5), Rasmussen's syndrome (3), and hemimegalencephaly (3). Class I Engel (9) and class II (2), mean follow-up of 8.4 months, range: 3-18 months. Mean blood loss: 85 cc, mean operating time: 210 min. CCWC: All had a diagnosis of Lennox-Gastaut syndrome (LGS), with etiologies of hypoxic insult (10), lissencephaly (2), bilateral band heterotropia (2), microgyria and pachygyria (2). Mean follow-up: 18 ± 4.7 (16-27 months). Drop attacks stopped in all the patients. Seizure frequency and duration decreased >90% (11) and >50% (5). HH: Type II (2), Type III (2), Type IV (3). 5 had IA outcome. The article emphasizes the role of endoscopic procedures for epilepsy surgery and provides a review of literature. This experience may subserve to coin the term "endoscopic epilepsy surgery" for a fast emerging subspeciality in the field of epilepsy surgery.

Evaluation of domestic and Yucatan swine nasal sinus anatomy as models for future sinonasal research of medications delivered by standard instruments used in functional endoscopic sinus surgery

There is a need to find an animal model to study new medications to improve mucosal wound healing after functional endoscopic sinus surgery (FESS). Current literature suggests swine as a potential candidate. The lack of information correlating swine computer tomography (CT) and endoscopic sinonasal anatomy prompted us to investigate them in the domestic and Yucatan swine to determine their feasibility as models to test new medications and drug-embedded stents applied using FESS techniques. Two domestic pig heads and 2 Yucatan pig heads were imaged using helical thin slice (1 mm) CT. Two rhinologists analyzed the images and performed endoscopy on the swine. Particular attention was given to accessing the frontal sinus and suturing stents to the nasal septum using standard endoscopic instruments. CT confirmed that swine sinonasal anatomy is largely similar to human, with all major sinuses present. The middle and inferior turbinates of swine arise from a single uniturbinate. The superior turbinates contain large concha bullosa. Unlike human, swine nasal septum is bone anteriorly and cartilage posteriorly. The frontal sinus ostia, regardless of head size, were consistently around 10 cm from the nasal aperture. On endoscopy, domestic swine frontal sinus ostia were easily accessible for topical medication deposition. Silastic splints can be sutured to the domestic swine septum through the posterior cartilaginous portion, allowing for studies involving medication-eluting material. The narrower nasal cavity of Yucatan pigs prohibited endoscopic maneuvers. Domestic swine, but not Yucatan, are a feasible model for future sinonasal research using standard FESS instruments.

Radiofrequency volumetric tissue reduction of the inferior turbinate in a sheep model

To validate the sheep model for endoscopic nasal surgery, and to utilize this model to compare the immediate and early postoperative histopathologic effects of four electrosurgical turbinate reduction techniques. Pilot comparative study of electrosurgical devices for inferior turbinate reduction using a sheep model. Three radiofrequency devices (one monopolar and two bipolar) were compared to monopolar electrosurgery in a sheep model of inferior turbinate reduction. Procedures were performed according to device manufacturer guidelines using standard endoscopic instruments. Normative acoustic rhinometry data were obtained for the sheep model. Histopathologic analysis of turbinate specimens was performed at postoperative day 0 and 21. Turbinate reduction was performed on seven sheep, one procedure on each side, yielding 14 turbinate specimens. Acoustic rhinometry was validated in the sheep model and demonstrated increased nasal volumes following decongestion and turbinate reduction. Submucosal destruction of glands and venous sinusoids and replacement with fibrosis were demonstrated as a common mechanism of action for all four electrosurgical devices. Epithelial disruption was seen with all devices on postoperative day 0. Squamous metaplasia and normal respiratory epithelial regeneration were documented variably between devices at postoperative day 21. The sheep model is useful for study of both the anatomic and histopathologic effects of endonasal procedures. Standard endoscopic instruments and acoustic rhinometry can be used in this model with reproducible results. In this pilot animal study, radiofrequency devices for inferior turbinate reduction demonstrated greater preservation of normal nasal mucosal respiratory epithelium when compared to monopolar electrosurgery.

NOTES-Assisted Transvaginal Splenectomy: The Next Step in the Minimally Invasive Approach to the Spleen

Natural orifice transluminal endoscopic surgery (NOTES) has marked yet another step forward in less-invasive surgical procedures. Access to solid organs located deep in the left hypochondrium can be difficult using this technique but the transvaginal approach with the patient positioned in full lateral decubitus may be an option. We present the case of a 60-year-old woman with a symptomatic splenic polycystic tumor. The procedure was carried out by a multidisciplinary team using a standard flexible videogastroscope and endoscopic instruments. Transvaginal visualization of the spleen and standard dissection of attachments were feasible, and splenectomy was completed using transvaginal stapling of the splenic hilum. The organ was extracted transvaginally. The postoperative course was uneventful. The patient had minimal postoperative pain and minimal scars, and was discharged on the second postoperative day. Transvaginal access can be safely used for operative visualization, hilum transection, and spleen removal with conventional instrumentation, reducing parietal wall trauma to a minimum. The clinical, esthetic, and functional advantages require further analysis.

Endoscope-Assisted Temporoparietal Fascia Harvest for Auricular Reconstruction

Reconstruction of microtia may require a temporoparietal fascia flap. The authors modified existing endoscopic temporoparietal fascia harvest techniques and applied them to auricular reconstruction to reduce incision size, scarring, and visible alopecia. Flap design was altered to include posterior occipital circulation to improve perfusion and decrease venous congestion. Cases of open and endoscope-assisted auricular reconstruction techniques have not been compared in the literature. Seventeen patients underwent Medpor auricular reconstruction with temporoparietal fascia flaps (eight open and nine endoscope-assisted). Physical outcome (scar size, location, appearance, and complication rate), flap size, surgical times, and blood loss were compared. Equipment and dissection techniques are reviewed. No flap complications occurred with either group. Endoscope-assisted incision length was 18 to 25 mm, compared with 150 to 200 mm using the open technique. No significant alopecia was noted in the endoscopic group, whereas most open patients had visible alopecia. Open surgical time averaged 325.9 minutes, and endoscopic surgical time averaged 276.5 minutes. Estimated blood loss averaged 56.3 cc for open and 45.6 cc for endoscopic procedures. Open temporoparietal fascia flap size averaged 8.87 x 9.75 cm, whereas endoscopic temporoparietal fascia flap size averaged 7.9 x 10.2 cm. Standard endoscopic brow-lift instruments were used. The optimal superior access port placement was the upper one-third/lower two-thirds junction of the flap. The endoscope-assisted temporoparietal fascia harvest technique for auricular reconstruction can minimize scarring, alopecia, and surgical time, with comparable blood loss. Flap size is comparable to that of the traditional open approach. The authors recommend a broadly based pedicle instead of one based solely off the superficial temporal artery.

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) Nephrectomy Using Standard Laparoscopic Instruments in the Porcine Model

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging technology that uses endoscopic instruments passed into the peritoneal cavity through hollow viscera to perform surgical procedures without the use of abdominal incisions. There are, however, limitations regarding the equipment available to simulate traditional surgery. The aim of this study was to determine the feasibility of a pure NOTES nephrectomy by using standard laparoscopic instruments through a modified transvaginal trocar. One 40-kg female swine underwent transgastric peritoneoscopy. Transgastric endoscopic visualization guided the introduction of a second transvaginal endoscope through a novel laparoscopic trocar/endoscopic overtube device. The retroflexed transgastric endoscope provided triangulated visualization as standard endoscopic instruments provided retraction, which allowed dissection of the kidney with standard laparoscopic instruments through our modified transvaginal trocar device. Each renal hilum, artery, vein, and ureter was dissected and divided with a transvaginal laparoscopic stapler. Transgastric and transvaginal NOTES accesses were easily achieved, and bilateral nephrectomies were performed. Completion of peritoneoscopy revealed complete hemostasis and identification of ligated ureters and hilar vessels. Total operative time was 40 and 20 minutes for the right and left kidney, respectively. One kidney was captured with a laparoscopic retrieval sac and removed intact through the vaginal defect. Pure NOTES nephrectomies are technically feasible in the porcine model by using standard laparoscopic instruments. Survival studies are necessary to determine the long-term complications and physiologic implications of NOTES nephrectomy. The development of innovative NOTES access trocars may allow for an increased armamentarium of NOTES instruments.