Endoscopic Surgery Techniques Research Articles

Endoscopic Thyroid Surgery through Breast and Axillary Approach

ABSTRACT Thyroid surgery was introduced since ages; it was initially started with large incision in the neck. Due to advancement in technology the minimally invasive surgery has been introduced for all organs. This technology is introduced in the thyroid surgery too. Different approaches have been established including minimally invasive video assisted, endoscopic, robotic and natural orifice thyroid surgery. Among these different approaches of endoscopic thyroid surgery, the breast and axillary approach is most acceptable and easy to perform. Here I am going to describe this technique of endoscopic thyroid surgery. How to cite this article Chand G, Agarwal A. Endoscopic Thyroid Surgery through Breast and Axillary Approach. World J Endoc Surg 2013;5(3):85-88.

Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors

Diagnosis of gastric subepithelial tumor (SET) has shown a rapid increase worldwide. Although, until now, endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET, the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection. However, endoscopic resection or laparoscopic wedge resection alone also has some limitations. Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large (larger than 25 mm diameter). On the other hand, gastric SET in a difficult location, such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection. The hybrid natural orifice transluminal endoscopic surgery (NOTES) technique is a combined method, including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs. This method may be performed safely with reasonable operation times, less bleeding, and adequate resection margin and regardless of tumor size. In particular, in the case of a difficult location for resection, such as the esophagogastric junction or pyloric ring, hybrid NOTES is currently believed to be an ideal treatment method.

Surgical skill and practical technique of endoscopic surgery for infertility patients in our clinic

Surgical skill and practical technique of endoscopic surgery for infertility patients in our clinic

Natural Orifice Transluminal Endoscopic Surgery and Upper Gastrointestinal Tract

Since the first transgastric natural orifice transluminal endoscopic surgery was described, various applications and modified procedures have been investigated. Transgastric natural orifice transluminal endoscopic surgery for periotoneoscopy, cholecystectomy, and appendectomy all seem viable in humans, but additional studies are required to demonstrate their benefits and roles in clinical practice. The submucosal tunneling method enhances the safety of peritoneal access and gastric closure and minimizes the risk of intraperitoneal leakage of gastric air and juice. Submucosal tunneling involves submucosal tumor resection and peroral endoscopic myotomy. Peroral endoscopic myotomy is a safe and effective treatment option for achalasia, and the most promising natural orifice transluminal endoscopic surgery procedure. Endoscopic full-thickness resection is a rapidly developing natural orifice transluminal endoscopic surgery procedure for the upper gastrointestinal tract and can be performed with a hybrid natural orifice transluminal endoscopic surgery technique (combining a laparoscopic approach) to overcome some limitations of pure natural orifice transluminal endoscopic surgery. Studies to identify the most appropriate role of endoscopic full-thickness resection are anticipated. In this article, I review the procedures of natural orifice transluminal endoscopic surgery associated with the upper gastrointestinal tract.

Technical Feasibility and Cosmetic Advantage of Hybrid Endoscopy-Assisted Breast-Conserving Surgery for Breast Cancer Patients

We developed a new procedure called hybrid endoscopy-assisted breast-conserving surgery (EBCS), which consists of a combination of plastic surgery and endoscopic surgery techniques. The purpose of this study was retrospectively to analyze the clinical outcome of hybrid EBCS and compare the cosmetic outcomes between hybrid EBCS and conventional breast-conserving surgery (CBCS). We reviewed medical records of patients who had undergone hybrid EBCS (n=73) or CBCS (n=90) between May 2005 and April 2011 and had been followed up in our department until March 2012. The clinical outcomes and cosmetic outcomes of these two groups were compared. The safety of hybrid EBCS was also analyzed by confirming its complications and pathological surgical margin. In the hybrid EBCS group, operation time was longer by 30-50 minutes. Blood loss was not significantly different between the two groups. The surgical margin of hybrid EBCS was as follows: 1 patient (1.4%) had a positive margin, 4 patients (5.5%) had a margin of <2 mm, in 9 patients (12.3%) the margin was ≥2 mm and <5 mm, and in 59 patients (80.8%) it was ≥5 mm. Seven cases (9.6%) of postoperative complications occurred in 6 hybrid EBCS patients. To date, no local recurrence has been observed in hybrid EBCS patients (postoperative observation period, 18.1±5.6 months). Compared with the CBCS group, the hybrid EBCS group had better cosmetic results, especially with a less noticeable operative scar (P<.01). Hybrid EBCS can provide sufficient free margin, and its surgical curability is acceptable. Additionally, this method is superior to CBCS in terms of cosmetic outcome.

Management of cerebrospinal fluid leak during endoscopic pituitary surgery

Dural opening and closures are major steps in endoscopic pituitary surgery. Restoring the normal anatomy at the end of the procedure creates a natural barrier between the intrasellar compartment and the sinonasal cavity. In this study, we present a relatively simple dural opening and closure technique for endoscopic pituitary surgery. This technique provides a better alternative to the use of a more complex nasoseptal flap or the multilevel closure with artificial materials as it restores the normal anatomy after the tumor removal and provides a better physiological barrier between the sinonasal cavity and the intrasellar compartment. Incision is performed in circular or horseshoe fashion leaving a small peduncle, and then the dura is reflected. Of the 733 endoscopic transsphenoidal procedures in 667 patients conducted between January 2006 and May 2012, we used this described technique in 50 cases (7.4%). In these 50 cases with dural flap, there was no postoperative CSF leakage. Intraoperative CSF leakage was observed in 135 (20.2%) of the 667 patients. In 15 (11.1%) of these 135 patients we used the dural flap technique accompanied with fat and/or fascia lata support. There was no postoperative leakage in these patients. In the remaining 120 (89.9%) patients who had intraoperative CSF leakage, we used fat and/or fascia lata for the reconstruction of the sella floor. But we observed postoperative CSF leakage in 12 (10%) of the 120 patients without the dural flap which were reoperated. The dural flap technique we employ has several advantages. First of all, it allows optimal physiological reconstruction after the surgery. Secondly, the bridge between the flap and the main dura helps maintain the vascular supply, which in turn can radically shorten the healing time. Thirdly, this technique is obviously a better alternative to the time consuming and expensive multilevel closures with tissue sealants and artificial grafts.

Endoscopic Endonasal Surgery for Two Cases of Giant Nasal Lobular Capillary Hemangiomas

Lobular capillary hemangioma (LCH) is a benign lesion originating in the vascular tissue of skin and mucosa. LCH rarely involves nasal cavity (LCHNC). Complete surgical excision is the treatment of choice. The endoscopic endonasal surgery (EES) technique can achieve good cosmetic results by avoiding external incision. In a patient with a rapidly growing intranasal lesion, LCH should be considered as a differential diagnosis. Rapid growth, epistaxis, and its gross findings often mimic malignancy. Histologic confirmation is inevitable. In this report, we present two patients with huge LCH and discussed the clinical, radiological and histological characteristics of LCHNC , and its treatment. doi: http://dx.doi.org/10.4021/jmc873w

The Performance of Multiple Transgastric Procedures Using the Natural Orifice Transluminal Endoscopic Surgery Technique: Is Pure NOTES Satisfactory?

Background/AimsAlthough several groups have demonstrated the usefulness of natural orifice transluminal endoscopic surgery (NOTES), there is still concern about frequent serious adverse events. We performed this study to determine the technical feasibility and safety of pure NOTES with a transgastric approach in a porcine model from the endoscopist's point of view.MethodsDiagnostic peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation with a transgastric approach using a two-channel therapeutic endoscope were performed in 10 healthy female minipigs. These procedures were performed in two acute models and eight survival models in consecutive order.ResultsThe technical success rate was 100% for peritoneoscopy (10/10), liver biopsy (5/5), salpingo-oophorectomy (10/10), and Fallopian tube ligation (10/10). Eight cases of adverse events occurred, including one case of splenic injury, one case of bleeding after liver biopsy, two cases of small bowel adhesion after salpingo-oophorectomy, two cases of hematoma at the salphingo-oophorectomy site, and two cases of partial dehiscence at the gastric closure site. The gastric puncture site was closed with seven to eight hemoclips in four cases and two hemoclips and an endoloop in four cases.ConclusionsThe use of pure NOTES for peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation may be technically feasible, but considerable adverse events can occur during or after the procedure. Further studies utilizing specialized techniques overcome several limitations of pure NOTES are therefore necessary.

Nuevas técnicas en cirugía endoscópica gastrointestinal

Medwave es una revista electrónica revisada por pares y de acceso gratuito, que contiene artículos originales de revisión sobre determinantes clínicos, sociales, políticos y económicos en salud, y de investigación en el ámbito clínico y biomédico. Medwave is an online-only, peer-reviewed and open Access biomedical general journal with original review articles con clinical, social, political and economic determinants of health, and research articles on clinical and biomedical aspects.

Does peritoneal perforation affect short- and long-term outcomes after transanal endoscopic microsurgery?

Peritoneal perforation (PP) is frequently reported as a complication of transanal endoscopic microsurgery (TEM). Nevertheless, these concerns have only rarely been addressed in the literature, with no mention of the long-term oncologic consequences of PP. A prospective database was analyzed with the intent to evaluate the influence of PP on the short- and long-term outcomes for patients undergoing TEM. Peritoneal perforation occurred in 28 (5.8%) of 481 patients who underwent TEM for a rectal neoplasm. The conversion rate to abdominal surgery was 10.7% (3/28). All the conversions occurred during the first 100 TEM procedures (3/100 vs 0/381; p = 0.007). The postoperative morbidity rate was 3.6% (1/28), and the 30-day mortality was nil. Compared with the group of patients who had no peritoneal perforation, the PP group showed a significantly longer operating time (120 vs 60 min; p < 0.001) and a significantly longer hospital stay (6 vs 4 days; p = 0.003). Nevertheless, the global morbidity rate and the type of complications according to Dindo's classification were similar. In the multivariate analysis, the only independent predictor of PP was tumor distance from the anal verge (p = 0.010). During a median follow-up period of 48 months (range, 12-150 months), no liver or peritoneal metastases were detected in 13 patients with rectal cancer. Peritoneal perforation does not seem to affect short-term or oncologic outcomes for patients submitted to TEM with full-thickness resection for upper rectum neoplasms. The use of TEM to resect rectal lesions involving the intraperitoneal rectum may therefore represent an intermediate step toward the development of transrectal natural orifice translumenal endoscopic surgery (NOTES) techniques.

Transvaginal Sigmoid Cancer Resection: First Case with 12 Months of Follow-Up—Technique Description

Several minimally invasive techniques using natural orifices as an entrance site to the peritoneal cavity have been described recently. Pure natural orifice translumenal endoscopic surgery (NOTES) techniques have been mainly implemented to perform cholecystectomies and appendectomies, while more complex operations like colon resections have been described in a hybrid setting and with the use of the transumbilical approach. Here we describe the technique of transvaginal sigmoid colon resection for cancer with standard laparoscopy equipment. After developing the transvaginal technique of sigmoid colon resection in an experimental sheep model, we have performed this operation in a human patient for cancer. Twelve months of follow-up is reported. A totally transvaginal R0 resection of the sigmoid colon for adenocarcinoma has been successfully performed in a female patient with laparoscopy equipment. The specimen included 13 lymph nodes, all of which were free of metastasis. Twelve months after surgery the patient is alive with no evidence of disease. A pure transvaginal NOTES approach to sigmoid colon cancer is feasible in human patients.

Endoscopic closure devices

Endoscopic closure devices

A Prospective Study to Evaluate the Efficacy of Frameless, Pinless Electromagnetic Image-Guided Navigation in Endoscopic Skull Base Surgery

Background: The concept of a two surgeons with four hands surgical technique in endoscopic skull base surgery limits constant optical based image-guided navigation. Also, rigid head fixation hinders endoscopic skull base surgery where frequent minor adjustments are required.

Endoscopic Frontal Sinus Drainage Draf Type III with Mucosal Transplants

This study was designed to evaluate the extent of restenosis that occurs after an endoscopic frontal sinus drainage Draf type III (Draf III; modified Lothrop procedure) using a modified technique with reconstruction of the frontal sinus drainage pathway with mucosal transplants, in combination with occlusive postoperative care. Retrospective case series was performed with 24 consecutive patients undergoing Draf III drainage between 2005 and 2010 using the modified technique of covering the bare bone with mucosal transplants from the nasal septum. To ensure optimal moist wound healing, occlusion of the nose was realized by taping the nose for 2 weeks postoperatively. Frontal ostium measurements were done intraoperatively and at follow-up visits for a minimum of 12 months. Data on patient history, demographics, comorbidities, and computed tomography scans were collected. Mean follow-up was 25.6 months. Eight patients were lost to follow-up. Ninety-four percent of frontal sinus neo-ostia remained open. One patient needed revision surgery using an osteoplastic flap with obliteration. The frontal neo-ostium narrowed by an average of 36.9% from 20.5 × 12.5 to 15 × 9.6 mm. On average, three visits were needed for postoperative care. The patients did not experience significant pain throughout the postoperative healing time. The modified Lothrop procedure is a well-established technique in endoscopic sinus surgery to handle difficult frontal sinus drainage pathways or revision surgeries. The modified technique provides good results in combination with minimized postoperative care and morbidity. A comparative study would be necessary to show superiority to the standard method of Draf III.

Pharyngeal pouch surgery: A combined open and endoscopic approach

Pharyngeal pouches are common, particularly in the elderly population, in whom they can cause significant morbidity. The advanced age of many patients and existing comorbidities mean that in some cases neither open nor endoscopic pouch stapling is possible. We present a technique of combined open and endoscopic pharyngeal pouch surgery, which may be used when other therapeutic options are limited.

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.

Pure NOTES sigmoid resection in an animal survival model

The potential to use single-site transluminal access to perform major surgical procedures is limited. In the current study, a pure natural orifice transluminal endoscopic surgery (NOTES) technique was developed for sigmoid resection, with combined transgastric and transvaginal access to the abdominal cavity and assisted by colonoscopy. This experimental study was conducted on a porcine model. Transgastric access was achieved by needle-knife incision and balloon dilation. Colonoscopy was used to maneuver the colon and expose the colic mesentery. Mesocolic dissection close to the bowel was carried out gastroscopically using a coagulating forceps. To prepare the anastomosis, a circular stapler anvil was introduced endoluminally. Subsequently, sigmoid resection was performed using a roticulating linear stapler inserted transvaginally. Bowel extraction was performed by invagination transrectally. After extracorporeal distal linear stapling of the sigmoid, colorectal anastomosis was completed by application of a circular stapling device transrectally. Gastric access closure was achieved using the over-the-scope clipping system (OTSC). The procedure was successful in all animals, with the operation time ranging from 150 to 270 minutes. The first animal died at postoperative day 5 from peritonitis due to an infected hematoma following spleen injury by an observation trocar. All other animals gained weight postoperatively. Animals were sacrificed after postoperative day 35. The work-up showed complete anastomotic healing and healed gastric closure. The OTSC clip was still in situ in all animals. The presented study shows that pure NOTES resection and anastomosis of the large bowel are feasible. Intraluminal organ manipulation provided excellent organ exposition and rendered one additional access site unnecessary. Transgastric preparation was shown to be safe and effective.

Dual-port technique in navigation-guided endoscopic resection for intraparenchymal brain tumor

Background:In navigation-guided endoscopic surgery performed via a single port, the interference of surgical instruments often disturbs the resection and hemostasis.Case Description:With regard to this, we designed a dual-port technique for navigation-guided endoscopic surgery in a 62-year-old man, with intraparenchymal anaplastic astrocytoma. Two transparent sheaths with Nelaton tubes were inserted in the front of the target lesion via an infinity-shaped burr hole, under the control of the navigation system. The lesion was removed partially using a rigid endoscope and several surgical tools through the bilateral ports. Using the new method, it was convenient to perform hemostasis with bipolar coagulation and aspiration, without any interference from the surgical instruments during the surgery.Conclusion:The offered dual-port technique may be included in surgery planning for elderly patients or patients in particular conditions, with intraparenchymal brain tumors.

Endoscopic Endonasal Surgery for Two Cases of Giant Nasal Lobular Capillary Hemangiomas

Lobular capillary hemangioma (LCH) is a benign lesion originating in the vascular tissue of skin and mucosa. LCH rarely involves nasal cavity (LCHNC). Complete surgical excision is the treatment of choice. The endoscopic endonasal surgery (EES) technique can achieve good cosmetic results by avoiding external incision. In a patient with a rapidly growing intranasal lesion, LCH should be considered as a differential diagnosis. Rapid growth, epistaxis, and its gross findings often mimic malignancy. Histologic confirmation is inevitable. In this report, we present two patients with huge LCH and discussed the clinical, radiological and histological characteristics of LCHNC, and its treatment. J Med Cases. 2013;4(1):34-38 doi: https://doi.org/10.4021/jmc873w

Commentary on “Are Natural Orifice Transluminal Endoscopic Surgery and Single-Incision Surgery Viable Techniques for Cholecystectomy?”

Commentary on “Are Natural Orifice Transluminal Endoscopic Surgery and Single-Incision Surgery Viable Techniques for Cholecystectomy?”