Transumbilical Endoscopic Surgery Research Articles

EVALUATION OF TRANSUMBILICAL ROUTE AS PRIMARY PORT IN LAPAROSCOPIC GYNECOLOGICAL SURGERIES

Background: Minimally invasive surgeries such as laparoscopic surgeries have become the order of the day for many surgical diseases.Singleport transumbilical laparoscopy, also known as embryonic natural orice transumbilical endoscopic surgery (E-NOTES), has emerged as an attempt to further enhance cosmetic benets and reduce morbidity of minimally invasive surgery.The main aim of this study was to assess the port site infection, cosmetic, patient satisfaction and outcome. Methods: Retrospective review was conducted 100 patients who underwent laparoscopic surgeries were included in the study and demographic details were noted for all the patients. All of them were given prophylactic antibiotics before the surgery and the surgeries were performed under anesthesia. Results: Atotal of 100 cases were studied. Tubal ligation was the main indication of surgery. The mean time recorded to establish pneumoperitoneum was 15-45 seconds. Post-operative primary port site infection rate was 3%. No intra-abdominal injury was noted during the entry of primary port and there was no port site hematoma or recorded hernia over the period of month Conclusion: Laparoscopy offers the advantage of rapid post op recovery.This technique of trans-umbilical primary port placement is one of the safest, fastest and easiest techniques to enter the peritoneal cavity

Gallbladder-preserving polypectomy for gallbladder polyp by embryonic-natural orifice transumbilical endoscopic surgery with a gastric endoscopy

Background and aimsCholecystectomy is performed for most gallbladder polyps (GPs). However, cholecystectomy results concerning complications in some patients. For benign GPs, adoption of gallbladder-preserving surgery is worth to recommend. We describe our experiences performing gallbladder-preserving polypectomy for GPs by embryonic-natural orifice transumbilical endoscopic surgery (E-NOTES) with a gastric endoscopy.MethodsThis is a retrospective study of patients with GPs who underwent gallbladder-preserving polypectomy by E-NOTES with a gastric endoscopy from April 2018 to September 2019 in our hospital. The operative time, intraoperative hemorrhage, intraoperative and postoperative complications, gallbladder emptying function were obtained and analyzed.ResultsThe procedure was performed successfully in all 12 patients with 5 cases of single polyp and 7 cases of multiple polyps. The range of GPs size was 2 mm to 15 mm. The mean operation time was (95.33 ± 23.08) minutes (55–135 min). There were no adverse events including heavy bleeding, mortality and conversion to open surgery during operation. All patients were discharged in 4–5 days after surgery without postoperative complications such as delayed bleeding, fever, peritonitis, intra-abdominal abscess and abdominal wall incisional hernia. All patients were followed up at 1, 3, 6, and 12 months postoperation who had almost no visible incision on the umbilical region, no recurrent GPs. The gallbladder emptying function decreased one month after surgery, and gradually improved 3, 6 and 12 months after surgery.ConclusionE-NOTES gallbladder-preserving polypectomy is a safe and effective option for patients with GPs and is close to scar-free surgery which can be performed in routine clinical practice.

Techniques of Laparoscopic Single Site Left Giant Ovarian Cystectomy Utilizing Traditional Instruments

Study Objective Single-site laparoscopy surgery is the most minimally invasive surgery for a gynecologic procedure, but traditional laparoscope surgery has the limitation of lack of exposure and limited surgical space when using traditional surgical instrumentation, such as in a giant ovary cyst. Trans-umbilical natural orifice transluminal endoscopic surgery (NOTES) offers similar benefits of traditional laparoscope surgery but also expands the horizon of traditional laparoscope surgery by allowing the surgeon to perform procedures that are typically limited to an abdominal approach. The advantages of NOTES may include no incisional pain as well as a better cosmetic outcome. These benefits help outweigh the obstacle of learning this novel approach. Our objective is to demonstrate the trans-umbilical NOTES technique as a combination of traditional laparoscope surgical skill with single-site surgical skill. Design Stepwise demonstration of the trans-umbilical NOTES technique for giant ovarian cystectomy with narrated video footage. Setting Academic tertiary care hospital. Patients or Participants A 27-year-old woman. Interventions Trans-umbilical NOTES giant ovarian cystectomy with combined abdominal surgical and single-site surgical skills. Measurements and Main Results A 27-year-old woman (gravida 1 para 1) with pelvic MRI: giant cyst of left ovary, size 145.6 * 83.1 * 170.1mm, no papillary structure requested ovary cyst removal with ovary preservation. She presented with a 1-year history of left pelvic pain. The giant ovary cyst was removed with minimal blood loss, and pathology revealed a ovarian teratoma. The patient had resolution of her left-sided pelvic pain. Conclusion Combined with traditional abdominal surgical skill, single-site surgical skills allow the surgeon to access the entire abdomen and perform ovarian cystectomy through a trans-umbilical single port. Trans-umbilical NOTES giant ovary cystectomy is not only possible but allows ovary cystectomy to be performed with minimal abdominal incision.

Clinical value of gallbladder-preserving cholelithotomy by natural orifice transumbilical endoscopic surgery

Objective To investigate the clinical value of gallbladder-preserving cholelithotomy by natural orifice transumbilical endoscopic surgery on patients with cholecystolithiasis. Methods A retrospective study was performed on data of 15 patients with cholecystolithiasis, who underwent gallbladder-preserving cholelithotomy by natural orifice transumbilical endoscopic surgery from April 2018 to July 2018. The operative data, including situation of operation, operative time, intraoperative hemorrhage, and postoperative complications were recorded. Results The procedure was performed successfully in all patients with a mean operative time of 108±12 min (ranged from 92-129 min). The intraoperative hemorrhage was 10-30 mL. Eight patients suffered from slight right upper abdominal pain, and 7 patients felt slight pain in umbilical a week after surgery. No fever, incision infection, umbilical hemia, peritonitis, and ascites were reported. The clear-liquid diet was recommended for one day after operation, and postoperative activity was allowed since the second day after operation. All patients were discharged on the fourth or fifth day, and all recovered to their normal life at one week after discharge. Follow-up showed that the scar was small and hidden in umbilical without visible incision after one month. Ultrasonic examination results showed that gallbladder contractile function worked perfectly in four patients and no gallbladder stone was found after three months. Conclusion Gallbladder-preserving cholelithotomy by natural orifice transumbilical endoscopic surgery is a safe and effective option for patients with cholecystolithiasis, provides excellent cosmetic outcomes, and can be appropriately carried out under the strict control of surgical indications. Key words: Cholecystolithiasis; Natural orifice transluminal endoscopic surgery; Transumbilicus; Gallbladder-preserving cholelithotomy

1671 Transumbilical Notes Pectopexy: Tips and Tricks

Video Objective Pectopexy is the most effective procedure to treat pelvic organ prolapse and can be used as an alternative to sacrocolpopexy. The minimally invasive access for pectopexy is divided into single-port and multi-port with or without robotic assistance. Transumbilical natural orifice transluminal endoscopic surgery (transumbilical laparoendoscopic single site surgery, transumbilical LESS) is an emerging minimally invasive approach, which reduces abdominal incision and enhances aesthetics. Pectopexy is an ingenious combination of the two approaches, which achieves a good clinical effect. These advantages outweigh the difficulties in learning the new technique. Our purpose was to show the surgical skills of the transumbilical LESS. Setting Xinxiang City Central Hospital Gynecologic Oncology, China Interventions Transumbilical single-site laparoendoscopic pectopexy was performed, which was a combination of laparoendoscopic and single-site surgeries. Conclusion Transumbilical LESS allows the surgeon to perform iliopectineal ligament after accessing the entire abdomen via a single port. This procedure can achieve a good clinical effect.

Transumbilical endoscopic surgery in the diagnosis of ascites of unknown origin.

To explore whether transumbilical endoscopic surgery (TUES) can effectively and safely elucidate the causes of ascites of unknown origin. Methods: A total of 23 consecutive patients with ascites of unknown origin who undertook TUES procedures in the Department of Gastroenterology of The Third Xiangya Hospital of Central South University between January 2014 and January 2016 were retrospectively investigated. Clinical manifestations, laboratory examinations and findings from radiological examinations and endoscopic investigations were noted before the procedure. Conditions of the abdominal cavity under endoscope, final diagnosis and outcome of patients were carefully recorded. Results: TUES procedure was successfully performed in all 23 patients with an operation time of (58.2±13.9) min. Twenty-two patients were undertaken biopsy on the nodules or masses that found in the abdominal cavity. Definite diagnoses were established in the overwhelming majority of patients (22/23). The most common causes of ascites for the 23 cases was tuberculosis (8 cases), followed by peritoneal carcinomatosis (6 cases), and pseudomyxoma peritonei (5 cases). Operation-related complications, such as postoperative bleeding, perforation, peritonitis, intraabdominal chronic abscesses, were not observed, except one case showed a transient moderate fever in 24 hours after operation. No mortality related to TUES occurred. We concluded that TUES was a feasible, economic and minimally invasive approach to access the peritoneal cavity. Conclusion: TUES combinated with biopsy can effectively elucidate the causes of ascites of unknown origin.

Transumbilical videolaparoscopic (single site) liver biopsy with laparoscopy equipment.

INTRODUCTION:Liver diseases have a high incidence in the whole world. In order to diagnose, stage and follow these diseases it is often necessary the execution of liver biopsy. There are many possible ways to perform the procedure and the rise of transumbilical endoscopic surgery (TUES) brings to the medical practice an additional good option.MATERIALS AND METHODS:The study is prospective, nonrandomised and cohort type. It involves 42 patients who underwent liver biopsy through TUES using conventional video laparoscopic material.RESULTS:Among the patients 18 (42.86%) underwent isolated liver biopsy and 24 (57.14%) to liver biopsy associated with umbilical hernia repair. Within those, 27 (64.28%) were male and 15 (35.71%) female. The average body mass index (BMI) was of 27.26 kg/m2, 10 were in the normal BMI range, 24 (57.14%) were in the overweight range, 6 (14.28%) had class I obesity and 2 (4.76%) had class II obesity. In none of the cases the procedure was converted to regular video laparoscopy, all the patients were discharged in the day after the procedure and reported a satisfactory aesthetic result.CONCLUSIONS:The study shows that liver biopsy using TUES has applicability and good results, including in obese patients that would have a contraindication to other methods.

Transumbilical endoscopic surgery for incarcerated inguinal hernias in infants and children

PurposeTo describe transumbilical laparoscopic herniorrhaphy after unsuccessful attempted manual reduction of incarcerated inguinal hernias in infants and children. MethodsIn our two hospitals, two-trocar transumbilical endoscopic surgery (TUES) is the standard technique used to repair incarcerated inguinal hernias in infants and children. Seventeen patients (aged 8months to 2.5years; median, 15months; 15 boys, 2 girls) with incarcerated inguinal hernias underwent urgent laparoscopy after unsuccessful attempted manual reduction. Two 3- or 5-mm trocars were inserted into the abdomen through two intraumbilical incisions, under laparoscopic guidance. The hernia was reduced by combined external manual pressure and internal pulling with bowel forceps. After inspection of the bowel, a round needle with a 2-0 nonabsorbable suture was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The hernial orifice was closed with an extraperitoneal purse-string suture around the internal inguinal ring, and tied with an intraperitoneal knot. A similar procedure was performed on the contralateral side if the processus vaginalis was patent. ResultsThe TUES procedure was successful in all patients. No conversions to open surgery were required. The mean operating time was 30min (range, 25–40min). All patients were discharged on the second postoperative day. No complications such as postoperative bleeding, hydrocele, or scrotal edema were observed. The mean follow-up period was 15months. No cases of testicular atrophy, hypotrophy, or hernia recurrence were reported. ConclusionsOur preliminary experience with using TUES for the treatment of incarcerated inguinal hernias in infants and children had satisfactory outcomes. This technique appeared to be safe, effective, and reliable, and had excellent cosmetic results.

Embryonic NOTES thoracic sympathectomy for palmar hyperhidrosis: results of a novel technique and comparison with the conventional VATS procedure

To avoid the disadvantages of chronic pain and chest wall paresthesia associated with video-assisted thoracic surgery (VATS) procedures, we developed a novel surgical technique for performing sympathectomy by embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) with a flexible endoscope. In this study, we compared the outcomes of E-NOTES with conventional VATS thoracic sympathectomy on palmar hyperhidrosis. From January 2010 to April 2011, a total of 66 patients with severe palmar hyperhidrosis were treated with thoracic sympathectomy in our department. Thirty-four transumbilical thoracic sympathectomies were performed via a 5-mm umbilicus incision with ultrathin gastroscope, then compared with 32 conventional needlescopic thoracic sympathectomies. Retrospective statistical analysis of a prospectively collected group of patients was performed. There was no significant difference with regard to gender, mean age, body mass index, and length of hospital stay between the two groups. The operative time for E-NOTES thoracic sympathectomy was longer than that of VATS thoracic sympathectomy (56.4 ± 10.8 vs. 40.3 ± 6.5 min, p < 0.01). No mortality, diaphragmatic hernia, or Horner syndrome was observed in either group. Postoperative questionnaires were returned by all treated patients with a mean time from operation to follow-up of 1.4 ± 0.3 years. All 66 patients receiving sympathectomy reported successful treatment of their palmar hyperhidrosis. Compensatory hyperhidrosis was noticed in 7 (20.1 %) and 6 (18.8 %) patients in the E-NOTES and VATS groups, respectively (p > 0.05). Postoperative pain and paresthesia were significantly reduced in the E-NOTES group at each time interval, and the aesthetic effect of the incision was superior in the E-NOTES group. Transumbilical-diaphragmatic thoracic sympathectomy is a safe and efficacious alternative to the conventional approach. This novel procedure can further reduce postoperative pain and chest wall paresthesia as well as afford maximum cosmetic benefits by hiding the surgical incision in the umbilicus.

Prospective, randomized clinical trial comparing the use of a single-port device with that of a flexible endoscope with no other device for transumbilical cholecystectomy: LLATZER-FSIS pilot study

Natural orifice transumbilical endoscopic surgery (NOTES) is a technique still in experimental development that requires clinical trials to assess its safety and efficacy. We present a pilot prospective, randomized, three-arm clinical trial of 1-year duration that was conducted as a noninferiority trial comparing single-incision laparoscopic surgery (SILS) and flexible single-incision surgery (FSIS) with conventional laparoscopy for elective cholecystectomy (NCT01558414). Sixty patients between aged 18 and 65 years who were eligible for elective cholecystectomy were randomly assigned in a 1:1:1 ratio (n = 20 per group): group A (SILS), single-incision endoscopic surgery using a transumbilical SILS™ device; group B (FSIS), single-incision transumbilical surgery using a flexible endoscope; and group C (CL), conventional laparoscopy. The main outcome variable of the study was "parietal complications" (wound infection, bleeding, and ventral hernia). The analysis was by intention to treat and attritions were not replaced. Cholecystectomy was performed in 100 % of the cases; perioperative complications occurred in only 1.6 % of the cases, and umbilical surgical wound infection in 3.33 %, with no differences between groups. After a minimum follow-up of 1 year, no differences were noted in the frequency of parietal complications and no ventral hernias occurred. Postoperative pain, hospital length of stay, and downtime from work were similar in all three groups. Surgical time was longer in cases in which a single-incision transumbilical approach was used (58.95 min for SILS and 54.15 for FSIS vs. 49.21 for laparoscopy). Single-incision transumbilical approaches are not inferior for safety or effectiveness compared with conventional laparoscopy. The transumbilical approach using a flexible endoscope is just as effective and safe as the other two procedures and is a promising single-incision approach.

Feasibility of endoscopic transumbilical thoracic sympathectomy in a porcine model

Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. Current methods are associated with risks of chronic neuropathic pain and a visible chest scar. We developed a novel surgical technique for the performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery with a flexible endoscope in a porcine model. Transumbilical flexible endoscopic thoracic sympathectomies were performed in seven farm pigs (three acute and four 4-week survivals). Under general anaesthesia, animals were intubated and mechanically ventilated with a dual lumen endotracheal tube through tracheostomy. A newly developed long transabdominal trocar was placed through the umbilicus. After insertion of a gastroscope through this trocar, a small incision was created on both sides of the diaphragm by a needle-knife. Then the gastroscope was inserted into the thoracic cavity, and the sympathetic chain was identified at the desired thoracic level and ablated. Operation time, safety and feasibility were recorded in all animals. The transumbilical thoracic sympathectomies were successfully completed in all pigs with a mean operation time of 66.7 ± 9.4 min. Intraoperative bleeding occurred in one pig during the electrosurgical incision of diaphragm tissue, which was successfully controlled by hot biopsy forceps. No other acute intraoperative complications were observed in any cases. In the acute group, the length of the diaphragm incision ranged from 4 to 5 mm in three pigs. In the survival group, the animals recovered promptly from surgery. In three pigs, a small pneumothorax was found in the postoperative chest X-ray, but all of them were completely resolved with conservative treatment. Autopsy showed all bilateral T3 sympathetic chains were successfully ablated and no evidence of vital structure injury or diaphragmatic hernia. Transumbilical flexible endoscopic thoracic sympathectomy is technically feasible, simple and safe in a porcine model. This technique can be used as a novel experimental platform for studies of natural orifice transluminal endoscopic surgery (NOTES) for intrathoracic surgery.

Comparison of embryonic nature orifice transumbilical endoscopic surgery with conventional laparoscopic surgery treatmenting Hirschsprung disease

Objective To compare the therapeutic effects of embryonic nature orifice transumbilical endosco-pic surgery(ENOTES) with conventional laparoscopic(CL) surgery in Hirschsprung disease(HD). Methods A total of 111 children from Sep.2009 to Dec.2010 were included in the retrospective study.The patients were divided into 2 groups: ENOTES group(66 cases) and CL group(45 cases). The general conditions of children were reviewed operative situation, postoperative complications and defecation 1 year after operation. Results In the left colectomy, there was no difference between 2 groups in age, weight, operative blood loss and postoperative stay(all P>0.05), but ENOTES took up less time than CL(P<0.05); in the subtotal colectomy, no significant difference existed in all series.All children underwent primary radical surgery, neither transfer to open surgery nor dead case.In ENOTES group, there were 9 cases suffering from enterocolitis postoperatively(13.6%), while 7 cases(15.6%) in CL group.Twenty-eight patients in ENOTES group and 12 in CL group were followed up for 1 year.Less abdominal distension postoperatively was noted in ENTOES group than CL group(P<0.05), but no other difference in other available data.In addition, no obvious operative scar was noted on the abdomen in ENOTES group, what meant better cosmetic benefit than CL. Conclusion HD treated with ENOTES can gain the same outcomes with CL with better cosmetic effect. Key words: Embryonic nature orifice transumbilical endoscopic; Conventional laparoscopic; Hirschsprung disease

Transumbilical thoracic sympathectomy with an ultrathin flexible endoscope in a series of 38 patients

The newest trend in the field of thoracic surgery, thoracic natural orifice transluminal endoscopic surgery (NOTES), is still in the early stages of development and limited to animal experiments. Transumbilical endoscopic surgery could work as a viable intermediate step before pure NOTES. We describe our experiences performing transumbilical-diaphragmatic thoracic sympathectomy with an ultrathin flexible endoscope for palmar and axillary hyperhidrosis in human patients. From April 2010 to January 2012, a total of 38 patients underwent transumbilical-diaphragmatic thoracic sympathectomy. Through the incision in the umbilicus, a newly developed long trocar was inserted into the abdominal cavity. An ultrathin endoscope was introduced through the long trocar and then passed through the rigid incision made in the left and right diaphragm and into the thoracic cavity. The ganglion was ablated at the desired thoracic level. Sympathectomy was performed successfully in all patients. Mean operation time was 68 ± 16 (range, 48-107) minutes. There was no mortality and no conversion to open surgery during the operation of any patient. At a median follow-up of 11 (range, 4-12) months after surgery, no diaphragmatic hernia was observed. The rate of palmar hyperhidrosis and axillary hyperhidrosis resolution was 100 and 75 %, respectively. Transumbilical endoscopic thoracic sympathectomy is technically feasible and safe, which has the possible advantages of pure NOTES and can be performed in routine clinical practice.

Efficacy and Safety of Single Port Laparoscopic Cholecystectomy: A Single Institute Experience

Background: Over the past 5 years, minimal access surgery has been moved toward a new less invasive single port access surgery. Like any new technique, there is a need to ensure that basic tenets of safety and efficacy are maintained. In this study, we demonstrate the efficacy and safety of single port laparoscopic surgery for cholecystectomy in 22 consecutive cases in single institution. Materials and methods: It is a case series of 22 patients (20 females/2 males) who underwent single port laparoscopic cholecystectomy (SPLC) a single laparoscopic surgeon at Barts and the Royal London NHS Trust performed all surgeries using straight conventional instruments from July 2009 to May 2011. Results: In our series, the operations were performed by SPLC successful in 21 patients. In one case an extra-port was added due to inadequate exposure. The mean age was 37.27 years (24-70). The mean BMI was 25.25 kg/m2 (21.1-35). The mean operative time was 69.21 minutes (30-90). Gallbladder perforations were recorded in three cases. Minor bleeding was found in one case. The mean hospital stay was <24 (10.05) hours. Visual analog scale was used to record pain severity and the mean was less than one. All patients had uneventful recovery. Conclusion: The results from current series show SPLC to be a promising technique. We established in this series that SPLC is a safe, efficacious and feasible technique, but it took longer to perform than standard surgery. It can be performed using straight instruments. However, routine application of this novel technique requires evaluation of its safety and effectiveness in large randomized studies. Abbreviation: SILS: Single incision laparoscopic surgery; SIMPLS: Single incision multiport laparoscopic surgery; OPUS: One port umbilical surgery; TUES: Transumbilical endoscopic surgery; SPAS: Single port access surgery, are acronyms of LESS: Laparoendoscopic single site surgery.

Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children

Background/Purpose There has been great interest in natural orifice transluminal endoscopic surgery in recent years. We report another new approach for pediatric inguinal hernia repair: transumbilical endoscopic surgery (TUES). Compared with the natural orifice transluminal endoscopic surgery technique, TUES can obtain similar scarless results on the abdomen. Methods In our hospital, 2-trocar TUES was the standard procedure used to repair pediatric inguinal hernias. Through 2 intraumbilical incisions, two 5-mm trocars were inserted into the abdomen under laparoscopic guidance. With the use of a needle-holding forceps, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The orifice of the hernial sac was closed extraperitoneally with a purse-string suture around the internal inguinal ring, and intraperitoneal knot-tying was performed. Results A total of 76 inguinal repairs were performed in 64 children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls). All operations were completed successfully by TUES, with the exception of one case of intraoperative bleeding because the inferior epigastric vein was punctured. The mean operating time was 20 minutes (range, 15-30 minutes). No postoperative bleeding, hydrocele, or scrotal edema in this group of patients was found, and there were no known cases of postoperative testicular atrophy or hypotrophy nor hernia recurrence on the symptomatic side. Conclusions Our preliminary experience shows satisfactory outcomes with TUES for completely enclosing inguinal hernias in children. This technique appears to be safe, effective, and reliable. The cosmetic result is excellent.

Covert laparoscopic cholecystectomy:a new minimally invasive technique.

To further improve our developed transumbilical endoscopic surgery (TUES), we developed a completely covert laparoscopic cholecystectomy (LC). Twelve cases of LC were recruited for this new approach. First, a 10-mm trocar was placed above the umbilicus for inserting the laparoscope. Two 5-mm trocars were then placed near the right and left ends of the superior margin of the suprapubic hair. After the 5-mm 30° laparoscope was shifted to the left suprapubic trocar, the harmonic scalper, electric hook, and grasper were inserted either through the 10-mm umbilical trocar or through the right suprapubic trocar. All gallbladders were successfully removed without intraoperative complications. The mean operating time was 28.5 ± 5.7 min (range 20-45 min). All patients felt well after surgery and did not need postoperative analgesia. They resumed free oral intake 6h after the procedure. All patients were satisfied with the appearance of the incisions, which were completely hidden in the umbilicus and suprapubic hair. The approach we developed has overcome both external instrument interference around the umbilicus and the loss of triangulation in the operative field. It is relatively simpler than a typical TUES and offers better cosmetic results.

Transumbilical endoscopic surgery: History, present situation and perspectives

Transumbilical endoscopic surgery or laparo-endoscopic single site (LESS) surgery has become an exciting area of surgical development as innovation continues to move in the 21(st) century to minimally invasive surgery. The history, present situation and perspectives are reviewed and the nomenclature of this technique is discussed in this article. The range of this technique has been applied in almost all abdominal diseases, surgeries for morbid obesity, hernia and so on, in recent years. It is estimated that 50%-80% of traditional laparoscopic surgery could be performed transumbilically in the next five years according to the LESSCAR consensus. Although the concept of transumbilical laparoscopic surgery is gaining traction rapidly and the instruments have been improved greatly, we should not advocate for slightly improved cosmetic value over safety. Multicenter, randomized and clinical trials are necessary to further elucidate the safety and efficiency of this new technique. Research that examines the efficacy of the new instruments on the market may be helpful to simplify the confusing landscape of new and novel products designed for this purpose.

Embryonic–Natural Orifice Transumbilical Endoscopic Surgery for Myomectomy with Traction of Multidirectional Sutures: A New Surgical Approach

Embryonic-natural orifice transumbilical endoscopic surgery is currently used for adnexectomy or hysterectomy. Embryonic-natural orifice transumbilical endoscopic surgery for myomectomy with traction of two directional sutures in a 32-year-old woman enabled the minimal surgical approach for myomectomy and efficient and safe morcellation and retrieving of myoma. This novel surgical approach could be used as part of minimal surgery in the surgical management of myoma.

Transummhilical laparoscopic cholecystectomy with improved instruments

Objective The major barrier to transumbilical endoscopic surgery is from external interference between the instruments handles around the umbilicus. We describe the technique of totally transumbilical endoscopic cholecystectomy by using improved instruments. Methods 54 cases of transumbilical laparoscopic cholecystectomy were performed with improved instruments in patients with gallbladder polyps (13 cases) and gallstones (41 cases). The new trocars without the proximal seal system on the sleeves were designed for this procedure. The instruments used in this study were 5 cm longer than commercially available ones. Results All the gallbladders were removed successfully without severe intraoperative bleeding during and postoperative complications. Mean operating time was 25-56 min (average 34±28 min). All the patients were satisfied with the abdominal cosmetic results, discharged 48 h after the operations, and returned to work within seven postoperative days.Conclusions The external interference between trocars and instruments can be partially avoided by using the improved instruments. Totally transumbilical laparoscopic cholecystectomy becomes feasible by this technique. Key words: Endoscopy; Transumbilical; Surgery; Cholecystectomy; TUES

Total Trans-Umbilical Laparoscopic Cholecystectomy And Inguinal Hernia Repair

Single-port transumbilical laparoscopy, also known as embryonic natural orifice transumbilical endoscopic surgery (E-NOTES), has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery.Here we report the first case of successful combined laparoscopic cholecystectomy and transabdominal preperitoneal (TAPP) inguinal hernia repair by totally transumbilical approach. The patient was discharged on the 1 post-operative day without post-operative complications.Combined laparoscopic cholecystectomy and inguinal hernia repair by totally transumbilical approach is feasible, safe and effective without any increased morbidity.