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1.
Li-Huan Zhu Wen Wang Shengsheng Yang Dazhou Li Zhijian Zhang Shengping Chen Xianjin Cheng Long Chen Weisheng Chen 《Surgical endoscopy》2013,27(6):2149-2155
Background
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.Methods
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.Results
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.Conclusions
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. 相似文献2.
Lucian Panait Stephanie G. Wood Robert L. Bell Andrew J. Duffy Kurt E. Roberts 《Surgical endoscopy》2013,27(7):2625-2629
Background
The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients.Methods
One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m2. These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19–62 years) and average BMI of 38.9 kg/m2 (range 35.2–44.9 kg/m2). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments.Results
The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered.Conclusions
NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy. 相似文献3.
Stephanie G. Wood Lucian Panait Robert L. Bell Andrew J. Duffy Kurt E. Roberts 《Surgical endoscopy》2013,27(8):2966-2966
Background
Transvaginal natural orifice transluminal endoscopic surgery (NOTES) procedures are at the forefront of minimally invasive innovation, remarkable for shorter recovery times and decreased postoperative pain [1, 2]. Most transvaginal procedures are performed as hybrid procedures [3]. To our knowledge, this is the first video depiction of a pure transvaginal umbilical hernia repair in a human.Methods
This is a 38-year-old woman, body mass index 36.4 kg/m2, with a symptomatic port site hernia in the umbilical region after a previous laparoscopic cholecystectomy. The patient was positioned in stirrups in a steep Trendelenburg position. Sterilization of vaginal cavity was performed with 10 % povidone–iodine solution. A 2 cm transverse incision at the posterior fornix was made, and a SILS port (Covidien, North Haven, CT) was introduced. One 12 mm trocar and two 5 mm trocars were placed through SILS port. Standard straight laparoscopic instruments were used. A 12 cm round Parietex mesh (Covidien) was placed in a specimen retrieval bag and deployed into the peritoneal cavity. The mesh was extracted, unfolded in the abdominal cavity, and circumferentially fixated to the abdominal wall with an AbsorbaTack device (Covidien). The colpotomy incision was closed with a running absorbable suture.Results
The procedure lasted 103 min and was performed on an outpatient basis. No intraoperative complications occurred. The patient was doing well and had no pain or recurrence at 2, 6, and 9 months’ follow-up.Conclusions
Our initial experience with transvaginal ventral hernia repair in humans suggests that this procedure is feasible and safe. This approach may improve cosmesis and decrease the risk of future ventral hernias. Potential cons may include a longer operative time, mesh infection, and risk of visceral injury with a pure transvaginal approach. As transvaginal surgery evolves, techniques and devices will become increasingly refined to tackle these challenges. 相似文献4.
Ion Georgescu Adrian Saftoiu Stefan Patrascu Isabela Silosi Eugen Georgescu Valeriu Surlin 《Surgical endoscopy》2013,27(7):2551-2556
Background
Natural orifice translumenal endoscopic surgery (NOTES) could offer multiple advantages compared with the laparoscopic approach. One such potential advantage, not yet proven, is the inferior inflammatory response, which translates into less significant operative stress. This study aimed to compare the immuno-inflammatory response between transgastric NOTES and laparoscopy for simple surgical procedures (oophorectomy) with reference to the cytokine levels.Methods
For this study, 20 female pigs were randomly assigned to either NOTES or laparoscopic oophorectomy. Seven animals were used as a control group and received only general anesthesia, with no other procedure performed. Blood samples were obtained before surgery, 1 h after the start of the procedure, and at the end of the intervention. The serum levels of IL1β and IL6 were determined using a porcine enzyme-linked immunosorbent assay (ELISA) kit. The mean operative time, intraoperative incidents, and postoperative complications were recorded. On postoperative day 14, the animals were killed, and gastric leak tests were performed.Results
Both the NOTES and laparoscopic procedures were successfully completed. No gastric leaks were observed during necropsy. The transgastric oophorectomy required a significantly longer time to perform than the laparoscopic surgery. Compared with the NOTES procedures, laparoscopic oophorectomy resulted in significantly higher levels of interleukin-1β (IL1β) (42.34 ± 5.26 ng/ml with NOTES vs 46.93 ± 4.79 ng/ml with laparoscopy; p = 0.028) and IL6 (66.95 ± 7.29 ng/ml with NOTES vs 71.75 ± 4.76 ng/ml with laparoscopy, p = 0.049) during the postoperative phase. No statistical difference was detected between the pre- and postoperative cytokine levels in the NOTES group.Conclusion
The study findings suggest that pure transgastric endoscopic surgery is a safe approach resulting in less perioperative inflammatory response than laparoscopy in the early postoperative phase. 相似文献5.
Santiago Horgan Ozanan R. Meireles Garth R. Jacobsen Bryan J. Sandler Alberto Ferreres Sonia Ramamoorthy Thomas Savides Toshio Katagiri Takayuki Dotai Michael Sedrak Saniea F. Majid Sheetal Nijhawan Mark A. Talamini 《Surgical endoscopy》2013,27(6):1872-1880
Background
Natural orifice transluminal endoscopic surgery (NOTES) has been the focus of several studies as a less invasive alternative to conventional laparoscopy to access and treat intracavitary organs. For the last 5 years, much has been accomplished with animal studies, yet the clinical utilization of this novel technique is still modest. After 2 years of experience in the laboratory, we started our clinical experience. We report our experience with clinical utilization of NOTES procedures from 2007 to 2010.Methods
Under UCSD institutional review board–approved trials, 104 patients were enrolled under seven different NOTES protocols from 2007 to 2010, where a NOTES procedure was offered as an alternative to conventional treatments. The treated pathologies were cholelithiasis, biliary dyskinesia, acute and chronic appendicitis, ventral hernias, morbid obesity, and achalasia. The access routes included transgastric (TG), transvaginal (TV), transesophageal (TE), and perirectal (PR).Results
Among the 104 patients enrolled, 103 underwent a surgical procedure starting with diagnostic laparoscopy, and 94 cases were deemed appropriate to proceed via a NOTES approach. There were 9 aborted NOTES procedures at the time of the initial peritoneoscopy before creating a NOTES access route. The reasons to not proceed with a NOTES procedure in the TV cholecystectomy group (n = 5) were a large amount of pelvic adhesions in 4 patients and a severe inflammation of the gallbladder in 1 patient. In the TG cholecystectomy group (n = 1), it was severe inflammation of the gallbladder. In the TG appendectomy group (n = 1), it was the presence of localized peritonitis. In the TE endoscopic myotomy group (n = 2), it was the presence of megaesophagus with an inability to clean the esophagus of food debris. The NOTES procedures performed were 48 TV cholecystectomies, 4 TV appendectomies, 8 TG cholecystectomies, 2 PR peritoneoscopies, 3 TG appendectomies, 3 TV ventral hernia repairs, 5 TE endoscopic myotomies, 3 TV sleeve gastrectomies, and 18 TG sleeve gastrectomies. The average body mass indexes for those in the sleeve gastrectomy group was 42.1 kg/m2 (TG route) and 40.6 kg/m2 (TV route). There were no intraoperative complication and no conversions to standard laparoscopy during these procedures. The average hospital stay was 1–2 days. One patient who underwent TV cholecystectomy required an emergency department visit for nausea and vomiting. To date, 3 patients who underwent TV cholecystectomy have become pregnant and delivered normally.Conclusions
NOTES is safe, feasible, and reproducible with previous training in the laboratory and a consistent team at a high-volume center. Prospective randomized studies of a large patient population are necessary to assess long-term results. 相似文献6.
Dana A. Telem Kyung Su Han Min-Chan Kim Ifode Ajari Dae Kyung Sohn Kevin Woods Varun Kapur Mohammad A. Sbeih Silvana Perretta David W. Rattner Patricia Sylla 《Surgical endoscopy》2013,27(1):74-80
Background
The authors’ group has previously described successful transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) in both porcine and cadaveric models using the transanal endoscopic microsurgery platform. This report describes the largest cadaveric series to date as optimization of this approach for clinical application continues.Methods
Between December 2008 and September 2011, NOTES transanal rectosigmoid resection with total mesorectal excision (TME) was successfully performed in 32 fresh human cadavers using transanal dissection alone (n = 19), with transgastric endoscopic assistance (n = 5), or with laparoscopic assistance (n = 8). The variables recorded were gender, body mass index (BMI), operative time, length of the mobilized specimen, integrity of the mesorectum and the resected specimen, and complications. Univariate statistical analysis was performed.Results
Of the 32 cadavers, 22 were male with a mean BMI of 24 kg/m2 (range 16.3–37 kg/m2). The mean operative time was 5.1 h (range 3–8 h), and the mean specimen length was 53 cm (range 15–91.5 cm). After the first five cadavers, specimen length significantly improved, and a trend toward decreased operative time was demonstrated. The mesorectum was intact in 100 % of the specimens. In nine cadavers, endoscopic dissection was complicated by organ injury. Evaluation by the operative approach demonstrated a significantly longer specimen with laparoscopic assistance (67.7 cm) than with transgastric assistance (45.4 cm) or transanal dissection alone (49.2 cm) (p = 0.013). Comparison of the technique used for inferior mesenteric pedicle division demonstrated both significantly decreased operative time (4.8 vs 6 h; p = 0.024) and increased specimen length (57.7 vs 39.6 cm; p = 0.025) when a stapler was used in lieu of a bipolar cautery device.Conclusion
Transanal NOTES rectosigmoid resection with TME is feasible and demonstrates improvement in specimen length and operative time with experience. Transitioning to clinical application requires laparoscopic assistance to overcome limitations related to NOTES instrumentation, as well as procedural training with fresh human cadavers. 相似文献7.
G. R. Jacobsen K. Thompson A. Spivack L. Fischer B. Wong J. Cullen J. Bosia E. Whitcomb E. Lucas M. Talamini S. Horgan 《Hernia》2010,14(1):89-91
Introduction
Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.Methods
The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.Results
The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.Conclusions
The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection. 相似文献8.
Yoshitaka Demura Norihiko Ishikawa Yasumitsu Hirano Noriyuki Inaki Aika Matsunoki Go Watanabe 《Surgical endoscopy》2013,27(12):4693-4701
Background
Natural orifice translumenal endoscopic surgery (NOTES) is a minimally invasive operation using devices such as flexible endoscopes and linear or circular staplers. Nevertheless, hand-sewn anastomosis in NOTES remains challenging. This study aimed to investigate the feasibility of transrectal robotic NOTES requiring intracorporeal small intestinal anastomosis and closure of the rectal anterior wall incision in a relevant human model.Methods
The authors developed a flexible rectal proctoscope with a diameter of 43 mm for transrectal robotic NOTES. Small intestinal anastomosis was performed in a porcine intestinal transrectal NOTES model using two robotic arms and a camera inserted through the proctoscope and a rectal anterior wall incision. The quality of transrectal small intestinal anastomosis using the da Vinci surgical system (transrectal robotic NOTES group) was compared with that of transabdominal anastomosis using the da Vinci surgical system (transabdominal robot-assisted surgery group) and transrectal anastomosis using traditional transanal endoscopic microsurgery (TEM) instruments (TEM NOTES group). The quality of transrectal rectal anterior wall suturing in the transrectal robotic NOTES group was compared with that of the TEM NOTES group and the open surgical instruments group (open group).Results
Robotic intracorporeal suturing was performed successfully in the porcine intestine model. During small intestinal anastomosis, burst pressure in the transrectal robotic NOTES group (67.7 ± 29.3 mmHg) was similar to that in the transabdominal robot-assisted surgery group (73.3 ± 18.2 mmHg) but significantly higher than in the TEM NOTES group (20.3 ± 24.0 mmHg; p < 0.01). During rectal anterior wall suturing, the burst pressure did not differ significantly between the transrectal robotic NOTES group (149.9 ± 81.1 mmHg) and the open group (195.0 ± 60.5 mmHg).Conclusions
The preliminary safety and efficacy of transrectal robotic NOTES was established. Further studies are required to determine the practical feasibility of this procedure. 相似文献9.
Anita Kurmann Corina Barnetta Daniel Candinas Guido Beldi 《World journal of surgery》2013,37(7):1656-1660
Background
Patients with peritonitis undergoing emergency laparotomy are at increased risk for postoperative open abdomen and incisional hernia. This study aimed to evaluate the outcome of prophylactic intraperitoneal mesh implantation compared with conventional abdominal wall closure in patients with peritonitis undergoing emergency laparotomy.Method
A matched case-control study was performed. To analyze a high-risk population for incisional hernia formation, only patients with at least two of the following risk factors were included: male sex, body mass index (BMI) >25 kg/m2, malignant tumor, or previous abdominal incision. In 63 patients with peritonitis, a prophylactic nonabsorbable mesh was implanted intraperitoneally between 2005 and 2010. These patients were compared with 70 patients with the same risk factors and peritonitis undergoing emergency laparotomy over a 1-year period (2008) who underwent conventional abdominal closure without mesh implantation.Results
Demographic parameters, including sex, age, BMI, grade of intraabdominal infection, and operating time were comparable in the two groups. Incidence of surgical site infections (SSIs) was not different between groups (61.9 vs. 60.3 %; p = 0.603). Enterocutaneous fistula occurred in three patients in the mesh group (4.8 %) and in two patients in the control group (2.9 %; p = 0.667). The incidence of incisional hernia was significantly lower in the mesh group (2/63 patients) than in the control group (20/70 patients) (3.2 vs. 28.6 %; p < 0.001).Conclusions
Prophylactic intraperitoneal mesh can be safely implanted in patients with peritonitis. It significantly reduces the incidence of incisional hernia. The incidences of SSI and enterocutaneous fistula formation were similar to those seen with conventional abdominal closure. 相似文献10.
Arun Nemani Ganesh Sankaranarayanan Jaisa S. Olasky Souheil Adra Kurt E. Roberts Lucian Panait Steven D. Schwaitzberg Daniel B. Jones Suvranu De 《Surgical endoscopy》2014,28(8):2443-2451
Background
A virtual reality-based simulator for natural orifice translumenal endoscopic surgery (NOTES) procedures may be used for training and discovery of new tools and procedures. Our previous study (Sankaranarayanan et al. in Surg Endosc 27:1607–1616, 2013) shows that developing such a simulator for the transvaginal cholecystectomy procedure using a rigid endoscope will have the most impact on the field. However, prior to developing such a simulator, a thorough task analysis is necessary to determine the most important phases, tasks, and subtasks of this procedure.Methods
19 rigid endoscope transvaginal hybrid NOTES cholecystectomy procedures and 11 traditional laparoscopic procedures have been recorded and de-identified prior to analysis. Hierarchical task analysis was conducted for the rigid endoscope transvaginal NOTES cholecystectomy. A time series analysis was conducted to evaluate the performance of the transvaginal NOTES and laparoscopic cholecystectomy procedures. Finally, a comparison of electrosurgery-based errors was performed by two independent qualified personnel.Results
The most time-consuming tasks for both laparoscopic and NOTES cholecystectomy are removing areolar and connective tissue surrounding the gallbladder, exposing Calot’s triangle, and dissecting the gallbladder off the liver bed with electrosurgery. There is a positive correlation of performance time between the removal of areolar and connective tissue and electrosurgery dissection tasks in NOTES (r = 0.415) and laparoscopic cholecystectomy (r = 0.684) with p < 0.10. During the electrosurgery task, the NOTES procedures had fewer errors related to lack of progress in gallbladder removal. Contrarily, laparoscopic procedures had fewer errors due to the instrument being out of the camera view.Conclusion
A thorough task analysis and video-based quantification of NOTES cholecystectomy has identified the most time-consuming tasks. A comparison of the surgical errors during electrosurgery gallbladder dissection establishes that the NOTES procedure, while still new, is not inferior to the established laparoscopic procedure. 相似文献11.
Purpose
Reconstruction of large, complex abdominal wall hernias is an ongoing challenge. Primary closure of such hernias is often not possible. The components separation technique (CST) is a practical option, however, recurrence rates remain unacceptably high. In an attempt to reduce recurrences, we added a biologic underlay mesh and a lightweight polypropylene onlay mesh to the traditional CST.Methods
Patients with a large hernia defect with or without multiple recurrences were selected to undergo a CST augmented with an acellular porcine dermal collagen mesh underlay. Following midline abdominal closure, a lightweight, large-pore polypropylene onlay mesh was fixed to the abdominal fascia. The skin and subcutaneous layers were closed over two sump drains and two closed suction drains.Results
Fifty-one patients underwent a mesh-reinforced CST from May 2006 to June 2010. The study population averaged 57.9 ± 1.5 years of age with 24 males and 27 females, BMI of 34.3 ± 0.9 kg/m2, ASA score of 2.62 ± 0.08, 29 % were smokers, 29 % were diabetic, and 69 % had at least one previous abdominal wall hernia repair. Operative time averaged 196.5 ± 7.2 min with a blood loss of 318 ± 24 mL, and average hernia defect size of 301 ± 31 cm2. Length of follow-up averaged 20.6 ± 2.1 months; surgical site occurrences were identified in 39 %, most commonly from skin necrosis. Hernia recurrence rate was 3.9 %.Conclusions
Repair of large, complex abdominal wall hernias by CST augmented with a biologic underlay mesh and a lightweight polypropylene onlay mesh results in lower recurrence rates compared to historical reports of CST alone. 相似文献12.
A. Espinosa-de-los-Monteros I. Domínguez D. Zamora-Valdés T. Castillo O. F. Fernández-Díaz H. A. Luna-Torres 《Hernia》2013,17(1):75-79
Purpose
Midline incisional hernia reconstruction by defect closure and reinforcement with either prosthetic or biologic materials has shown to significantly decrease recurrence rates even for complex cases. The purpose of this study is to evaluate outcomes regarding large incisional hernia reconstruction with components separation technique using rectus muscle plication as a reinforcement method.Methods
Thirteen patients having large midline incisional hernias and either history of abdominal wall contamination or recurrence in the presence of mesh were treated between January 2007 and December 2011 with closure using components separation technique reinforced by rectus muscle plication.Results
Average hernia square was 222 cm2, and mean follow-up was 24 months. Complications occurred in 6 patients with a mean time to resolution of 59 days. One recurrence was present.Conclusions
When use of mesh or biologic materials is not desired, rectus muscle plication is a feasible tool as a reinforcement method after large hernia closure with components separation. 相似文献13.
Patricia Sylla Dae Kyung Sohn Sevdenur Cizginer Yusuf Konuk Brian G. Turner Denise W. Gee Field F. Willingham Maylee Hsu Mari Mino-Kenudson William R. Brugge David W. Rattner 《Surgical endoscopy》2010,24(8):2022-2030
Background
The feasibility of transanal rectosigmoid resection with transanal endoscopic microsurgery (TEM) was previously demonstrated in a swine nonsurvival model in which transgastric endoscopic assistance also was shown to extend the length of colon mobilized transanally.Methods
A 2-week survival study evaluating transanal endoscopic rectosigmoid resection with stapled colorectal anastomosis was conducted with swine using the transanal approach alone (TEM group, n = 10) or a transanal approach combined with transgastric endoscopic assistance (TEM + TG group, n = 10). Gastrotomies were created using a needleknife and balloon dilation, then closed using prototype T-tags. Outcomes were evaluated and compared between the groups using Student’s t-test and Fisher’s exact test.Results
Relative to the TEM group, the average length of rectosigmoid mobilized in the TEM + TG group was 15.6 versus 10.5 cm (p < 0.0005), the length of the resected specimen was 9 versus 6.2 cm (p < 0.0005), and the mean operative time was 254.5 versus 97.5 min (p < 0.0005). Intraoperatively, no organ injury or major bleeding was noted. Two T-tag misfires occurred during gastrotomy closure and four small staple line defects requiring transanal repair including one in the TEM group and three in the TEM + TG group (p = 0.2). Postoperatively, there was no mortality, and the animals gained an average of 3.4 lb. Two major complications (10%) were identified at necropsy in the TEM + TG group including an intraabdominal abscess and an abdominal wall hematoma related to T-tag misfire. Gastrotomy closure sites and colorectal anastomoses were all grossly healed, with adhesions noted in 60 and 70% and microabscesses in 50 and 20% of the gastrotomy sites and colorectal anastomoses, respectively.Conclusions
Natural orifice translumenal endoscopic surgery (NOTES) for rectosigmoid resection using TEM with or without transgastric endoscopic assistance is feasible and associated with low morbidity in a porcine survival model. Transgastric assistance significantly prolongs the operative time but extends the length of the rectosigmoid mobilized transanally, with a nonsignificant increase in complication rates related to gastrotomy creation. 相似文献14.
Introduction
With approximately 1 million ventral and inguinal hernia repairs performed in the United States each year, even small rates of complications translate into large numbers of patients. Less invasive approaches that potentially lower morbidity deserve consideration, recognizing there are many technical considerations that currently limit their use. We describe a reproducible technique and lessons learned in our laboratory that answer some existing questions with regards to the use of NOTES® for hernia repair.Methods
A non-survival porcine model with general anesthesia was utilized in all cases. Each animal underwent transgastric peritoneal access with a percutaneous endoscopic gastrostomy (PEG) technique, and the gastrotomy was dilated with a wire-guided balloon dilatation catheter. An Esophageal Z-stent delivery device (Cook Medical, Winston-Salem, NC) was modified ex-vivo to allow us to introduce and protect a 10 × 15 cm lightweight polypropylene hernia prosthetic with pre-placed sutures. Once deployed, the sutures were pulled through the abdominal wall using a looped spinal needle technique in combination with the flexible endoscope. After the four anchoring sutures were tied, proprietary endoscopically placed tacks (Cook Medical) were placed at regular intervals between the sutures to secure the edges of the prosthetic.Results
Hernia repairs were performed on five animals. In each case, we successfully completed prosthetic delivery and deployment into the peritoneal cavity, anchoring to the abdominal wall with full-thickness abdominal wall sutures, and endoscopically placed nitinol tacks. All prosthetics were deployed flat against the anterior abdominal wall. Operative times ranged from 65 to 120 min.Conclusion
Transgastric abdominal wall hernia repair is feasible, consistent, and reproducible. In particular, the delivery system can successfully deliver the prosthetic across the gastric wall via a transoral route. Survival animal experiments investigating outcomes related to quality of repair, microbiology, adhesions, and visceral closure need to be done. Human studies are not recommended until these issues are formally investigated.15.
Joseph A. Trunzo Michael F. McGee Leandro T. Cavazzola Steve Schomisch Mehrdad Nikfarjam Jessica Bailey Tripurari Mishra Benjamin K. Poulose Young-Joon Lee Jeffrey L. Ponsky Jeffrey M. Marks 《Surgical endoscopy》2010,24(7):1727-1736
Background
The immunologic and physiologic effects of natural orifice translumenal endoscopic surgery (NOTES) versus traditional surgical approaches are poorly understood. Previous investigations have shown that NOTES and laparoscopy share similar inflammatory cytokine profiles except for a possible late-phase tissue necrosis factor-α (TNF-α) depression with NOTES. The local peritoneal reaction and immunomodulatory influence of pneumoperitoneum agents in NOTES also are not known and may play an important role in altering the physiologic insult induced by NOTES.Methods
In this study, 51 animals were divided into four study groups, which respectively underwent abdominal exploration via transgastric NOTES using room air (AIR) or carbon dioxide (CO2) or via laparoscopy (LX) using AIR or CO2 for pneumoperitoneum. Laparotomy and sham surgeries were additionally performed as control conditions. Measurements of TNF-α, interleukin-1β (IL-1β), and IL-6 were performed for peritoneal fluid collected after 0, 2, 4, and 6 h and on postoperative days (PODs) 1, 2, and 7.Results
Of the 45 animals assessed, 6 were excluded because of technical operative complications. The findings showed that LX-CO2 generated the most pronounced response with all three inflammatory markers. However, no significant differences were detected between LX-CO2 and either NOTES group at these peak points. No differences were encountered between NOTES-CO2 and NOTES-AIR. Subgroup comparisons showed significantly higher levels of TNF-α and IL-6 with NOTES-CO2 than with LX-AIR on POD 1 (p = 0.022) and POD 2 (p = 0.002). The LX-CO2 subgroup had significantly higher levels of TNF-α than the LX-AIR subgroup at 4 h (p = 0.013) and on POD 1 (p = 0.021). No late-phase TNF-α depression occurred in the NOTES animals.Conclusion
The local inflammatory reaction to NOTES was similar to that with traditional laparoscopy, and the previously described late-phase systemic TNF-α depression in serum was not reproduced. At the peritoneal level, NOTES is no more physiologically stressful than laparoscopy. Furthermore, regardless of which gas was used, the role of the pneumoperitoneum agent did not affect the cytokine profile after NOTES, suggesting that air pneumoperitoneum is adequate for NOTES. 相似文献16.
Background
NOTES is believed to induce less surgical trauma than open and laparoscopic surgery. The degree of surgical trauma can be assessed by measuring serum levels of acute-phase proteins such as CRP and TNF-α. We conducted a prospective randomized survival trial in which the inflammatory responses after laparoscopic, open, and NOTES transgastric uterine horn resection were compared. The aim of this study was to investigate whether NOTES procedures induce less inflammatory response.Methods
Thirty pigs were randomized into three groups to undergo open, laparoscopic, or transgastric uterine horn resection. Weight, body temperature, and postoperative recovery were recorded and venous blood samples were taken for analysis of CRP and TNF-α at different time points. Analyses of CRP and TNF-α were performed using pig-specific ELISA assays.Results
Procedure time was significantly longer for NOTES [median = 121 min (range = 94–155)] compared with that for open surgery [median = 22 min (14–27)] and laparoscopy [median = 37 min (20–45)] (p < 0.0001). There was a nonsignificant tendency for shorter recovery time for the NOTES animals. Twenty-seven animals survived for 4 weeks. One animal in each group was euthanized prior to 4 weeks. All animals gained weight during the 4-week period with no significant differences. Only animals in the NOTES group showed a significant weight gain during the first postoperative week (p = 0.007). On postoperative day (POD) 1, CRP was significantly lower in the NOTES group compared with the open and laparoscopic groups (mean = 0.72 ± 0.22, 0.98 ± 0.26, and 0.97 ± 0.20, respectively; p = 0.048). The CRP levels were normalized on day 14. Throughout the study there were no significant changes in TNF-α levels in the laparoscopic and NOTES groups. At POD 3 the open surgery group showed significantly higher TNF-α levels than the other groups (p = 0.036).Conclusions
Despite the longer operating time, the transgastric NOTES approach seems to be less traumatic than open or laparoscopic uterine horn resection in this porcine model. 相似文献17.
Lauren Buck Joel Michalek Kent Van Sickle Wayne Schwesinger Juliane Bingener 《Journal of gastrointestinal surgery》2008,12(11):2010-2014
Background Natural orifice transluminal endoscopic surgery (NOTES) ventral hernia repair could avoid abdominal wall incisions. The infectious
risk for mesh placement is of concern. We compared NOTES with laparoscopic mesh placement.
Methods Thirty-seven swine were randomized to abdominal wall polypropylene mesh placement via NOTES or laparoscopy or NOTES control.
All animals received antibiotics and gastric irrigation; the laparoscopy group also received preoperative acid suppression.
In the NOTES mesh group, the 2-cm2 polypropylene mesh was placed using a transgastric transportation device and clipped to the anterior abdominal wall. The
control animals underwent endoscopy (no gastrotomy) followed by laparoscopic mesh placement or NOTES only without mesh placement.
Necropsy was performed at 14 days.
Results One NOTES mesh placement was incomplete (endoscope failure). All mesh animals survived to 14 days. At necropsy, significantly
more mesh infections were noted in the NOTES mesh versus laparoscopy group (4:11 vs 0:14; p = 0.03). Gastric irrigation reduced the bacterial load significantly in all groups (p < 0.001). Infection was independent of gastric bacterial load. No difference between acid suppressed and non-suppressed animals
was seen.
Conclusion The mesh placement via NOTES is technically feasible but has a high infection rate despite irrigation. Sterile conduits are
needed to enable NOTES-type hernia repair with mesh.
Presented at the 49th annual meeting of the Society for Surgery of the Alimentary Tract, May 21, 2008, San Diego, CA. 相似文献
18.
Anders Meller Donatsky Barbara Juliane Holzknecht Magnus Arpi Peter Vilmann Søren Meisner Lars N. Jørgensen Jacob Rosenberg 《Surgical endoscopy》2013,27(6):1914-1922
Background
One of the biggest concerns associated with transgastric surgery is contamination and risk of intra-abdominal infection with microbes introduced from the access route. The purpose of this study was to evaluate the effect of oral decontamination with chlorhexidine on microbial contamination of the endoscope.Methods
In a prospective, randomized, single-blinded, clinical trial the effect of chlorhexidine mouth rinse was evaluated. As a surrogate for the risk of intra-abdominal contamination during transgastric surgery, microbial contamination of the endoscope during upper endoscopy was examined. Patients referred to upper endoscopy were assessed for eligibility and randomized to either chlorhexidine or no mouth rinse. Culture samples were collected from gastric aspirates and endoscopes. The primary outcome measure was colony forming units (CFU) in the endoscope samples. Secondary outcome measures were species specific effect of chlorhexidine on micro-organisms with abscess forming capabilities and the effect of proton pump inhibitor (PPI) treatment on CFU.Results
Chlorhexidine mouth rinse resulted in a significant reduction of CFU in the endoscope samples (p = 0.001). There was no species specific effect and micro-organisms with abscess forming capabilities were equally present. PPI treatment was associated with significantly higher CFU counts in both the gastric (p = 0.004) and endoscope samples (p = 0.049).Conclusions
Chlorhexidine mouth rinse was effective in reducing microbial contamination of the endoscope, but micro-organisms with abscess forming capabilities were still present. PPI treatment significantly increased CFU and should be discontinued before transgastric surgery. 相似文献19.
Purpose
Treatment guidelines for abdominal wound dehiscence (WD) are lacking. The primary aim of the study was to compare suture to mesh repair in WD patients concerning incisional hernia incidence. Secondary aims were to compare recurrent WD, morbidity, mortality and long-term abdominal wall complaints.Methods
A retrospective chart review of 46 consecutive patients operated for WD between January 2010 and August 2012 was conducted. Physical examination and a questionnaire enquiry were performed in January 2013.Results
Six patients were treated by vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) before definitive closure. Three patients died early resulting in 23 patients closed by suture and 20 by mesh repair. Five sutured, but no mesh repair patients had recurrent WD (p = 0.051) with a mortality of 60 %. Finally, 18 sutured and 21 mesh repair patients were eligible for follow-up. The incidence of incisional hernia was higher for the sutured patients (53 vs. 5 %, p = 0.002), while mesh repair patients had a higher short-term morbidity rate (76 vs. 28 %, p = 0.004). Abdominal wall complaints were rare in both groups.Conclusions
Suture of WD was afflicted with a high incidence of recurrent WD and incisional hernia formation. Mesh repair overcomes these problems at the cost of more wound complications. VAWCM seems to be an alternative for treating contaminated patients until definitive closure is possible. Long-term abdominal wall complaints are uncommon after WD treatment. 相似文献20.
Kiyokazu Nakajima Toshirou Nishida Tsuyoshi Takahashi Yoshihito Souma Johji Hara Takuya Yamada Toshiyuki Yoshio Tateki Tsutsui Takeshi Yokoi Masaki Mori Yuichiro Doki 《Surgical endoscopy》2009,23(12):2650-2655