Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study

Background

Most natural orifice transluminal endoscopic surgery (NOTES) procedures to date rely on the hybrid technique with simultaneous laparoscopic access to protect against access-related complications and to achieve adequate triangulation for dissection. This is done at the cost of the potential benefits of this new minimally invasive technique. This study aimed to evaluate the feasibility and safety of a transgastric (TG) pure-NOTES procedure in a diagnostic setting.

Methods

A TG pure-NOTES procedure with endoscopic ultrasonograpy (EUS)-guided access and over-the-scope-clip (OTSC) closure was performed for 10 pigs in a survival and feasibility study. A full macroscopic necropsy with subsequent histologic evaluation was performed on postoperative day (POD) 14. The outcome parameters were uncomplicated follow-up assessment, survival, intraoperative complications, intraabdominal pathology, macroscopic full-thickness closure, and histology-proven full-thickness healing of the gastrotomy.

Results

An uncomplicated postoperative course was reported for 9 of the 10 pigs, and survival was reported for all 10 pigs. For all the pigs, EUS-guided access was performed successfully with a median duration of 25?min (range, 12–62?min) and without intraoperative complications or access-related lesions at necropsy. An OTSC closure was achieved with a median duration of 11?min (range, 3–28?min). The OTSC provided immediate closure, but according to the authors’ definition of a full-thickness healing evaluated by histologic examination, this was not achieved in any of the cases. Although all the animals survived until POD 14, intraabdominal chronic abscesses were present in 3 of the 10 pigs at necropsy.

Conclusions

The EUS-guided TG access proved to be feasible without access-related complications. Although OTSC provided an immediate closure, the histopathology raised concerns regarding the risk of perforation. Together with the high risk of intraabdominal infection, TG pure-NOTES is not yet ready for routine clinical practice.     

Stress response and well-being after open,laparoscopic, and NOTES transgastric uterine horn resection in a randomized porcine model

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.     

No-incision (NOTES) versus single-incision (single-port) surgery for access to sites of peritoneal carcinomatosis: a back-to-back animal study

Background

Preoperative radiological diagnosis and evaluation of limited peritoneal carcinomatosis (PC) is suboptimal. Triangle laparoscopy is considered a noncarcinologic option due to the risk of tumoral spreading through the lateral ports into the abdominal wall muscles. Open surgery is therefore often needed to characterize PC. A minimally invasive approach would be progress.

Methods

We aimed to compare access rates to elective sites of PC using natural orifice transluminal endoscopic surgery (NOTES) with those using single-port laparoscopic surgery (SPLS). Sixteen acute experiments were performed in a live porcine model. Back-to-back NOTES and SPLS standardized peritoneoscopy were conducted in a cross-over design. Access rates to 11 elective sites of PC were considered as end points based on operators’ consensus and necropsy verification.

Results

Access to the targets was successful in 89?% with NOTES and 80?% with SPLS (p?=?0.27). NOTES and SPLS achieved a 100?% access rate to the diaphragmatic domes and paracolic gutters, to the splenic area, to the pelvic floor, and to the trigonal bladder (p?>?0.99). Access rates of NOTES versus SPLS to other elective sites of PC were the following: mesentery root (94?% vs. 0?%, p?p?p?=?0.85), and hepatic pedicle (8?% vs. 100?%, p?Conclusions Both transgastric NOTES and SPLS provided quick and easy access to most elective sites of PC, except for the mesenteric vessel root (better achieved by NOTES) and the hepatic pedicle (better achieved by SPLS). Both techniques could be improved or combined to overcome their specific drawbacks.     

NOTES transvaginal hybrid cholecystectomy: the United States human experience

Background

“Pure” NOTES and “hybrid” NOTES procedures have gained popularity during the past few years. However, most of these published series have been documented outside the United States.

Methods

This is a prospective, nonrandomized series of patients. Female subjects who presented to the University of California at San Diego surgery clinic for elective cholecystectomy were offered participation in this study. Patients met the following criteria: aged 18–75 years; diagnosis of gallbladder disease that required cholecystectomy and American Society of Anesthesiology (ASA) class 1. Hybrid NOTES transvaginal technique was used for cholecystectomy.

Results

A total of 27 women underwent hybrid transvaginal NOTES cholecystectomy during a 43-month period. The median age was 40.1 (range 23–63) years. The mean body mass index was 25.2 (range 16.4–34.1). All patients had an ASA I–II classification. The mean operative time was 92 (range 38–165) min. There was no conversion to an open operation. The mean hospital stay was 1.07 (range 1–2) days. Patients were followed for a mean of 3.32 (range 0.06–12.2) months. There were no postoperative complications. No scars were visible on the abdominal wall.

Conclusions

This study is the largest series of hybrid transvaginal cholecystectomy published in the United States. With our experience, we demonstrate that this technique is safe and clinically viable.     

Broad clinical utilization of NOTES: is it safe?

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.     

Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese

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.     

Plasma soluble vascular adhesion molecule-1 levels are persistently elevated during the first month after colorectal cancer resection

Introduction

Plasma from the second and third weeks after minimally invasive colorectal resection (MICR) has high levels of the proangiogenic proteins VEGF and angiopoietin 2 and also stimulates, in vitro, endothelial cell (EC) proliferation and migration, which are critical to wound and tumor angiogenesis. Soluble vascular cell adhesion molecule-1 (sVCAM-1) stimulates EC chemotaxis and angiogenesis. The impact of MICR on blood levels of sVCAM-1 is unknown. This study’s purpose was to determine plasma sVCAM-1 levels after MICR in colorectal cancer (CRC) patients.

Methods

Blood samples from 90 patients (26% rectal, 74% colon) were obtained preoperatively, on postoperative days (POD) 1 and 3, and at other points during the next 2?months. The late samples were bundled into 7-day time blocks. sVCAM-1 levels were determined in duplicate via ELISA and reported as ng/ml. Student’s t test was used for data analysis (significance, P?Results The mean incision length was 7.3?±?3.1?cm, and the conversion rate was 3%. Compared with preoperative (PreOp) levels (811.3?±?233.2), the mean plasma sVCAM-1 level was significantly higher on POD 1 (905.7?±?292.4, P?P?Conclusions MICR for CRC is associated with a persistent increase in plasma sVCAM-1 levels during the first month. This sustained increase may promote angiogenesis and stimulate the growth of residual tumor cells early after surgery.     

Quantifying mental workloads of surgeons performing natural orifice transluminal endoscopic surgery (NOTES) procedures

Background

During natural orifice transluminal endoscopic surgery (NOTES), surgeons often have difficulties orienting the surgical view and manipulating instruments accurately, which increases their level of mental and physical fatigue. This study quantified mental workload by measuring the spared mental resources of surgeons performing NOTES training tasks.

Methods

Assessment of mental workload was conducted in both a benchtop and a hybrid animal model. Using the benchtop model, surgeons were required to pass a ring as many times as possible in 6?min. Using the hybrid model, surgeons were required to dissect the gallbladder. While performing those primary tasks, the surgeon was required to identify true visual signals among many false signals displayed on an adjacent monitor. They were asked to repeat the trials using laparoscopy. The surgeons’ performance on the primary and secondary tasks using the NOTES and laparoscopic approaches were recorded and compared.

Results

The nine surgeons who completed the trials in the benchtop model successfully transferred 13?±?4 rings between targets using laparoscopy compared with a mean of 1.2?±?1.0 rings transferred using NOTES (P?P?=?0.005). Using the hybrid model, 10 surgeons achieved a 55% accuracy rate performing the laparoscopic task. This was found to be significantly higher (P?=?0.006) than when the task was performed using the NOTES platform (39%).

Conclusion

The results showed that performance of a task using the NOTES platform increases surgeons’ mental workload. Because difficulty performing NOTES is associated with flexible endoscopy, the authors expect that new operating systems providing stable platforms will help to decrease the mental workload of surgeons and enhance eye–hand coordination in performing NOTES.     

Robotic liver resection: technique and results of 30 consecutive procedures

Background

Robotic surgery can enhance a surgeon’s laparoscopic skills through a magnified three-dimensional view and instruments with seven degrees of freedom compared to conventional laparoscopy.

Methods

This study reviewed a single surgeon’s experience of robotic liver resections in 30 consecutive patients, focusing on major hepatectomy. Clinicopathological characteristics and perioperative and short-term outcomes were analyzed.

Results

The mean age of the patients was 52.4?years and 14 were male. There were 21 malignant tumors and 9 benign lesions. There were 6 right hepatectomies, 14 left hepatectomies, 4 left lateral sectionectomies, 2 segmentectomies, and 4 wedge resections. The average operating time for the right and left hepatectomies was 724?min (range 648–812) and 518?min (range 315–763), respectively. The average estimated blood loss in the right and left hepatectomies was 629?ml (range 100–1500) and 328?ml (range 150–900), respectively. Four patients (14.8%) received perioperative transfusion. There were two conversions to open surgery (one right hepatectomy and one left hepatectomy). The overall complication rate was 43.3% (grade I, 5; grade II, 2; grade III, 6; grade IV, 0) and 40% in 20 patients who underwent major hepatectomy. Among the six (20.0%) grade III complications, a liver resection–related complication (bile leakage) occurred in two patients. The mean length of hospital stay was 11.7?days (range 5–46). There was no recurrence in the 13 patients with hepatocellular carcinoma during the median follow-up of 11?months (range 5–29).

Conclusions

From our experience, robotic liver resection seems to be a feasible and safe procedure, even for major hepatectomy. Robotic surgery can be considered a new advanced option for minimally invasive liver surgery.     

Peritoneal inflammatory response of natural orifice translumenal endoscopic surgery (NOTES) versus laparoscopy with carbon dioxide and air pneumoperitoneum

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.     

Multislice-Spiral-CT zur Diagnostik beim Polytrauma

Background

In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized.

Question

Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner?

Material and methods

Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3–81 years) were evaluated retrospectively. The average ISS score was 32.8±12 points (range: 17–75 points).

Results

The average time in the ED, prior to CT, was 33±14 min. The CT scans lasted 16±5 min and the total diagnostic time was 48±14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days.

Conclusion

The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.     

Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy

Introduction

A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC).

Methods

Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18?years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.).

Results

Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68?min; p?<?0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8?mg morphine equivalents; p?=?0.02). Visual Analog Scale pain scores (scale 0–10) were less in the TVC group at 30?min (1 vs. 5; p?=?0.02) and 60?min (2 vs. 5; p?=?0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p?=?0.01). SF-36 scores were similar at 1 and 3?months postoperatively.

Conclusions

This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.     

Transplantation with hyper-reduced liver grafts in children under 10 kg of weight

Background

We had previously described a left lateral segment hyper-reduction technique capable of sizing the graft according to the volume of the abdominal cavity of the recipient.

Aim

The purpose of our study was to evaluate our 14-year live-donor liver transplantation experience with in situ graft hyper-reduction in children under 10 kg of weight.

Patients and methods

Between January 1997 and May 2011, we performed 881 liver transplants. Two hundred and seventy-seven (n?=?277) involved pediatric recipients, of which 102 (37 %) were from live donors. Thirty-five (n?=?35) patients under 10 kg of weight underwent hyper-reduced living donor liver transplants. There were 21 females (60 %) and 14 males (40 %), with a median age of 12 months (range 3–23) and a median weight of 7.7 kg (range 5.6–10).

Results

Median operative time was 350 min (range 180–510). Median cold ischemia time was 180 min (range 60–300). Twenty-six (n?=?26) patients required intraoperative transfusion of blood products. There were 49 postoperative complications involving 26 patients (74 % morbidity rate). One-, 3-, and 5-year survival rates were 87, 79, and 74 %, respectively. Twenty-eight patients are currently alive.

Conclusions

Hyper-reduced grafts provide an alternative approach for low-weight pediatric recipients. The relatively high immediate postoperative morbidity could be related to the complexity of these patients.     

Reconstructive surgery using interference screw fixation for painful accessory navicular in adult athletes

Objective

To examine the effectiveness of a new technique for reattaching the posterior tibial tendon (PTT) using a bone tunnel and interference screw after resection of the accessory navicular for painful accessory navicular (type II) in adult athletes.

Methods

Ten adult athletes (7 male, 3 female; mean age 30?years, range 23–45) underwent reconstruction using a bone tunnel with an interference screw for a painful accessory navicular. All patients complained of pain on the medial aspect of the foot after eversion sprain during sports activities and radiographs revealed type II accessory navicular. Clinical evaluation with the American Orthopaedic Foot and Ankle Society Ankle–Hindfoot Scale (AOFAS) and visual analogue scale (VAS) before surgery was compared with that at most recent follow up (mean 30?months, range 24–39).

Results

Mean AOFAS score improved from a preoperative 62.8?±?2.9 points (range 61–82) to a postoperative 92.1?±?7.0 points (range 83–100; p?p?Conclusions The presented technique reconstructs the bone-tendon interface of the PTT at the primary navicular with sufficient fixation after resection of the accessory navicular, which preserves the strength of the PTT in adult athletes with an intractably painful accessory navicular.     

The lateral decubitus position improves transoral endoscopic access to the posterior aspects of the thorax

Background

The success of natural orifice transluminal endoscopic surgery (NOTES) depends on an adequate exploration of surgical regions. Currently, limited data are available regarding the optimal position for the NOTES approach for thoracic surgery. This study therefore aimed to evaluate the effectiveness of transoral thoracic exploration in a canine model placed in a lateral decubitus position.

Methods

A total of 14 dogs were used in this study. Transoral thoracoscopy was performed using a custom-made metal tube via an incision over the vestibular incision with the animal in a supine position. After thoracic exploration, the animal was placed in a lateral decubitus position. The thoracic intervention (surgical lung biopsy, pericardial window creation, and dorsal sympathectomy) was performed by passing a flexible bronchoscope through the lumen of a metal tube.

Results

The mean operative time for this procedure was 70 min (range 45–100 min). For 12 dogs, all procedures were completed without major complications. However, for one dog, the exploration of the thoracic cavity was incorrect (the right lower lobe had been misinterpreted as the left lower lobe). Another dog had minor bleeding because of an intercostal artery injury that occurred during sympathectomy.

Conclusion

The posterior aspect of the thoracic cavity can be exposed via a transoral approach with the animal in a lateral decubitus position. This approach may be considered as an adjuvant to the supine approach, in which exploration of the posterior thoracic cavity is restricted.     

Robot-assisted transvaginal peritoneoscopy using confocal endomicroscopy: a feasibility study in a porcine model

Background

Optical biopsy methods such as probe-based confocal laser endomicroscopy (pCLE) provide useful intraoperative real-time information, especially during minimally invasive surgery with flexible endoscopic or robotic platforms. By translating the probe at constant pressure across the target tissue, undistorted “mosaics” can be produced. However, this poses ergonomic challenges with a conventional flexible endoscope.

Methods

A 100?μm confocal depth pCLE probe was integrated into a previously described seven degrees-of-freedom articulated endoscopic robot. After estimating the average workspace created by a female pneumoperitoneum, the accessibility of the peritoneal cavity by the device for robot-assisted pCLE peritoneoscopy was calculated. To demonstrate its in vivo feasibility, the robot was inserted transvaginally in a pig, under laparoscopic vision. Optical biopsy was performed of several targets within the peritoneal cavity.

Results

The workspace analysis calculated that 88?% of the surface of an estimated average female pneumoperitoneum could be contacted by the probe using the robot transvaginally. In vivo, the robot was manoeuvred to provide views of all abdominal and pelvic organs. At each target there was robotic acquisition of still pCLE images, and slowly translating images for the construction of increased field-of-view mosaics up to 2?mm in length. Optical biopsies took 1–2?min per target, and at 3.5?μm lateral resolution, the mosaic images showed characteristic features of anterior abdominal wall, liver, and spleen.

Conclusion

In the porcine model, the robotically actuated method of performing peritoneoscopy and pCLE mosaicked optical biopsy is safe and provides a consistent means of acquiring near-histological grade images of submesothelial tissue. Clinical translation is likely to provide sufficient accessibility of the peritoneal cavity.     

Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model

Background

The accepted palliative treatment for malignant gastric outlet obstruction (GOO) is surgical bypass or placement of self-expandable metal stents. We developed a safe and simple natural orifice transluminal endoscopic surgery (NOTES) technique for gastrojejunostomy using a fully covered, anastomosing metal stent in a porcine model.

Methods

Under general anesthesia, 11 pigs underwent gastrojejunostomy with a 4 cm length anastomosing metal stent. After gastrotomy formation using a needle knife, the jejunum was drawn into the stomach with alligator forceps. A jejunotomy was then performed in the gastric cavity, which was followed by deployment of an anastomosing metal stent under fluoroscopic guidance. Next, the first portion of the duodenum was resected by an endoscopic linear stapler via laparoscopy, thereby creating the model of GOO. Oral feeding was resumed 24 h after the procedure, and animals were euthanized at 1, 2, and 4 weeks after the operation.

Results

Side-to-side gastrojejunostomy was successfully completed through NOTES in 10/11 animals. Ten pigs stayed healthy until the planned sacrifice. The mean gastrojejunostomy procedure time was 41 min (range 15–94 min). By postmortem examination, anastomoses were still intact without intraperitoneal necrosis or adhesion. Histological examination revealed adequate submucosal apposition in all ten experimental pigs undergoing successful endoscopic gastrojejunostomy.

Conclusion

Creating a gastrojejunostomy by NOTES using an anastomosing metal stent seems to be a safe, feasible, durable, and reproducible method for GOO.     

Totally laparoscopic stapled distal pancreatectomy

Purpose

To evaluate the outcomes of totally laparoscopic distal pancreatectomy (LDP).

Methods

A prospective database of patients treated within a single institution was studied retrospectively. Between March 2003 and January 2010, 15 patients underwent pancreatic transection with the use of a stapler, followed by sealing of the pancreatic stump with fibrin-coated collagen fleece (TachoComb) in LDP.

Results

LDP was completed successfully in all 15 patients. The median operating time and blood loss were 168 min (range 105–213 min) and 36 ml (range 12–89 ml), respectively. The median drain amylase level peaked at 969 IU/l (93–3077 IU/l) on postoperative day (POD) 1, and then dropped to 165 IU/l (30–846 IU/l) on POD 3. The median hospital stay was 7 days (range 4–15 days). Biochemical pancreatic leaks developed in three patients (20 %), but there was no clinical pancreatic fistula or postoperative hemorrhage.

Conclusions

Our study shows that the combined use of a stapler and TachoComb decreased the incidence of pancreatic fistulas after LDP. This procedure offers more efficient and consistent results than those achieved by closing the pancreatic stump by stapling alone.     

Diagnostic study and meta-analysis of C-reactive protein as a predictor of postoperative inflammatory complications after gastroesophageal cancer surgery

Purpose

This study assessed the diagnostic accuracy of C-reactive protein (CRP) after gastroesophageal cancer resection for postoperative inflammatory complications (PIC).

Methods

The clinical data and CRP values of patients operated on for gastroesophageal cancer surgery between 1997 and 2009 were retrospectively analyzed. The results of this study were compared with published data using a meta-analytic approach for diagnostic outcomes.

Results

Of 210 patients included in the study, 59 developed PIC (28.1?%; 95?% CI: 22.5–34.5?%). On the postoperative day (POD) 4 and 7, CRP had the best diagnostic accuracy for PIC (AUC 0.77; 95?% CI, 0.64–0.91, AUC 0.81; 95?% CI, 0.71–0.91). Using a cut-off value of 141?mg/L (95?% CI, 131–278?mg/L) for CRP on POD 4, the sensitivity was 0.78 (95?% CI, 0.55–0.91), the specificity was 0.70 (95?% CI, 0.53–0.83) and the NPV was 0.89 (95?% CI, 0.77–0.95). The in-hospital mortality rate was 3.3?% (95?% CI, 1.5–6.9?%). In a diagnostic meta-analysis that included two additional studies, CRP had a significant predictive value after POD 3.

Conclusion

There is limited evidence for the diagnostic accuracy of CRP levels for PIC after gastroesophageal cancer surgery. CRP levels on POD 4 might be useful to rule out PIC, but its diagnostic accuracy is moderate at best. For clinical routine use CRP levels are clearly not sufficient to predict PIC and have to be interpreted in the context of the whole clinical picture.     

Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML)

Introduction

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches.

Objective

To present LESS and NOTES in its historical context and to clarify the associated terminology.

Method

Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT).

Results

The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4?years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that ‘laparoendoscopic single-site surgery’ (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy.

Discussion

The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.