经自然腔道内镜手术的研究进展

经自然腔道内镜手术(NOTES)作为一种新兴的手术类型,目前已成为微创内镜外科领域的研究热点,其具有体表无创、患者痛苦小、术后恢复快等优点,但同时也存在手术难度大、技术要求高、受器械限制明显的缺点及腹腔感染、穿刺孔漏等并发症风险增加的问题.尽管NOTES技术仍处于发展的起步阶段,随着技术的进步、技能的提高以及观念的革新,其必将逐步成熟,引领微创外科进入全新时代.     

经脐途径经自然腔道内镜手术诊断不明原因腹水的价值

目的：初步探讨经脐途径经自然腔道内镜手术（NOTES）诊断不明原因腹水的诊断价值。方法以2009年6月至2014年10月长海医院消化内科收治的16例不明原因腹水患者为研究对象,对其行经脐途径内镜下腹腔探查术,记录手术过程、结果及并发症发生情况。结果16例不明原因腹水患者均顺利完成腹腔探查,并获得明确诊断,其中10例诊断为结核性腹膜炎,另6例诊断为癌性腹水。16例患者术后均恢复良好,均未出现近期及远期相关并发症。结论经脐途径NOTES腹腔探查简便可行,技术难度低,对常规方法不能明确病因诊断的腹水进行腹腔探查术是可行、安全的方法。     

经自然腔道内镜手术在心胸外科中的研究及应用进展

经自然腔道内镜手术(NOTES)是指利用人体的自然腔道(如胃、阴道、膀胱等),不经皮肤切口,将内镜穿破腔道管壁进入体腔进行内镜下手术的外科学技术,多用于腹部外科、泌尿外科等。胸部的解剖特点使得在该部位实施NOTES的手术风险较高。为提高临床工作者对NOTES的认识,该文就NOTES在心胸外科中的应用条件、腔道入路的选择及方式、闭合方法、手术风险、研究进展、存在问题及应用前景等进行了介绍。     

单钳道内镜下经自然腔道胃空肠吻合术在胃出口道梗阻中的初步探索

目的探讨单钳道内镜下经自然腔道胃空肠吻合术治疗胃出口道良恶性梗阻的效果。方法 2018年10月-2019年8月该院消化内镜中心通过20例猪胃及上段空肠建立离体动物模型,选择经自然腔道内镜手术(NOETS),在该模型上采用单钳道内镜下经NOTES胃空肠吻合术,以明确该手术方法治疗胃出口道梗阻的可行性及有效性。结果均成功进行胃空肠吻合,镜身可经吻合口顺利进入空肠上段,手术时间(33.6±6.5)min,金属夹8～10枚,吻合口无渗液。结论该术式成功构建胃空肠吻合,对胃出口道梗阻提供新的手术方式,为临床研究的进一步开展提供理论支持。     

经胃入路自然腔道内镜手术诊断不明原因腹痛1例

<正>在临床中,以慢性腹痛为就诊症状者较多见,但病因复杂,部分患者病因诊断不明确,给患者带来痛苦,同时也为临床诊治带来困惑。部分腹痛仅靠实验室、影像学及内镜等检查均无法明确诊断。以往传统手术下[1]腹腔探查术因其创伤大、痛苦多、并发症较多、费用高和恢复慢等逐渐被腹腔镜所取代,腹腔探查已作为诊断不明原因慢性腹痛的重要手段。如何减轻患者痛苦、经济负担等,微创内镜技术已成为临床研究热点。经胃入路经自然腔道内镜手术(natural     

10例经阴道纯自然腔道内镜肾切除术的围手术期护理

对10例经阴道纯自然腔道内镜手术(NOTES)肾切除术进行了围手术期护理.护理要点为:①术前进行心理护理,使患者在最佳的心理状态下接受手术;②做好充分的术前准备,如肠道准备、阴道准备、皮肤准备等;③术后加强呼吸道管理,密切观察阴道出血情况,注意各引流管护理,防止腹胀或肠梗阻的发生;④加强术后舒适护理,保障患者良好恢复;做好出院宣教,加强术后随访.本组10例均痊愈出院.     

经阴道自然腔道内镜辅助腹腔镜下肾部分切除术的护理

[目的]探讨经阴道自然腔道内镜手术(NOTES)辅助腹腔镜下肾部分切除术的护理方法。[方法]回顾性分析2013年8月—2016年1月14例肾肿瘤施行经阴道NOTES辅助腹腔镜下肾部分切除术的临床资料。术前重点协助病人完善检查明确诊断、做好心理护理、肠道及阴道准备、皮肤准备等,术后严密监测生命体征、切口及引流管护理、活动指导,采取有效护理措施预防并发症的发生。[结果]手术均获成功完成;1例肾上极肿瘤因开放肾动脉后肾实质创面持续出血改行根治性肾切除术;术后均无尿瘘发生;术后继发出血1例,保守治疗后痊愈。术后随访3个月~30个月,病人均健康存活,无肿瘤复发。[结论]经阴道NOTES辅助腹腔镜下肾部分切除术安全、可行,术后疼痛轻,恢复快,疗效确切,美容效果佳,且不影响术后性功能。精心的围术期护理是配合新术式开展的护理关键。     

经自然腔道内镜手术治疗重症急性胰腺炎合并多器官功能障碍

目的：探讨经自然腔道内镜手术（NOTES）对重症急性胰腺炎（SAP）合并多器官功能障碍（MOD）的治疗价值。方法选择2010年3月至2014年10月中山大学附属东华医院收治的SAP患者99例,将其随机分为NOTES组51例和对照组48例。NOTES组患者入院4h内实施NOTES腹腔内镜治疗、腹腔灌洗、腹膜透析及综合治疗。NOTES组患者探查腹腔病变及实施内镜治疗,对照组患者采用非手术综合治疗,比较两组SAP患者的胃、肠、肺、肝、肾功能,治愈率和死亡率。结果入院第4、8、14天腹腔压力、胆红素、丙氨酸氨基转移酶（ALT）、白蛋白、肌酐、尿素氮值与对照组之间差异有统计学意义（P<0.05）。NOTES组患者治愈率98.0%,转科率为2%,两组治愈率、死亡率差异有统计学意义（P<0.01）。 NOTES组患者平均住院日（18.98±7.88）d,对照组患者平均住院日（56.85±20.54）d,两组差异有统计学意义（P<0.01）。结论以NOTES腹腔探查及微创治疗为先导的综合疗法,是治疗SAP合并MOD患者的有效模式。     

腹腔镜和经胃的自然腔道内镜手术在不明原因腹水诊断中的临床应用比较

目的总结经腹腔镜和经胃的自然腔道内镜手术(NOTES)行腹腔探查及腹膜活检在不明原因腹水的临床应用体会。方法回顾性分析该科2014年1月-2015年10月,20例经腹腔镜和2015年5月-2016年7月经胃NOTES检查11例不明原因腹水的临床资料,并对两组手术的手术时间、住院费用、住院时间、术中出血、术后腹痛评分、术后3天白细胞和发热进行比较。结果腹腔镜检查组20例,11例诊断为结核性腹水,8例诊断为癌性腹水,1例诊断不明;NOTES检查组9例诊断为结核性腹水,1例诊断为癌性腹水,1例诊断为肝硬化腹水。两组诊断明确30例(96.8%),结核性腹水20例(64.5%),癌性腹水9例(29.0%)。腹腔镜组与NOTES组比较:手术时间长、住院费用高,差异有统计学意义(P0.05);术后住院时间长,差异有统计学意义(P0.05);术中出血、术后腹痛评分、术后3天白细胞和发热差异无统计学意义(P0.05)。结论两种检查方法均能快速准确地诊断腹水原因,以利于治疗,且手术创伤小,严重并发症少。但经胃NOTES较经腹腔镜更具有优势。     

经自然腔道腹腔镜辅助先天性巨结肠症根治术的临床效果观察

目的 探讨经自然腔道腹腔镜辅助先天性巨结肠根治术用于婴幼儿先天性巨结肠症（HD）的临床效果.方法 回顾性分析2009年6月至2012年6月在我院经脐或经肛门行腹腔镜下改良Soave巨结肠根治术60例患儿的临床资料.结果 本组手术均获得成功,手术时间（132±14） min,腹腔镜腹内操作时间为（78±12） min,术中出血约（35.0±20.4） ml,肠功能恢复时间为（22±8）h,住院时间为（8±2）d.扩肛时间为（50.0±0.5）d.腹部切口甲级愈合率100％.随访1年,患儿生长发育良好.所有患儿均未发生切口感染、腹盆腔出血、尿潴留等早期并发症.排便功能随着术后时间的延长逐渐恢复.手术后4个月各组患儿肛门直肠功能均基本恢复正常.结论 经自然腔道腹腔镜辅助先天性巨结肠根治术创伤轻,术后恢复快、并发症少,可进一步减少腹壁创伤,美容效果更佳.     

Identifying and overcoming the potential barriers to the adoption of natural orifice transluminal endoscopic surgery

Natural orifice translumenal endoscopic surgery (NOTES) is an emerging innovative approach to performing minimally invasive surgical procedures. In its full potential, the concept of incisionless surgery will have mass appeal to patients. However, the barriers to adopting NOTES will have to be overcome before widespread acceptance of these techniques can occur. These potential barriers include infection, visceral leakage, difficulties in tissue manipulation, and increased cost. The history of surgical innovation has continuously overcome similar problems in other settings, and all of these potential obstacles are likely solvable. Training surgeons will be an additional barrier that will need to be overcome, but this obstacle will need to be approached differently than when laparoscopy was introduced, as standards are higher today for privileging and credentialing in most hospitals than 20 years ago. Alternative technologies that were not adopted prior to the introduction of NOTES may now appear more viable making the competitive environment more complex. Increased funding for comparative effectiveness studies and training for competency in innovation will also need original solutions, but are clearly in our patients' best interest.     

Current status and activity regarding natural orifice translumenal endoscopic surgery (NOTES) in Japan

Natural orifice translumenal endoscopic surgery (NOTES) is a new, minimally invasive technique in the field of gastroenterological surgery. Research on NOTES has rapidly progressed all over the world. A joint committee on NOTES organized by the Japan Society for Endoscopic Surgery (JSES) and the Japan Gastroenterological Endoscopy Society (JGES) established Japan NOTES to encourage the responsible development and safe adoption of NOTES into clinical practice. This paper provides an overview of the current activity in regard to NOTES in Japan.     

Natural orifice transluminal endoscopic surgery (NOTES): Assessment of peritoneal bacterial load after intraperitoneal antimicrobial wash and evaluation of hemodynamic changes in a porcine model

Abstract

Aims. Natural orifice transluminal endoscopic surgery (NOTES) is a promising newly developed procedure; however, it is associated with many complications. The main aim of our study is to assess whether peritoneal wash with antibiotics decreases the bacterial load contamination related to the transgastric approach. Methods. Ten female farm pigs underwent transgastric peritoneoscopy with fallopian tubal ligation. Five pigs were randomized to antibiotic wash of the peritoneal cavity and five to placebo. All animals were given one intravenous dose of antibiotic before the procedure. Hemodynamic variables were continuously monitored throughout the procedure. The next day, peritoneal cultures were taken. The fallopian tubes were inspected to determine the success of ligation and the gastric incision sites were assessed for leakage. Results. No significant difference was noted between the antibiotic peritoneal wash group and the placebo group in terms of peritoneal bacterial load with respective median colony-forming units per ml (CFU/ml) of 0 [0; 1] vs. 0 [0; 4], p = 0.637. No clinically significant hemodynamic changes were noted during the procedure. Conclusions. The results of our study indicate that NOTES carries minimal risk of peritoneal bacterial contamination, regardless of the use of intraperitoneal antibiotics, and is not associated with hemodynamic compromise.     

经口腔前庭腔镜甲状腺切除术6例经验

目的 探讨经口腔前庭腔镜甲状腺切除手术的技术方法,评价该手术入路的安全性和可行性.方法 对6例女性患者施行经口腔前庭3孔法腔镜甲状腺切除术,结节性甲状腺肿5例,其中2例伴囊性变、1例伴腺瘤样增生,甲状腺滤泡性腺瘤1例.观察手术时间、术中出血量、术后住院时间及术后并发症情况.结果 均成功完成手术,无中转开放,手术时间65 min(45～110 min),术中出血量13 mL(5 ～ 30 mL),术后平均住院时间5d(3～8d).术后仅2例刻下皮肤小块淤斑,术后均予口服补充优甲乐.无皮下积液感染,无喉上神经、喉返神经损伤,无甲状旁腺功能低下.所有患者颈部及体表无任何该手术相关疤痕,对美容效果很是满意.结论 中国人下颌骨颏部较扁平,经口腔前庭腔镜甲状腺切除术操作难度不高,手术安全可行,术后美容效果好,值得推广应用.     

Robotic natural orifice transluminal endoscopic surgery (R-NOTES): Literature review and prototype system

In minimally invasive surgery methods such as laparoscopic surgery, surgical instruments are introduced through small incisions to minimize patient trauma and recovery times. To reduce the number of incisions, new techniques such as natural orifice transluminal endoscopic surgery (NOTES) have been proposed. Compared to laparoscopic surgery, the NOTES approach, which requires new technology and improved instruments, presents some unique challenges. Robotic NOTES (R-NOTES) could be an enabling technology for these procedures. In this paper, we first review relevant work in R-NOTES. We then present our work and the system architecture for an R-NOTES prototype system incorporating wireless command and control. The system was tested twice in swine animal studies.     

Gastric lymphatic basin dissection for sentinel node biopsy using hybrid natural orifice transluminal endoscopic surgery (NOTES)

Abstract

The aim of the present study was to describe a method of gastric lymphatic basin dissection for sentinel node biopsy using natural orifice transluminal endoscopic surgery with laparoscopic assistance (hybrid NOTES) in a porcine model. Lymph node dissection was performed in three healthy female domestic farm pigs (each around 40 kg) between October, 2007, and December, 2007. The pigs were administered a general anesthetic and laparoscopy-guided transvaginal colpotomy was performed. A two-channel endoscope was then inserted through the incision into the peritoneal cavity via the transvaginal route. An endoscope was inserted simultaneously into the mouth and indocyanine green solution was injected into the submucosal layer of the gastric wall at four sites. Dyed omentum and lymphatics were dissected using a laparoscopic dissector and the grasping forceps of a transvaginal endoscope. Lymphatics and omentum (mean 13.3 cm, range 8–20 cm) were removed transvaginally. The mean number of detected and resected sentinel nodes was 2.6 (range 1–4, diameter 2～12 mm). Sentinel lymphatic basin dissection was performed successfully and without intraoperative complications in all three cases. Hybrid NOTES is technically feasible, and this procedure may represent an alternative to laparoscopic sentinel lymph node dissection of the stomach.     

Emergency transvaginal hybrid natural orifice transluminal endoscopic surgery

In a clinical series, 10 consecutive female patients with intra-abdominal infections were successfully treated with natural orifice transluminal endoscopic surgery (NOTES) performed transvaginally. The surgery, which consisted of a hybrid NOTES procedure using a transvaginal approach, was performed on an emergency basis by the surgical team on call. The indications for surgery were acute cholecystitis (n?=?6), acute appendicitis (n?=?2), and pelvic peritonitis (n?=?2) with intra-abdominal infection. The procedure was successfully performed in all patients using a dual-channel endoscope and mini-laparoscopy assistance. This is the first clinical series in which NOTES has been performed on an emergency basis to treat intra-abdominal infections. Transvaginal surgery for intra-abdominal infection is a feasible procedure for groups experienced in the elective NOTES approach.