Hybrid minimally invasive surgery—a bridge between laparoscopic and translumenal surgery

Background The peroral transluminal approach to the peritoneal cavity appears safe, feasible, and may further reduce the invasiveness of surgery. However, flexible endoscopes have multiple limitations inside the peritoneal cavity, which can potentially be overcome by blending the use of both a laparoscope and a flexible upper endoscope—a hybrid approach. The goal of the present study was to evaluate a hybrid minimally invasive technique for cholecystectomy in a porcine model. Methods Hybrid cholecystectomies were performed in acute experiments on 50-kg pigs under general anesthesia. Pneumoperitoneum was created with a Veress needle, and a laparoscopic 10-mm port was inserted. Under laparoscopic observation, the gastric wall incision was done with an endoscopic needle-knife and sphincterotome, and the upper endoscope was advanced into the peritoneal cavity. A laparoscopic 10-mm port was inserted into the right upper quadrant of the abdomen for gallbladder traction to facilitate exposure of the cystic duct and artery. Via the biopsy channel of the flexible endoscope, and using a knife with an isolated tip, a needle knife, and clips, both the cystic duct and artery were identified, clipped, and transected. The gallbladder itself was then dissected and retracted through the mouth, and the gastric wall incision was closed with endoscopic clips. Results Five hybrid cholecystectomies were performed without complications. The laparoscopic port enabled a stable pneumoperitoneum, good traction and counter-traction, and improved spatial orientation and visualization. Necropsy did not reveal any intraperitoneal complications. Conclusions The hybrid approach increases safety of initial gastric puncture and gastric wall incision, improves orientation and navigation of the flexible endoscope inside the peritoneal cavity, simplifies peroral transgastric cholecystectomy, and could be used to decrease invasiveness of laparoscopic surgery and to facilitate development and clinical introduction of transgastric endoscopic procedures. Electronic Supplementary Material The online version of this article (doi:) contains supplementary material, which is available to authorized users. This work was presented in part at SAGES Annual Meeting, Dallas, Texas, April 2006     

Hybrid transvaginal cholecystectomy: a novel approach

Natural Orifice Transluminal Endoscopic Surgery (NOTES) allows cholecystectomy to be performed by means of a flexible scope introduced through the stomach, rectus, bladder, or vagina. However, available endoscopes have several limitations if used in the peritoneal cavity. The hybrid technique reported overcomes these limitations by using conventional 5-mm laparoscopic instruments through the umbilical scar and transabdominal sutures for retraction. After creating the pneumoperitoneum with a Veress needle, a 5-mm port is introduced into the umbilicus followed by a 5-mm, 30° scope. A culdotomy then is performed under direct and laparoscopic views. The flexible endoscope is inserted into the pelvis through the vagina and advanced to expose the gallbladder. Three or more transabdominal sutures are placed through the gallbladder wall for retraction. Cholecystectomy then is performed using conventional 5-mm laparoscopic instruments through the 5-mm umbilical port. Finally, stay sutures are removed and the specimen is retrieved through the vagina. Six patients successfully have undergone this new procedure. In our opinion this hybrid approach increases safety, overcomes the limitation of the current instrumentation, and maintains most of the advantages of Natural Orifice Transluminal Endoscopic Surgery.     

Per-oral dual scope NOTES cholecystectomy in porcine model (with video)

Background  

Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument [1–3]. Therefore, “pure NOTES” transgastric cholecystectomy has not yet been described. The authors successfully performed “pure NOTES” transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure [4]) that allows completion of the procedure by pure NOTES without an external instrument.     

Flexible robotics: a new paradigm

PURPOSE OF REVIEW: The use of robotics in urologic surgery has seen exponential growth over the last 5 years. Existing surgical robots operate rigid instruments on the master/slave principle and currently allow extraluminal manipulations and surgical procedures. Flexible robotics is an entirely novel paradigm. This article explores the potential of flexible robotic platforms that could permit endoluminal and transluminal surgery in the future. RECENT FINDINGS: Computerized catheter-control systems are being developed primarily for cardiac applications. This development is driven by the need for precise positioning and manipulation of the catheter tip in the three-dimensional cardiovascular space. Such systems employ either remote navigation in a magnetic field or a computer-controlled electromechanical flexible robotic system. We have adapted this robotic system for flexible ureteropyeloscopy and have to date completed the initial porcine studies. SUMMARY: Flexible robotics is on the horizon. It has potential for improved scope-tip precision, superior operative ergonomics, and reduced occupational radiation exposure. In the near future, in urology, we believe that it holds promise for endoluminal therapeutic ureterorenoscopy. Looking further ahead, within the next 3-5 years, it could enable transluminal surgery.     

Experience with a new 3-mm laparoscope in complex neonatal minimally invasive surgery: a preliminary report

Neonatal minimally invasive surgery requires small, light-weight instruments and excellent image quality to be performed safely and efficiently. We performed laboratory studies comparing the image quality of a new 3-mm 14-cm telescope with a 5-mm 25-cm telescope with identical viewing angles and found they were very similar. We employed the new 3-mm telescope exclusively in endosurgical procedures on 5 infants weighing less than 4 kg and found the image quality and light intensity to be more than adequate. In addition, we found the shorter length and lighter weight easier to maneuver in the limited working space of the neonatal abdomen or hemithorax. Our experience with the new 3-mm telescope is superb for the demands of complex neonatal endosurgical procedures.     

New applications for endoscopy: the emerging field of endoluminal and transgastric bariatric surgery

Endoluminal and transgastric procedures are evolving concepts that combine the skills and techniques of flexible endoscopy with minimally invasive surgery. Precisely how this technology and skill set will be applied in the field of general surgery is not yet known, but the treatment of obesity with an endoluminal or transgastric procedure holds great promise. As the demand for bariatric surgery increases, efforts will be directed toward developing less morbid and less costly treatment options that can provide substantial weight loss and resolution of comorbid conditions. Natural orifice bariatric procedures may include short-term weight loss in preparation for a definitive laparoscopic procedure, revisional procedures to reduce stoma or pouch size or repair fistulas, or primary therapy that provides durable weight loss. The latter application will undoubtedly appeal to patients and referring physicians if it can be performed as an outpatient procedure with significantly less morbidity than a laparoscopic procedure. Early preclinical and clinical work has been published in this area, but many technical obstacles must be overcome before a primary endoluminal or transgastric bariatric procedure can be offered. This article reviews the endoluminal and transgastric technology currently available, the endoluminal procedures currently performed, and the future of these technologies with respect to bariatric surgery.     

Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments

Introduction Natural orifice translumenal endoscopic surgery (NOTES) is an evolving field and suitable instruments are lacking. The purpose of this study was to perform transvaginal cholecystectomies using instruments incorporated into a magnetic anchoring and guidance system (MAGS). Methods Non-survival procedures were conducted in pigs (n = 4). Through a vaginotomy created under direct vision, a rigid access port was inserted into the peritoneal cavity and used to maintain a CO₂ pneumoperitoneum. MAGS instruments were deployed through the port and held in place on the peritoneal surface using magnetic coupling via an external handheld magnet which was optionally exchanged for an 18ga percutaneous threaded needle anchor; instruments included a tissue retractor (a clip-fixated magnet or flexible graspers) and a cautery dissector. A gastroscope was used for visualization. Results The first two procedures ended prematurely due to instrumentation shortcomings and inadvertent magnetic coupling between instruments; one case required a laparoscopic rescue. Three new forms of instrumentation were developed: (1) a longer access port (50 cm) which provided easier deployment of instruments and suitable reach, (2) a more robust cauterizer with a longer, more rigid, pneumatically deployed tip with better reach and sufficient torque to allow blunt dissection, and (3) a more versatile tissue retractor with bidirectional dual flexible graspers which provided excellent cephalad fundus retraction and inferiolateral infundibulum retraction. With these modifications, 100% of the cholecystectomy was completed in the third and fourth animals using only a NOTES/MAGS approach. Retrieval of the tissue retractor resulted in a rectal injury in the third animal but further procedural modifications resulted in a successful procedure in the fourth animal with no complications. Conclusions While still under development with more refinements needed, completely transvaginal cholecystectomy using MAGS instruments is feasible. By offering triangulation and rigidity, MAGS may facilitate a NOTES approach while alleviating shortcomings of a flexible platform.     

Retraction and triangulation with neodymium magnetic forceps for single-port laparoscopic cholecystectomy

Introduction  There have been attempts to minimize the invasiveness of laparoscopic cholecystectomy by reducing the size and/or the number of the operating ports and instruments. These attempts create technical challenges related principally to retraction and triangulation necessary to expose the surgical field for a safe surgery. A new technique based on retraction and triangulation with magnetic instruments for single port laparoscopic surgery is presented. Methods  Between March 2007 and December 2008, 40 laparoscopic cholecystectomies were performed with single-port laparoscopic surgery with the assistance of magnetic forceps (IMANLAP™ project). The surgical technique is described, and the intraoperative and postoperative course of the patients is assessed. Results  There were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. Depending on the patient’s anatomy, a 1-mm needle was added in some cases. There were no interactions observed between the magnetic devices and the anesthetic monitoring and the rest of the devices of the operation room. Conclusions  This new procedure is feasible and safe. The main goal is control of the magnetic field, allowing enough controlled strength for retraction and sufficient triangulation for adequate exposure of the surgical field. This allows for the use of a single port through which an optic device with a working channel can perform the operation with safety. Finally, the procedure can be performed in a manner similar to the traditional laparoscopic cholecystectomy, and it also appears to be simple to learn.     

Laparoscopic-assisted transgastric endoscopy: current indications and future implications.

BACKGROUND: Endoscopic access to the proximal gastrointestinal tract may prove difficult for a variety of anatomic reasons. Under laparoscopic visualization, trocars can be placed into the stomach with the subsequent introduction of a flexible endoscope directly into the body of the stomach. The purpose of this study was to describe this technique and demonstrate that it is safe, effective, and feasible. METHODS: Six patients with altered proximal foregut anatomy were examined. Five patients had previously undergone laparoscopic Roux-Y gastric bypass, and one patient had severe distal esophageal stenosis precluding distal passage of an endoscope. All patients required endoscopic retrograde cholangiopancreatography (ERCP), and one patient underwent closure of a symptomatic gastrogastric fistula. In each patient, two 5-mm ports were inserted and tacking sutures placed between the gastric body and the anterior abdominal wall. Subsequently, a flexible endoscope was inserted into the stomach through a gastrotomy under direct visualization. Picture-in-picture technology enabled simultaneous monitoring of the laparoscopic and endoscopic field. RESULTS: The operative time ranged from 64 minutes to 93 minutes. All therapeutic endoscopic procedures were successful. The anterior gastrotomies were either closed primarily or a feeding tube was placed. Patients reported minimal postoperative pain. No complications resulted from the procedures. CONCLUSION: In an age where surgeons and gastroenterologists are focusing on the stomach as an access point for transgastric endoscopic surgery, we view the stomach as a portal into the gastrointestinal tract. In patients with limited access for traditional endoluminal therapy, laparoscopic-assisted transgastric endoscopy can be performed safely and efficiently.     

Ureteroscopy under local anesthesia

Ureteroscopy has been performed with local anesthesia with and without sedation in 30 patients. Flexible endoscopes were used in 18, rigid endoscopes alone in 7, and rigid and flexible instruments in 5 patients. The flexible instruments ranged in size from 4F to 10F, while rigid instruments were 10F to 12F. Although most procedures were diagnostic, calculi were removed from the distal ureter in 4 patients and from the midureter in 1 patient. Ultrasonic lithotripsy was utilized in 1 patient. The success and tolerance of flexible or distal rigid ureteroscopy with local anesthesia permits its recommendation in carefully selected patients.     

Experience with a training program for transgastric procedures in NOTES

Introduction  

The transgastric approach to the abdominal cavity has been under experimental investigation in recent years as a method of natural orifice transluminal endoscopic surgery (NOTES). In this study our team, consisting of surgeons and gastroenterologists, focused on training techniques with currently available instruments to perform transgastric procedures. The purpose of this paper is to evaluate the learning process during the establishment of a training program for NOTES. Therefore several procedures were tested in terms of training issues such as the applicability of instruments and techniques for both gastroenterologists and surgeons.     

Minimally invasive needlescopic cholecystectomy

We utilized a mini-sized grasper and retractor measuring 2.5 mm in diameter and a new mini-sized laparoscope measuring 3 mm in diameter to perform a laparoscopic cholecystectomy. A 10/12-mm trocar was inserted as the first trocar for the laparoscope and specimen extraction. Under a direct laparoscopic view, the mini-sized grasper and retractor were inserted and the laparoscopic procedures were performed mainly through the 5-mm trocar placed on the left upper quadrant as the working port. These procedures were successfully performed on five patients with a comparable operation time to that of a conventional laparoscopic cholecystectomy, but appeared to be more minimally invasive.     

Transgastric endoscopic splenectomy

BACKGROUND: We have previously reported the feasibility of diagnostic and therapeutic peritoneoscopy including liver biopsy, gastrojejunostomy, and tubal ligation by an oral transgastric approach. We present results of per-oral transgastric splenectomy in a porcine model. The goal of this study was to determine the technical feasibility of per-oral transgastric splenectomy using a flexible endoscope. METHODS: We performed acute experiments on 50-kg pigs. All animals were fed liquids for 3 days prior to procedure. The procedures were performed under general anesthesia with endotracheal intubation. The flexible endoscope was passed per orally into the stomach and puncture of the gastric wall was performed with a needle knife. The puncture was extended to create a 1.5-cm incision using a pull-type sphincterotome, and a double-channel endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated with air through the endoscope. The spleen was visualized. The splenic vessels were ligated with endoscopic loops and clips, and then mesentery was dissected using electrocautery. RESULTS: Endoscopic splenectomy was performed on six pigs. There were no complications during gastric incision and entrance into the peritoneal cavity. Visualization of the spleen and other intraperitoneal organs was very good. Ligation of the splenic vessels and mobilization of the spleen were achieved using commercially available devices and endoscopic accessories. CONCLUSIONS: Transgastric endoscopic splenectomy in a porcine model appears technically feasible. Additional long-term survival experiments are planned.     

Pure natural orifice transluminal endoscopic surgery (NOTES) nephrectomy using standard laparoscopic instruments in the porcine model

PURPOSE: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging technology that uses endoscopic instruments passed into the peritoneal cavity through hollow viscera to perform surgical procedures without the use of abdominal incisions. There are, however, limitations regarding the equipment available to simulate traditional surgery. The aim of this study was to determine the feasibility of a pure NOTES nephrectomy by using standard laparoscopic instruments through a modified transvaginal trocar. MATERIALS AND METHODS: One 40-kg female swine underwent transgastric peritoneoscopy. Transgastric endoscopic visualization guided the introduction of a second transvaginal endoscope through a novel laparoscopic trocar/endoscopic overtube device. The retroflexed transgastric endoscope provided triangulated visualization as standard endoscopic instruments provided retraction, which allowed dissection of the kidney with standard laparoscopic instruments through our modified transvaginal trocar device. Each renal hilum, artery, vein, and ureter was dissected and divided with a transvaginal laparoscopic stapler. RESULTS: Transgastric and transvaginal NOTES accesses were easily achieved, and bilateral nephrectomies were performed. Completion of peritoneoscopy revealed complete hemostasis and identification of ligated ureters and hilar vessels. Total operative time was 40 and 20 minutes for the right and left kidney, respectively. One kidney was captured with a laparoscopic retrieval sac and removed intact through the vaginal defect. CONCLUSIONS: Pure NOTES nephrectomies are technically feasible in the porcine model by using standard laparoscopic instruments. Survival studies are necessary to determine the long-term complications and physiologic implications of NOTES nephrectomy. The development of innovative NOTES access trocars may allow for an increased armamentarium of NOTES instruments.     

Natural orifice surgery with an endoluminal mobile robot

Natural orifice transgastric endoscopic surgery promises to eliminate skin incisions and reduce postoperative pain and discomfort. Such an approach provides a distinct benefit as compared with conventional laparoscopy, in which multiple entry incisions are required for tools and camera. Endoscopy currently is the only method for performing procedures through the gastrointestinal tract. However, this approach is limited by instrumentation and the need to pass the entire scope into the patient. In contrast, an untethered miniature robot inserted through the mouth would be able to enter the abdominal cavity through a gastrotomy for exploration of the entire peritoneal cavity. In this study, the authors developed an endoluminal robot capable of transgastric abdominal exploration under esophagogastroduodenoscopic (EGD) control. Under EGD control, a gastrotomy was created, and the miniature robot was deployed into the abdominal cavity under remote control. Ultimately, future procedures will include a family of robots working together inside the gastric and abdominal cavities after their insertion through the esophagus. Such technology will help to reduce patient trauma while providing surgical flexibility.     

NOTES: cadaveric rendezvous hybrid small bowel resection

Background  Natural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques [1–4]. Before NOTES gains widespread popularity, it must be proven to be a safe and efficacious technique [5]. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation. Methods  Currently, most investigational NOTES procedures are performed using a single transgastric, transcolonic, or transvaginal access point to the abdomen. In order to provide greater range of motion and freedom of movement, a rendezvous procedure using simultaneous transgastric and transcolonic approaches was used to perform a small bowel resection. This video demonstrates a successful NOTES hybrid small bowel resection with the use of two laparoscopic ports in a cadaveric model. A powered stapling device attached to a flexible shaft is introduced transcolonically and facilitates division and re-anastamosis of the small bowel. A dual-channel operating endoscope introduced transgastrically allows for precise dissection and creation of enterotomies necessary for the small bowel resection. Conclusions  While technically challenging, NOTES hybrid small bowel resection can be accomplished with specially designed instrumentation utilizing the rendezvous technique. There are several technical limitations preventing this procedure from being completed in a pure NOTES fashion. A safe method of creating blind enterotomies will be needed to eliminate laparoscopic visualization of the enterotomy sites. Adequate endoscopic exposure and retraction of tissue is still difficult and currently requires percutaneous adjuncts. New closure devices will be needed for safe and reliable NOTES enterotomy closure. With the development of such instruments, this, as well as other NOTES procedures, will become more technically feasible. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Early experience in human hybrid transgastric and transvaginal endoscopic cholecystectomy

Background  

Abdominal procedures have been performed for a long time through the anterior abdominal wall. Since the first reports in the 1980s, laparoscopy has become the standard for cholecystectomy, with many advantages over open procedures. Now a natural-orifice approach to the peritoneal cavity may further reduce the invasiveness of surgery by either diminishing or avoiding abdominal incisions. Several orifice routes to the abdominal cavity have been described: transgastric, transvaginal, transvesical, and transcolonic. Although most experiences with the porcine model showed the possibility of these approaches, few surgeons reported experiences with humans. The authors present their complete early experience with transgastric (TG) and transvaginal (TV) cholecystectomies in human beings.     

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

Objective  This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy. Methods  Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope. Results  A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1). Conclusion  This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.     

Endoscopic orchidectomy and salpingohysterectomy of pigeons (Columba livia): an avian model for minimally invasive endosurgery

To evaluate a minimally invasive endosurgical system in birds, endoscopic orchidectomy and salpingohysterectomy were evaluated in 11 male and 14 female pigeons (Columba livia). Anesthesia was maintained by using isoflurane delivered by a pressure-cycle ventilator and produced good to excellent anesthesia during 96% of procedures. Endosurgery was performed with a 2.7-mm telescope system, 3-mm human pediatric laparoscopy instruments, and a 4.0-MHz radiofrequency device. Mean +/- SD surgery times for bilateral orchidectomy and salpingohysterectomy procedures were 39 +/- 18 minutes and 34 +/- 15 minutes, respectively. Procedures were generally straightforward, with any minor complications easily overcome. Surgical complications were generally minor, with mild hemorrhage and focal coagulative damage to the kidney being most common. All pigeons recovered quickly (20 +/- 11 minutes), with 95% displaying good to excellent recoveries. No birds exhibited any clinically apparent morbidity or mortality associated with endosurgery. At least 1 male and 1 female bird were subjected to elective euthanasia and necropsy on postoperative days 1, 3, 5, 10, 20, and 90 to determine the success and side effects of surgery. Gross and histologic abnormalities, when observed, were generally mild, with hemorrhage and partial necrosis of the cranial kidney present in 27% of males. Mild damage or hematoma associated with the left kidney was also reported in 28% of females. The surgical objectives were achieved in 23 of 25 pigeons. The 2 surgical failures (regenerated testes in a male and large oviductal remnant in a female) were attributed to endosurgical inexperience and occurred during the first procedures. Salpingohysterectomy does not appear to prevent ovarian development and ovulation in the pigeon, at least not during the first 3 postoperative months. Orchidectomy and salpingohysterectomy appear to be safe procedures when performed using appropriate equipment and techniques. Endosurgery offers a valuable, minimally invasive alternative to the standard coeliotomy techniques commonly used in birds.     

Needlescopic Cholecystectomy Versus Needlescope-assisted Laparoscopic Cholecystectomy

This clinical study was performed to compare the feasibility, safety, and best use of the needlescope and needlescopic instruments. Needlescopic cholecystectomy (NC) or needlescope-assisted cholecystectomy (NAC) was performed in 40 cases of gallbladder (GB) stone or polyp. There were 12 men and 28 women, with a mean age of 51.8 years (range, 27 to 79 y). The port sites consisted of three 2-mm ports at the right upper quadrant and one 12-mm port at the umbilicus. To evaluate the feasibility and safety of the needlescope, the time taken to perform each operative step was compared for NC and NAC. Operation time was divided into: (1) skin incision to insertion of the 4 ports; (2) insertion of the 4 ports to cannulation into the cystic duct; (3) time of intraoperative cholangiography (IOC); (4) skin incision to cutting of the cystic duct without IOC; (5) cutting the cystic duct to dissection of the GB; (6) dissection of the GB to removal of the GB; (7) removal of the GB to skin closure; and (8) total operation time. IOC was performed successfully in 10 cases of NC and 10 cases of NAC. Respective mean times of the 8 steps were 5.4 versus 5.3 minutes, 34.2 versus 32.2 minutes, 20.1 versus 18.4 minutes, 33.9 versus 31.3 minutes, 19.6 versus 18.9 minutes, 3.1 versus 2.9 minutes, 10.0 versus 10.2 minutes and 82.5 versus 77.8 minutes for NC versus NAC, respectively. There were no significant differences in any of the factors related to surgical procedures between the 2 groups, and there were no perioperative complications. The use of a needlescope and needlescopic instruments was feasible and safe for laparoscopic cholecystectomy in both surgical laparoscopic procedures for highly selected patients.