The NOTES approach to management of urinary bladder injury

Background and Objectives:

Inadvertent bladder injury is a potential complication of various urological and pelvic surgeries. Bladder injury can also be a complication of natural orifice transluminal endoscopic surgery (NOTES). The aim of this study was to test the feasibility of a NOTES approach to repair bladder lacerations in a blinded porcine study.

Methods:

Intentional bladder lacerations were made to mimic accidental injury during NOTES in 7 pigs. In 3 animals, the site of bladder injury was identified and repaired by a blinded endoscopist. Bladder laceration and transluminal access sites were closed with Endoclips. Leak test was performed to confirm adequate closure. Survival animals were monitored postoperatively and surgical sites were inspected for abscess, bleeding, or damage to surrounding structures at necropsy.

Results:

Complete endoscopic closure of bladder injuries was achieved in all 7 animals with a negative leak test. The site of laceration was successfully identified by the blinded endoscopist and repaired in all 3 animals in which it was attempted. Survival animals had an uneventful postoperative course without any complications.

Conclusion:

This blinded feasibility study shows that urinary bladder injury occurring during NOTES can be successfully managed via a NOTES approach using currently available endoscopic accessories.     

Systemic Inflammatory Response After Natural Orifice Translumenal Surgery: Transvaginal Cholecystectomy in a Porcine Model

Objective:

We analyzed circulating TNF-α and IL-6 to determine systemic inflammatory responses associated with transvaginal cholecystectomy in a porcine model.

Methods:

Six female pigs were used for a survival study after transvaginal cholecystectomy (NOTES group) using endoscopic submucosal dissection (ESD) instruments and a single-channel endoscope. Blood was drawn preoperatively and 24 hours and 48 hours postoperatively. Four pigs were used as controls. In addition, laparoscopic cholecystectomy was performed in 2 pigs for laparoscopic control.

Results:

In all 6 pigs in the NOTES group, no major intraoperative complications occurred. No significant differences were found between control, laparoscopic, and NOTES groups in terms of preoperative IL-6 level (P=0.897) and at 24 hours (P=0.790), and 48 hours postoperatively (P=0.945). Similarly, there was no significant difference in mean preoperative (P=0.349) and mean day 2 postoperative TNF-α levels (P=0.11). But a significant increase in day 1 postoperative TNF-α levels in the laparoscopic group compared with that in the control and NOTES groups was observed (P=0.049). One limitation of our study is that the sample size was relatively small.

Conclusion:

NOTES is safe in animal models in terms of anatomical and cellular level changes with minimal systemic inflammatory host responses elicited. Further study needs to be carried out in humans before NOTES can be recommended for routine use.     

Safety of Culdotomy as a Surgical Approach: Implications for Natural Orifice Transluminal Endoscopic Surgery

Objective:

To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES).

Methods:

A retrospective chart review of women undergoing culdotomy for tubal sterilization (N=219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications.

Results:

No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P = .068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI <30 (11.4% versus 1.5%, P = .011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries.

Conclusion:

Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.     

Pure transvesical NOTES uterine horn resection in swine as an appendectomy model

Background

Because of size limitation, the lack of reliable instruments, and bladder closure methods, transvesical natural orifice translumenal endoscopic surgery (NOTES) is still in its infancy. The porcine uterine horn is similar to the human vermiform appendix. Therefore, the resection of the porcine uterine horn is an established animal model for the human appendectomy. In this study, we evaluated the feasibility of a pure transvesical NOTES approach to uterine horn resection in a porcine model.

Methods

We performed five operations on three female pigs (30?C35?kg) under general anesthesia in the Trendelenburg position. The laparoscope at the umbilicus was used only for the purpose of documentation. We used a rigid ureteroscope and a customized access system that prevented gas leakage and facilitated in-and-out passage of the instruments. A vesicostomy was created on the posterolateral bladder wall by using a needle knife through the channel of the ureteroscope. The uterine horn resection was performed by using an electric needle knife, hot forceps, and a polypectomy snare through the access system placed in vesicostomy. Bladder closure was performed with extracorporeal ties using metal clip tagged threads and a knot-pusher.

Results

We successfully performed the pure transvesical NOTES uterine horn resections. The mean total operative time was 141.8 (±58.7) min, and blood loss was minimal in all cases. No leakage was observed at the bladder repair sites after filling with normal saline. The removed uterine horns were approximately 6?C12-cm long and 0.6?C0.8?cm in diameter. On final inspection, the urethras were not damaged.

Conclusions

This study demonstrates the feasibility of a pure transvesical NOTES uterine horn resection in a porcine model. To the best of our knowledge, this is the world??s first report on a pure transvesical NOTES with a therapeutic purpose. This study shows the potential for adoption of the transvesical approach in NOTES procedures.     

Development of tasks and evaluation of a prototype forceps for NOTES

Background and Objectives:

Few standardized testing procedures exist for instruments intended for Natural Orifice Translumenal Endoscopic Surgery. These testing procedures are critical for evaluating surgical skills and surgical instruments to ensure sufficient quality. This need is widely recognized by endoscopic surgeons as a major hurdle for the advancement of Natural Orifice Translumenal Endoscopic Surgery.

Methods:

Beginning with tasks currently used to evaluate laparoscopic surgeons and instruments, new tasks were designed to evaluate endoscopic surgical forceps instruments.

Results:

Six tasks have been developed from existing tasks, adapted and modified for use with endoscopic instruments, or newly designed to test additional features of endoscopic forceps. The new tasks include the Fuzzy Ball Task, Cup Drop Task, Ring Around Task, Material Pull Task, Simulated Biopsy Task, and the Force Gauge Task. These tasks were then used to evaluate the performance of a new forceps instrument designed at Pennsylvania State University.

Conclusions:

The need for testing procedures for the advancement of Natural Orifice Translumenal Endoscopic Surgery has been addressed in this work. The developed tasks form a basis for not only testing new forceps instruments, but also for evaluating individual performance of surgical candidates with endoscopic forceps instruments.     

Laparoendoscopic Single-site and Natural Orifice Transluminal Endoscopic Surgery in Urology: A Critical Analysis of the Literature

Context

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery.

Objective

To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology.

Evidence acquisition

A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology.

Evidence synthesis

In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES.

Conclusions

NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.     

Total Laparoscopic Hysterectomy Utilizing a Robotic Surgical System

Objectives:

To describe the use of a robotic surgical system for total laparoscopic hysterectomy.

Methods:

We report a series of laparoscopic hysterectomies performed using the da Vinci Robotic Surgical System. Participants were women eligible for hysterectomy by standard laparoscopy. Operative times and complications are reported.

Results:

We completed 10 total laparoscopic hysterectomies between November 2001 and December 2002 with the use of the da Vinci Robotic Surgical System. Operative results were similar to those of standard laparoscopic hysterectomy. Operative time varied from 2 hours 28 minutes to 4 hours 37 minutes. Blood loss varied from 25 mL to 350 mL. Uterine weights varied from 49 g to 227 g. A cystotomy occurred in a patient with a history of a prior cystotomy unrelated to the robotic system.

Conclusion:

Total laparoscopic hysterectomy is a complex surgical procedure requiring advanced laparoscopic skills. Tasks like lysis of adhesions, suturing, and knot tying were enhanced with the robotic surgical system, thus providing unique advantages over existing standard laparoscopy. Total laparoscopic hysterectomy can be performed using robotic surgical systems.     

Transperitoneal Transvesical Laparoscopic Repair of Vesicovaginal Fistulae: Experience of a Tertiary Care Centre in Northern India

Objective

To present our experience of treating supratrigonal vesicovaginal fistulae by laparoscopic technique and their long-term follow-up.

Material and Methods

Between January 2008 and June 2012, 28 cases of supratrigonal fistulas were repaired by laparoscopic transperitoneal transvesical technique with interposition flap. The obstetric fistula was present in 18 and gynecologic fistula in 10 patients. Single supratrigonal fistula was present in 26 patients and in 2 patients there were 2 fistulae lying side to side. The vaginal opening was closed as single layer interrupted suture and cystotomy closed as single layer continuous suture by 3-0 polygalactin. The omentum was used as interposition flap in all except 2 cases in whom postero-superior vesical fold of peritoneum was used. The open conversion was required in 2 cases. The urethral catheter was removed in 4 weeks following a micturating cystogram.

Result

The mean fistula size was 1.2 cm (range 0.8-2.5 cm). Open conversion was performed in 2 cases of whom one had excess carbon-dioxide retention and cardiac arrhythmia and in another case the needle of 3-0 polygalactin was avulsed and lost in peritoneal cavity which was recovered following laparotomy. All patients were continent following the catheter removal. The median follow-up is 24 months. None developed any complication related to laparoscopic repair till last follow-up.

Conclusion

Laparoscopic repair of supratrigonal vesicovaginal fistulae is an effective and safe minimally invasive treatment with excellent result.Key Words: Transperitoneal approach, Laparoscopic surgery, Vesicovaginal fistulae     

Natural Orifice-Assisted Laparoscopic Appendectomy

Background and Objectives:

Natural orifice transluminal endoscopic surgery involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. We report the utilization of the vaginal opening at the time of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy as a natural orifice for appendectomy.

Methods:

We reviewed cases of 42 patients who underwent total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy followed by appendectomy, performed by applying a stapler and removing the appendix transvaginally. By using a small-diameter laparoscope, the appendix was mobilized, especially in patients with adhesions, endometriosis, or retrocecal appendix, to facilitate transvaginal access with the stapler.

Results:

All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 5 minutes to 10 minutes. Appendiceal pathology included serosal adhesions (14), fibrous obliteration of the lumen (12), endometriosis (4), serositis (2), and carcinoid tumor (1), among others.

Conclusions:

Appendectomy performed with an endoscopic stapler introduced transvaginally for amputation and retrieval following total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy appears to be a safe and effective modification of established techniques with acceptable outcomes.     

Pure transvesical NOTES appendectomy using a 5-mm rigid laparoscope: a feasibility and survival study with porcine models

Background

Previously, the authors demonstrated the feasibility of a pure transvesical natural orifice translumenal endoscopic surgery (NOTES) for uterine horn resection (UHR) using a rigid ureteroscope in swine as an appendectomy model. However, visualization was poor, and there was room for improvement. The authors have assessed the feasibility and safety of a revised technique that uses a 5-mm rigid laparoscope.

Methods

Eight operations on four female pigs (35–40 kg) were performed as a proof of concept study. Four right-side operations were performed in a survival model. The surgical procedure was similar to the original technique. However, the rigid ureteroscope was replaced by a 5-mm laparoscope after modification of the access system. In addition, the clipped metal threads used for bladder closure were easily placed with a long 13-gauge needle. In the survival model, a Foley catheter was placed for 1 day.

Results

The new technique provided considerably better visualization and operability than the original technique. The mean total operative time was 96.6 ± 18.2 min, and the mean estimated blood loss was 15.0 ± 13.5 ml. On postoperative day 3, pig 2 in the survival study died of peritonitis resulting from a small bowel injury. The lab results for the other pigs demonstrated no adverse events and tolerable immune responses. Necropsy showed complete healing of the vesicotomy.

Conclusions

The revised transvesical NOTES UHR technique improved the outcomes and feasibility of the original technique. This approach may be translatable to human appendectomy procedures in the future.     

Transvaginal Repair of a Large Chronic Porcine Ventral Hernia with Synthetic Mesh Using NOTES

Background:

Ventral incisional hernias still remain a common surgical problem. We tested the feasibility of transvaginal placement of a large synthetic mesh to repair a porcine hernia.

Methods:

Seven pigs were used in this survival model. Each animal had creation of a 5-cm hernia defect and underwent a transvaginal repair of the defect with synthetic mesh. A single colpotomy was made using a 12-cm trocar for an overtube. The mesh was cut to size and placed through the trocar. A single-channel gastroscope with an endoscopic atraumatic grasper was used for grasping sutures. Further fascial sutures were placed every 5cm.

Results:

Mesh repair was feasible in all 7 animals. Mean operative time was 133 minutes. Technical difficulties were encountered. No gross contamination was seen at the time of necropsy. However, 5 animals had positive mesh cultures; 7 had positive cultures in the rectouterine space in enrichment broth or on direct culture.

Conclusion:

Transvaginal placement of synthetic mesh to repair a large porcine hernia using NOTES is challenging but feasible. Future studies need to be conducted to develop better techniques and determine the significance of mesh contamination.     

VIDEO-ASSISTED ANAL FISTULA TREATMENT: TECHNICAL CONSIDERATIONS AND PRELIMINARY RESULTS OF THE FIRST BRAZILIAN EXPERIENCE

Backgroung

Anorectal fistula represents an epithelized communication path of infectious origin between the rectum or anal canal and the perianal region. The association of endoscopic surgery with the minimally invasive approach led to the development of the video-assisted anal fistula treatment.

Aim

To describe the technique and initial experience with the technique video-assisted for anal fistula treatment.

Technique

A Karl Storz video equipment was used. Main steps included the visualization of the fistula tract using the fistuloscope, the correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening which can be accomplished through firing a stapler, cutaneous-mucosal flap, or direct closure using suture.

Results

The mean distance between the anal verge and the external anal orifice was 5.5 cm. Mean operative time was 31.75 min. In all cases, the internal fistula opening could be identified after complete fistuloscopy. In all cases, internal fistula opening was closed using full-thickness suture. There were no intraoperative or postoperative complications. After a 5-month follow-up, recurrence was observed in one (12.5%) patient.

Conclusion

Video-assisted anal fistula treatment is feasible, reproducible, and safe. It enables direct visualization of the fistula tract, internal opening and secondary paths.     

A simple, effective technique for port-site closure after laparoscopy

Background and Objectives:

Fascial closure of port sites represents a challenging issue in laparoscopic surgery. The aim of this article is to introduce a procedure that allows the safe suturing of the abdominal fascia in these wounds.

Methods:

We herein describe a simple technique for fascial closure after laparoscopy using a transcutaneous approach and standard surgical instruments for suture.

Results:

The method was used in 34 patients with no intraoperative incidents and no port-site hernias during a mean follow-up of 23.9 months (median 20.5, range 5 to 47).

Conclusion:

The procedure is easy to perform, safe, fast, and inexpensive.     

Robotic-Assisted Laparoscopic Nephroureterectomy and Bladder Cuff Excision

Background and Objectives:

Our aim was to show that bladder cuff excision and distal ureterectomy can be safely performed by using the LigaSure device during robotic-assisted laparoscopic nephroureterectomy.

Methods:

A 60-year-old man presented with gross hematuria. He was diagnosed with upper urinary tract transitional cell carcinoma (TCC) on the left side and was scheduled for robot-assisted laparoscopic surgery. Without changing the patient''s position, sealing with the LigaSure atlas for bladder cuff excision and distal ureterectomy was performed.

Results:

The operating time was 140 minutes from the initial incision to skin closure of all incisions. The estimated blood loss during the surgery was 120mL. There were no intraoperative or postoperative complications. The Foley drain was removed on day 3 after normal cystographic findings, and the patient was discharged from the hospital on the fourth postoperative day.

Conclusion:

Robot-assisted nephroureterectomy with distal ureterectomy in the same position using a LigaSure device is a safe alternative for upper tract transitional cell carcinoma.     

Transvaginal Cholecystectomy without Abdominal Ports

Background:

Pioneers in natural orifice transvaginal cholecystectomy are in search of an approach that uses less percutaneous assistance. The approach must be safe and affordable. The authors present a successful cholecystectomy using a technique of transvaginal operative laparoscopy with no abdominal ports.

Methods:

A 24-year-old female patient with gallbladder lithiasis underwent a natural orifice cholecystectomy with only one transvaginal 12-mm port, using a laparoscope with a working channel. We used laparoscopic instruments 5 mm in diameter by 43cm in length (including a needle holder, Maryland dissector clamp, spatula, hook, suction cannula, and clip applier) and assistance with percutaneous marionette leashes.

Results:

The patient stayed in the hospital for 24 hours and was discharged without pain and without scars.

Conclusion:

Transvaginal cholecystectomy performed using an operative laparoscope with a working channel is possible in select cases. This technique requires no abdominal ports and is an alternative to culdolaparoscopy or hybrid transvaginal procedures with flexible endoscopes.     

Combined treatment of symptomatic massive paraesophageal hernia in the morbidly obese

Introduction:

Repair of large paraesophageal hernias by itself is associated with high failure rates in the morbidly obese. A surgical approach addressing both giant paraesophageal hernia and morbid obesity has, to our knowledge, not been explored in the surgical literature.

Methods:

A retrospective review of a bariatric surgery database identified patients who underwent simultaneous repair of large type 3 paraesophageal hernias with primary crus closure and Roux-en-Y gastric bypass (RYGB). Operative time, intraoperative and 30-day morbidity, weight loss, resolution of comorbid conditions and use of anti-reflux medication were outcome measures. Integrity of crural closure was studied with a barium swallow.

Results:

Three patients with a mean body mass index of 46kg/m² and mean age of 46 years underwent repair of a large paraesophageal hernia, primary crus closure, and RYGB. Mean operative time was 241 minutes and length of stay was 4 days. There was no intraoperative or 30-day morbidity. One patient required endoscopic balloon dilatation of the gastrojejunostomy. At 12 months, all patients were asymptomatic with excellent weight loss and resolution of comorbidities. Contrast studies showed no recurrence of the hiatal hernia.

Conclusion:

Simultaneous laparoscopic repair of large paraesophageal hernias in the morbidly obese is safe and effective.     

Endourological Treatment of Foreign Bodies in the Urinary System

Background and Objectives:

In this retrospective study, nature, clinical presentations, diagnostic modalities, and endoscopic treatment of urinary system foreign bodies were evaluated.

Methods:

A total of 8 cases were treated with endoscopic surgery between February 15, 2007 and June 12, 2012. Clinical findings, radiologic diagnosis, and management were reviewed.

Results:

We observed that urinary tract foreign bodies were generally secondary to iatrogenic causes; however, bladder/urethral foreign bodies could also be due to self-insertion. Clinical findings were different secondary to their location in the urinary system. All foreign bodies were treated endoscopically.

Conclusions:

Foreign bodies of the urinary system can successfully be treated with endoscopic modalities without any complications.     

Hybrid Transureteral Nephrectomy in a Survival Porcine Model

Background and Objectives:

Natural-orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. Recently, the feasibility of using the ureter as a natural orifice for natural-orifice transluminal endoscopic surgery nephrectomy has been demonstrated in a nonsurvival porcine model. The purpose of this study was to assess the outcomes of transureteral laparoscopic natural-orifice transluminal endoscopic surgery nephrectomy in a survival porcine model.

Methods:

Three pigs underwent hybrid transureteral natural-orifice transluminal endoscopic surgery nephrectomy. An experimental balloon/dilating sheath was inserted over a wire to dilate the urethra, ureteral orifice, and ureter. Through a bariatric 12-mm laparoscopic port, the ureter was opened medially and the hilar dissection was performed. Next, 2 needlescopic ports were placed transabdominally to facilitate hilar transection. The kidney was morcellated using a bipolar sealing device and extracted via the ureter using the housing of a bariatric stapling device. The ureteral orifice was closed with a laparoscopic suturing device. The bladder was drained by a catheter for 10 to 14 days postoperatively. Pigs were euthanized on postoperative day 21.

Results:

All surgical procedures were successfully completed, with no intraoperative complications. One pig had an episode of postoperative clot retention that resolved with catheter irrigation. Each pig was healthy and eating a normal diet prior to euthanasia.

Conclusions:

This study demonstrates the feasibility of a hybrid transureteral approach to nephrectomy in a survival porcine model. This technique avoids the intentional violation of a second organ system and the risk for peritoneal contamination. Improved instrumentation is needed prior to implementation in the human population.     

Small bowel obstruction after FloSeal use

Objective:

FloSeal is a thrombin-gelatin hemostatic matrix that is used to obtain hemostasis. There have been isolated case reports of FloSeal causing bowel obstructions, requiring surgical intervention. We report 3 cases of what we believe were FloSeal-induced small bowel obstructions (SBO).

Methods:

We present a series of small bowel obstructions after FloSeal use. Our series includes urology, gynecologic oncology, and general surgery cases at the same institution where the product was appropriately used and resulted in the same complication.

Results:

FloSeal was used for hemostasis in all patients. In each instance, a small bowel obstruction developed in 7 days to 9 days. All patients were reexplored laparoscopically and found to have an intense inflammatory reaction at the site of the FloSeal. The adhesions were lysed and the obstructions resolved.

Conclusions:

Although further study is needed, the common factor in all these SBOs was a hemostatic agent. In our and others’ series, the time to SBO was 7 days to 9 days. If an early postoperative SBO occurs after FloSeal is used, prompt reexploration should be considered.