经自然腔道内镜手术的研究进展

近年来,经自然腔道内镜手术已在全球取得了长足的发展.目前,已有大量经自然腔道内镜手术应用于实验动物及人体,如经阴道胆囊切除术、经阴道阑尾切除术、经胃阑尾切除术、经膀胱腹腔镜检术等.本文就目前经自然腔道内镜手术的研究进展及面临的挑战作一综述.     

经自然腔道内镜技术和单孔腹腔镜技术在结直肠外科手术中的应用

经自然腔道内镜手术（NOTES）和单孔腹腔镜手术（LESS）是当今国际微创外科领域的研究与临床应用热点。NOTES技术尚待进一步的发展．而LESS技术是现阶段最可行的体表“无疤痕”技术。是NOTES技术的过渡阶段。虽然腹腔镜辅助的NOTES结直肠手术和完全的NOTES结直肠手术已经见诸报道．但是该手术目前仍然主要处于动物试验阶段。LESS技术在结直肠手术中的应用已经较为广泛．其可行性已经为较多的文献资料证实．而其是否符合肿瘤根治原则尚需进一步的研究确定。     

Natural orifice transluminal endoscopic surgery and localized resection for colorectal neoplasia

Modern methods of surgical intervention have the potential to provide effective, definitive management of early stage colorectal neoplasia by truly minimally invasive means. Margin-free clearance of early colonic neoplasia from within the intestinal lumen can already now be effected by endoscopic submucosal dissection in the colon and transluminal endoscopic microsurgery (TEM) in the rectum. Natural orifice transluminal endoscopic surgery (NOTES) offers the potential for providing transmural, full thickness excision as TEM does but at sites in the colon proximal to the rectum. The next conceptual advance required to make this practice an effective reality lies in evolving surgical regional staging strategies to effectively partner localized resective approaches and allow their deployment as definitive curative therapy. As the most compelling modality for nodal status ascertainment in the absence of lymphatic basin excision for other malignant disease processes, it seems timely to reconsider sentinel node biopsy in cancer of the colon and rectum. Whether by this means or indeed any other, such an ability to confidently identify patients with node negative disease would allow nascent innovative techniques flourish as definitive management for confined (N0) T1 and T2 cancers and so allow the application of available advanced technology for clinical benefit. Conversely, the development of a specific clinical niche for NOTES (whether, as here, for full thickness localized colonic excision or nodal staging alone) would greatly benefit the evolution and incorporation of this surgical strategy into clinical care paradigms.     

结直肠肿瘤类-NOTES手术实践与关键技术

结直肠肿瘤类-NOTES手术具有创伤小、恢复快等优势。与传统腹腔镜手术比较,该技术的最大特点在于经自然腔道取标本以及独特的消化道重建方式与技巧。随着结直肠肿瘤类-NOTES手术的不断推广,类-NOTES手术的相关技术要点也在逐步积累完善,其术后疗效也在获得证实。当然,类-NOTES手术想要更好的普及和发展,建立起一系列完整详细的技术规范体系是至关重要的,这也需要从解剖学、手术技术、手术方式等多个方面来综合考虑。本文就结直肠肿瘤类-NOTES手术的实践经验和技术要点谈一下个人的心得体会。     

Natural orifice hysterectomy

Minimally invasive surgery (MIS) such as natural orifice surgery is perceived as a relatively recent development partly because many MIS techniques utilize new technology and devices. However, a natural orifice/MIS approach for hysterectomy (vaginal hysterectomy, VH) has existed for over a century. VH is typically thought of in the realm of the urogynecologist as a component of reconstructive pelvic surgery for pelvic organ prolapse. However, current evidence supports the use of VH in women with other benign conditions such as uterine fibroids and abnormal bleeding. Despite the evidence and availability of several MIS options for hysterectomy, the majority of hysterectomies continue to be performed via laparotomy. VH is the least invasive approach to hysterectomy, and its use should be encouraged as the preferred MIS option for women requiring uterine removal for benign conditions.     

Natural orifice transluminal endoscopic surgery: Educational challenge

Natural orifice translumenal endoscopic surgery (NOTES) training is unique in that it crosses specialty lines and most practitioners do not possess both the knowledge and skill to perform the procedures in their current form. The learning process becomes even more complex because the field is in constant evolution with advances in technology and technique being introduced almost daily! The challenges of learning NOTES illustrates a larger problem in all procedurally based medical specialties today-the pace of change has become so rapid that a practicing physician's technical skills become out of date within five to ten years of completing residency or fellowship training. As a result, practicing physicians must develop a strategy to rapidly learn about a new technique or technology and introduce it safely into their practice while satisfying the concerns of their hospital's credentialing committee. This chapter will explore the options for learning new procedures and discuss the rapidly expanding armamentarium of education institutes and the developing technology to measure procedural competence.     

超声刀在腹腔镜直肠全系膜切除术中的临床应用

目的探讨超声刀在腹腔镜直肠全系膜切除术（Total mesorectal excision，TME）的临床应用价值。方法我院自2004年8月～2007年5月。应用超声刀在腹腔镜下对33例直肠癌患者实施TME术。结果33例患者手术顺利，无中转开腹，手术时间115～320min，平均155min；术中出血10～100ml，平均50ml；术后1～2d恢复胃肠功能并下床活动。住院时间5—14d，平均8d。术中及术后无并发症发生。术后随访1月至3年，无复发。结论应用超声刀行腹腔镜TME术，保肛率高，创伤小，出血少，烟雾少。术后恢复快，是一极具应用前景的微创外科新技术。     

Short-Term Outcomes After Robotic-Assisted Total Mesorectal Excision for Rectal Cancer

Background Laparoscopic total mesorectal excision for rectal cancer remains a difficult procedure with high conversion rates. We have sought to improve on some of the pitfalls of laparoscopy by using the DaVinci robotic system. Here we report our two-year experience with robotic-assisted laparoscopic surgery for primary rectal cancer. Methods A prospectively maintained database of all rectal cancer cases starting in November 2004 was created. A series of 39 consecutive unselected patients with primary rectal cancer was analyzed. Clinical and pathologic outcomes were reviewed retrospectively. Results 22 patients had low anterior, 11 intersphincteric and six abdominoperineal resections. Postoperative mortality and morbidity were % and 12.8%, respectively. The median operative time was 285 minutes (range 180–540 mins). The conversion rate was 2.6%. A total mesorectal excision with negative circumferential and distal margins was accomplished in all patients, and a median of 13 (range 7–28) lymph nodes was removed. The anastomotic leak rate was 12.1%. The median hospital stay was 4 days. There have been no local recurrences at a median follow-up of 13 months. Conclusions Robotic-assisted surgery for rectal cancer can be carried out safely and according to oncological principles. This approach shows promising short-term outcomes and may facilitate the adoption of minimally invasive rectal surgery.     

经自然腔道取标本在腹腔镜直肠癌根治术中的应用进展

直肠癌根治手术从最初提出全直肠系膜切除(TME)理念到腹腔镜广泛应用于直肠癌根治,经过30多年的迅猛发展,腹腔镜直肠癌TME手术现已成为直肠癌患者的首选术式,但是该手术用于取出肿瘤标本的腹壁辅助切口与当今微创手术理念相悖,避免腹壁切口成为胃肠外科医生和直肠癌患者共同诉求。经自然腔道取标本手术(NOSES)在全腔镜下完成直肠癌根治及消化道的重建,标本经自然腔道(直肠或者阴道)取出,无腹壁辅助切口,更符合微创实际,操作更简便。研究NOSES腹腔镜直肠癌根治术的手术进展,旨在为该术式提供一定的参考。     

腹腔镜全直肠系膜切除保肛治疗低位直肠癌(附42例报告)

目的　探讨腹腔镜下完成全直肠系膜切除 (TME)、低位 /超低位 /行结肠 -肛管吻合治疗低位直肠癌的可行性。　方法　按TME原则 ,在腹腔镜下对 4 2例低位直肠癌患者实施低位 /超低位 /结-肛吻合术。　结果　 4 2例腹腔镜TME、低位 /超低位 /结肠 -肛管吻合术均获成功 ,保肛率 10 0 %。手术时间 (110～ 2 10 )分钟 ,平均 12 5分钟 ;术中出血 (5～ 80 )ml,平均 2 0ml;术后 1～ 2天恢复胃肠功能并下床活动 ,住院时间 (5～ 14 )天 ,平均 8天。术后 18例应用了止痛剂 ,术中及术后均无并发症发生。　结论　腹腔镜下行TME低位 /超低位结肠 -肛管吻合术治疗低位直肠癌可行。具有创伤小、出血少、保肛率高、术后疼痛轻、恢复快等优点外 ,对自主神经丛的保护更准确 ,术后肛门括约肌功能、排尿功能良好     

Natural orifice transluminal endoscopic surgery (NOTES) as a diagnostic tool in the intensive care unit

Background Autopsy studies confirm that many intensive care unit (ICU) patients die from unrecognized sources of abdominal sepsis or ischemia. Computed tomography (CT) scans can be of limited use for these diagnoses and difficult to obtain in critically ill patients who require significant support for transport. Bedside laparoscopy has been described but still is cumbersome to perform. Bedside flexible endoscopy as a diagnostic tool or for placement of gastrostomy tubes is a standard ICU procedure. Natural orifice transluminal endoscopic surgery (NOTES) can provide access to the peritoneal cavity as a bedside procedure and may decrease the number of patients with unrecognized intra-abdominal catastrophic events. Methods Pigs were anesthetized and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilatation. The transgastric endoscope was used to explore all quadrants of the abdominal cavity. The small bowel was visualized to complete the exploration. The transgastric access location was then managed with the use of a gastrostomy tube. The animals were euthanized and analyzed. Results Eight pigs were studied and complete abdominal exploration, including diaphragm visualization, was possible in all cases. Endoscopy-guided biopsies were performed, adhesions lysed, and the gallbladder successfully drained percutaneously. The small bowel was run successfully with percutaneous needlescopic suture graspers. Conclusions These animal studies support the concept that NOTES, with management of the gastric opening with a gastrostomy tube, may be another approach for finding unrecognized sources of abdominal sepsis or mesenteric ischemia in difficult ICU patients. These encouraging results warrant a prospective human trial to assess safety and efficacy. Presented at the Scientific Session of the Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, TX, 26–29 April 2006 Disclosure: Case Western Reserve University, University Hospitals of Cleveland, Raymond P. Onders M.D., and Anthony Ignagni have the intellectual property of the devices used or equity in Synapse Biomedical which manufactured the diaphragm pacing technology used in this study     

Natural orifice translumenal endoscopic surgery (NOTES) for innovation in hepatobiliary and pancreatic surgery: preface

Introduction  Natural orifice translumenal endoscopic surgery (NOTES) has captured the interest of interventional endoscopists and may represent the next stage of evolution of minimally invasive surgery. It provides the potential for performance of incisionless operations. It is gaining momentum both in the animal laboratory and in human case reports. Developments in the field of NOTES have led to the formation of the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) in 2006. Materials and methods  In this special issue, the current trends in NOTES in the field of hepatobiliary and pancreatic surgery are featured, including NOTES cholecystectomy, hepatectomy splenectomy, pancreatic necrosectomy, and the future of NOTES. In this issue, we discuss the potential benefits of these procedures in hepatobiliary and pancreatic surgery. Conclusion  We have just started the evaluation process for this new technology. The concept of NOTES is becoming established and is enormously advantageous for the patient. Both the surgeon and gastroenterologist should contribute to developing NOTES in making use of their specialties.     

Tratamiento del cáncer de recto mediante escisión completa del mesorrecto por vía transanal. Resultados en 100 pacientes consecutivos

IntroductionThe aim of this study is to describe and evaluate our clinical short-term surgical results of laparoscopic transanal total mesorectal excision.MethodsAnalysis of 100 consecutive patients with mid and lower rectal cancer who underwent transanal total mesorectal excision from November 2013 to September 2018. Main outcomes described are operative data, morbidities, mortality and quality of the specimen. A comparative analysis was done between gender and simultaneous vs. non simultaneous abdominal-perineal surgery.ResultsMean patient age was 67 years (56-75), and 67% were male. On MRI, 50% were stage T3 tumors, and 52% had positive nodes. Mean distance of the tumor from anal verge was 4.9 ± 1.3 cm. A total of 58% underwent neoadjuvant treatment. Mean operative time was 262 ± 40.7 min; it was shorter in females (P < .001) and in simultaneous 2-field surgery. Median specimen distal free margin was 1.5 cm (0.5-2.4). A total of 89% of the specimens were with complete mesorectum, with better results when a simultaneous approach was used (P = .047). The mean number of retrieved lymph-nodes was 15.2 ± 11.6, and 26% of patients had positive nodes. Median length of stay was 5.5 days (4-8). Morbidities occurred in 36% of cases, and one patient died.ConclusionsAccording to our experience, laparoscopic transanal total mesorectal excision is safe and effective with adequate circumferential and distal free margins and high quality of the resected mesorectum specimen. Post-operative morbidity is acceptable, according to the current literature.     

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.     

后入路法经阴道自然腔道内镜子宫肌瘤切除术的临床研究

目的探索和建立使用后入路法经阴道自然腔道内镜手术(vaginal natural orifice transluminal endoscopic surgery,vNOTES)在子宫肌瘤切除术中的技术和应用价值。 方法选择上海市第一妇婴保健院妇科2017年11月至2019年3月期间21例后壁子宫肌瘤患者行vNOTES子宫肌瘤切除术,收集并分析手术时间、术中出血量、术后并发症发生率、术后住院时间,术后视觉模拟评分(visual analogue scale,VAS)、术后肠道功能恢复时间等临床资料。 结果其中1例因后入路失败转经脐单孔腹腔镜操作,手术未造成其他脏器损伤;其余20例手术均顺利完成。20例患者的年龄32～48岁,平均(39.9±4.2)岁;体质量指数17.63～23.03 kg/m²,平均(20.7±1.73)kg/m²;手术时间80～135 min,平均(116.07±23.38)min;肌瘤直径5～9 cm,平均(6.96±1.22)cm;术中出血量50～300 ml,平均(78.57±69.93)ml;术后12 h VAS 2～4分,平均(2.14±0.66)分;术后排气时间12～46 h,平均(28.57±7.42)h;术后住院时间2.5～4 d,平均(3.3±0.67)d。无中转开腹手术,未输血,未发生手术并发症,经术后随访,未发生泌尿系及肠管损伤、切口愈合不良。 结论vNOTES子宫肌瘤切除术对子宫后壁肌瘤是一种安全可行的可选术式,且较经脐单孔腹腔镜更加微创。     

Natural orifice translumenal surgery: Flexible platform review

Natural orifice translumenal surgery (NOTES) has garnished significant attention from surgeons and gastroenterologists, due to the fusion of flexible endoscopy and operative technique. Preliminary efforts suggest that NOTES holds potential for a less invasive approach with certain surgical conditions. Many of the hurdles encountered during the shift from open to laparoscopic surgery are now being revisited in the development of NOTES. Physician directed efforts, coupled with industry support, have brought about several NOTES specific devices and platforms to help address limitations with current instrumentation. This review addresses current flexible platforms and their attributes, advantages, disadvantages and limitations.     

经阴道自然腔道内镜手术在异位妊娠中的应用八例分析

目的探索经自然腔道内镜手术(natural orifice transluminal endoscopic surgery,NOTES)在异位妊娠治疗中的可行性、安全性及有效性。 方法中国医学科学院北京协和医院妇产科于2015年6月至2016年5月共完成8例经阴道NOTES异位妊娠患侧输卵管切除术。记录患者年龄、体质量指数、阴道分娩数、停经时间、血β－HCG(人绒毛膜促性腺激素)、肿物大小、子宫直肠窝积血、手术时间、术中出血量等指标。 结果8例患者的手术均成功完成,无中转传统腹腔镜手术或开腹手术,无并发症发生。年龄(33 ± 4.8)岁,体质量指数(24.2 ± 1.8)kg/m²,阴道分娩(1.5 ± 0.8)次,停经时间(52.3 ± 4.9)d,术前血β－HCG(10 280 ± 7 948.6)U/ml,肿物大小(2.75 ± 0.5)cm,子宫直肠窝积血(105 ± 98.3)ml,手术时间(41.9 ± 3.7)min,术中出血量(8.4 ± 5.6)ml。术后随访血β－HCG水平下降理想,阴道伤口愈合良好。 结论经阴道NOTES可安全、有效完成异位妊娠输卵管切除,但需要进一步前瞻性研究来评估其完整临床应用。     

经自然腔道内镜外科的发展趋势

Natural orifice translumenal endoscopic surgery(NOTES)is a surgical technique which is performed with an endoscope passed through a natural orifice,and then through an internal incision in the viscera(stomach,vagina or rectum)to perform intraabdominal operations.Since the first successful transgastric appendectomy performed by Dr.Rao and Reddy in 2004,NOTES is developing rapidly.The advantages of NOTES include no injury and scar in the body surface;lower anesthesia requirements;faster recovery and shorter hospital stays;avoidance of transabdominal wound infections.NOTES can also be applied to patients who are not suitable for open surgery and lapascopic surgery.NOTES has the potential to revolutionize the field of minimally invasive surgery by eliminating abdominal incisions,however,the safety and efficacy of NOTES still needs to be investigated in lhe future.