经阴道腹腔镜在泌尿外科手术的适应症和临床应用

经自然腔道内镜手术（nature orifice transluminal endoscopic surgery,NOTES）由于其微创、美容效果好等优势在泌尿外科应用越来越广泛。目前认为经阴道途径是NOTES中最好的一种手术入路。近几年经阴道NOTES在泌尿外科领域进行了大量的临床方面的研究,技术逐渐成熟和完善。随着磁性锚定导航系统（MAGS）和机器人辅助腹腔镜技术在泌尿外科手术中的应用,经阴道NOTES应用前景广阔。本文就近几年经阴道NOTES在泌尿外科临床上的应用做一个综述。     

Natural orifice surgery applied for colorectal diseases

Clinical natural orifice surgery has been applied to abdominal surgery in recent years, mostly using transvaginal and transgastric access. Rectal and transcolonic natural orifice transluminal endoscopic surgery (NOTES) were tested in animal and cadaver models by a few research groups. Despite the potential advantages of transcolonic NOTES for colorectal diseases, it has not yet been clinically applied. The first successful series of human applications of transcolonic NOTES in the literature from the NOTES Research Group in Brazil provide new possibilities in the field in new transrectal procedures for rectal cancer and benign disease. Successful first human reports on Transcolonic NOTES potentially brings new frontiers and applications for minimally invasive surgery. The treatment of colorectal diseases through flexible Perirectal NOTES Access is a promising new approach alongside existing laparoscopic and open surgery to improve patient care.     

NOTES—third generation surgery. Vain hopes or the reality of tomorrow?

Background Laparoscopic approach has made many procedures less invasive; however, it seems like this is not enough. The newest challenge for the medical environment is applying the scarless surgery in humans. In this article, we review the origin, current state of art, and future of natural orifice transluminal endoscopic surgery (NOTES). The registered base of research in humans is yet scarce; however, the porcine model experimental studies hold a great promise. In NOTES, peritoneal cavity can be easily achieved, and some procedures are feasible through the natural orifices like digestive tract, vagina, or urinary bladder. If safety and advantages of these approaches will be proven beyond question, NOTES procedures are likely to be adapted in humans after overcoming the critical obstacles, like reliable closure methods, indispensable equipment invention, the multidisciplinary specialists training, etc. The aim of this article was to review available literature to provide current state of art in NOTES surgery. Materials and methods Medical databases were searched for animal and human experience with NOTES to give an overview of history, current state of art, and future of this technique. Results NOTES is currently the subject of the intensive research. It seems like this is only the matter of time when a transluminal access to the abdominal or even thoracic cavity will become the reality. Moreover, this will enable the management of some diseases in a possibly minimally invasive pattern, nearly painless and leaving no scar at all.     

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.     

NOTES: new dimension of minimally invasive surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery. NOTES eliminates abdominal incisions and incision‐related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Since the first NOTES was reported by Kalloo et al. in 2004, significant achievements in the laboratory have occurred. Clinical use in humans has been limited, but several cases and one small clinical trial were published recently. As a further technical revolution in minimally invasive surgery, NOTES has the promising potential to be safer, less invasive, provide better cosmesis and possibly be more cost‐effective. The purpose of the present article was to review the development and current status of NOTES and highlight important advances associated with this innovative approach.     

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.     

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 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.     

Natural Orifice Translumenal Endoscopic Surgery: A Critical Review

Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional puncture of one of the viscera (e.g., stomach, rectum, vagina, urinary bladder) with an endoscope to access the abdominal cavity and perform an intraabdominal operation. Early laboratory work focused on feasibility studies, including such accomplishments as pure transgastric splenectomy and gastrojejunostomy. Contemporary laboratory work is investigating the infectious and immunologic implications of NOTES and honing the tools and techniques required for complex abdominal operations. Today NOTES has entered the clinical arena in a few cases: the first clinical series of transgastric peritoneoscopy has recently been published; multiple groups are accumulating patients in studies of NOTES cholecystectomy, either via the transgastric or transvaginal route; and a series of transgastric appendectomies has been well publicized, yet it remains unpublished. Although clinical NOTES is gaining momentum, the field should remain in check while rigorous laboratory work is performed and cogent clinical trials are undertaken. The zeal for NOTES should not take precedence over the welfare of the patient.     

Scarless surgery for a huge liver cyst: A case report

IntroductionSymptomatic or complicated liver cysts sometimes require surgical intervention and laparoscopic fenestration is the definitive treatment for these cysts. We performed minimally invasive surgery, hybrid natural orifice transluminal endoscopic surgery (NOTES) without scarring, for a huge liver cyst.Presentation of caseAn 82-year-old female presented with a month-long history of right upper abdominal pain. We diagnosed her condition as a huge liver cyst by morphological studies. She denied any history of abdominal trauma. Her serum CEA and CA19-9 were normal and a serum echinococcus serologic test was negative. Laparoscopic fenestration, using a hybrid NOTES procedure via a transvaginal approach, was performed for a huge liver cyst because we anticipated difficulty with an umbilical approach, such as single incision laparoscopic surgery (SILS). Her post-operative course was uneventful and she was discharged from our hospital three days after surgery. Pain killers were not required during and after hospitalization. No recurrence of the liver cyst or bulging was detected by clinical examination two years later.DiscussionA recent trend of laparoscopic procedure has been towards minimizing the number of incisions to achieve less invasiveness. This hybrid NOTES, with a small incision for abdominal access, along with vaginal access, enabled painless operation for a huge liver cyst.ConclusionWe report a huge liver cyst treated by hybrid NOTES. This approach is safe, less invasive, and may be the first choice for a huge liver cyst.     

ESD和隧道技术经口内镜下肌切开术(POEM)

经自然腔道内镜手术(NOTES)是指经人体自然腔道的内镜手术,近年来,NOTES技术已成为目前消化内镜微创技术发展的主要方向之一。然而目前在这一领域,临床的努力方向和研究的重点已经转移到制造病理性腔壁内和邻近腔壁的新的微创入路方法上,包括了更多常规介入性内镜诊疗操作。近来,有学者提出了新NOTES这一概念,其核心内容为经人体自然腔道,使用内镜进行手术,以取得病理组织、切除病变或解决梗阻、狭窄等问题,并不局限于进入腹腔。如消化内镜领域的经口内镜肌切开术(POEM)、黏膜下隧道内镜切除术(STER)、经口幽门肌切开术(POP)、内镜黏膜下剥离术(ESD)、内镜下全层切除术(EFTR)等,被称作new NOTES或near NOTES。其中POEM作为一项较新的NOTES技术,自2010年出现以来发展较为迅速,以黏膜下隧道技术和肌切开术为其基本技术,在新NOTES中应用较为广泛,治疗效果较确切,在贲门失弛症手术治疗上已可作为一线治疗的选择。本文就目前POEM的发展进行综述。     

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.     

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.     

Current status and future perspectives in laparoendoscopic single‐site and natural orifice transluminal endoscopic urological surgery

Objective of this study is to provide an evidence‐based analysis of the current status and future perspectives of scarless urological surgery. A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single‐site surgery (LESS). In addition, experience with LESS and NOTES at our own institution has been considered. All clinical and investigative reports for LESS and NOTES procedures in the urological literature have been considered. A wide variety of clinical procedures in urology have been succesfully completed by using LESS techniques. Thus far, experience with NOTES has largely been investigational, although early clinical reports are emerging. Further development of instrumentation and platforms is necessary for both techniques to become more widely adopted throughout the urological community.     

Transvaginal specimen removal in minimally invasive surgery

The demand for urological surgical treatment associated with better cosmesis, lower morbidity rates and shorter hospitalization constantly grows. The transvaginal route has been proposed in an attempt to avoid long abdominal incisions for the removal of the large laparoscopic specimens. Moreover, the transvaginal NOTES approach represents a promising evolution of laparoscopic surgery to a more “minimally invasive” alternative. The current review summarizes the available experience in the literature in transvaginal conventional laparoscopy and NOTES in urology, gynecology and general surgery. The clinical outcome is presented. The most important issues associated with the transvaginal approach are the complications and the postoperative sexual function. These issues are presented.     

经阴道自然腔道内镜卵巢囊肿剥除术十例临床分析

目的评估经阴道自然腔道内镜(natural orifice transluminal endoscopic surgery,NOTES)卵巢囊肿剥除术的可行性、安全性及术后恢复情况。 方法回顾分析2017年9－12月在上海市第一妇婴保健院妇科行NOTES卵巢囊肿剥除术患者10例,所有患者取阴道后穹窿入路2.5 cm切口,置入硅胶密封圈后,装上Port,建立气腹后用传统腹腔镜行患侧卵巢囊肿剥除术。统计卵巢囊肿大小、手术时间、术前与术后血色素差值、术中出血量、术后24 h视觉模拟疼痛评分(visual analog scale,VAS)及术后恢复排气时间。 结果其中1例患者因双侧卵巢成熟性囊性畸胎瘤合并多囊卵巢综合征,由于卵巢门出血略活跃、缝合困难影响手术进展,中转为传统腹腔镜手术之外,其他患者均经阴道腹腔镜完成,手术均无并发症、无输血。9例患者的平均手术时间78.3 min,术前与术后血色素的平均差值18.3 g/L,平均术中出血量23.3 ml,术后24 h VAS平均0.55分,术后平均恢复排气时间17.5 h,平均住院时间4.7 d。 结论NOTES卵巢囊肿剥除术后患者的切口疼痛感较轻,具有术后恢复快、腹部无瘢痕、美观的优势,合适的病例选择加上灵活的手术技巧,NOTES卵巢良性囊肿剥除是安全可行的。     

NOTES – Cholezystektomie ohne sichtbare Narben

The use of natural orifices for operations in the abdominal cavity (natural orifice transluminal endoscopic surgery, or NOTES) could be a conclusive development in the field of minimally invasive surgery. Early in the 1990s we had experiences with posterior colpotomy for removal of specimens in laparoscopic surgery. This is why we use the transvaginal approach in NOTES and combine it with a trocar hidden in the umbilicus. With this technique we could perform cholecystectomy without a visible scar. The operation could become routine also because of the use of our well-known rigid optics and instruments. From June 2007 until April 2008 we operated on 57 patients using this method. All operations finished successfully, and the mean operation time was 54 min. There was one complication. An abscess in the Douglas room had to be evacuated laparoscopically. All other postoperative courses were uneventful. After a minimum follow-up of 3 months, none of the patients had symptoms in the vagina or during sexual intercourse.     

NOTES-Natural orifice transluminal endoscopic surgery: Why not?

Since natural orifice transluminal endoscopic surgery (NOTES) was first described by Anthony Kalloo, it has attracted tremendous interest from surgeons and gastroenterologist all around the world. This special issue of the World Journal of Gastrointestinal Surgery explores the current possibilities and future potential of the most disruptive revolution in the field of surgery represented by the NOTES approach. In the future, new technologies developed for this approach and deeper insight into several gastrointestinal diseases will lead to the design of completely new interventional procedures and change the way we will operate, bringing us to the previously unimaginable goal of "no scar surgery".     

Rapid communication: transvaginal single-port NOTES nephrectomy: initial laboratory experience

BACKGROUND AND PURPOSE: Natural orifice translumenal endoscopic surgery (NOTES) using purpose-built equipment has never been applied to urologic surgery. Herein, we present our initial experience with a trans-vaginal single-port NOTES nephrectomy. METHODS AND RESULTS: An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline and the TransPort Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA) was passed transvaginally. This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. Dissection was performed using an endoscopic needle knife and a tissue grasper for retraction. Via the 12-mm port, the renal artery and vein were taken separately with a vascular EndoGIA and standard laparoscopic titanium clips, respectively. The kidney was placed in a 10-mm EndoPouch retriever and removed intact via the vagina. The total operative time was 300 minutes. Conclusion: Transvaginal NOTES nephrectomy can be accomplished in a porcine model. Additional testing on survival animals is necessary to validate this approach.     

经阴道纯NOTES肾切除术2例报告并文献复习

目的：评价经阴道纯自然腔道内镜手术（NOTES）肾切除术的临床可行性和有效性。方法：对1例右肾无功能和1例左。肾结石并左肾萎缩、左肾无功能的女性患者行经阴道纯NOTES肾切除术。患者取全麻,截石位。切开阴道后穹窿,置入Triport及操作器械。所有操作均经此Triport完成,按照普通腹腔镜肾切除方法游离并切除患肾,装入自制标本袋,自阴道后穹窿切口取出。留置盆腔引流管,缝合阴道后穹窿切口。结果：手术均顺利完成,术中未出现肠管、实质性器官和大血管损伤等并发症。手术时间分别为330min、300min,术中失血量分别为300ml、250ml。例1、2分别于术后第2、1天下床活动,第3、2天肛门通气并进饮食。2例均于术后第6天痊愈出院,患者体表均无切口或穿刺孔。结论：经阴道纯NOTES肾切除术临床应用可行,美容优势明显,可在临床选用。但仍需进一步研发、完善相关器械。