Transvaginal endoscopic cholecystectomy using a simple magnetic traction system

Abstract

Natural orifice transluminal endoscopic surgery (NOTES) is still at an early stage of clinical development. The development of new instruments is required to overcome some of the current limitations of NOTES. We thus performed transvaginal endoscopic cholecystectomies to determine the feasibility of using a magnetic traction system. Experiments were performed in a non-survival porcine model (n = 4). The magnet-fixed endoscopic clip was attached to the apex of the gallbladder fundus and held together with the external handheld magnet across the abdominal wall. The gallbladder fundus was then retracted to the cephalic direction by moving the external handheld magnet and the gallbladder was dissected from the liver bed. The gallbladder was placed in the endocatch material and delivered through the vagina. NOTES cholecystectomies via the transvaginal approach were successfully performed in a porcine model. The magnetic traction system was effective in achieving adequate exposure in all pigs. The magnetic traction system provides vigorous, multi-axial traction as required for the cholecystectomy procedure. There were no complications during the procedure other than minor bleeding from the liver bed. The mean procedure time was 133.8 minutes (range, 105 to 175 minutes). Our study successfully demonstrated the feasibility of the magnetic traction system in NOTES.     

国内首例经阴道腹腔镜胆囊切除术

目的探讨临床开展经自然腔道内镜手术(PURE NOTES),采用经阴道腹腔镜切除胆囊的可行性、安全性和优越性。方法胃镜下针刀切开阴道后穹窿3cm,切口处安放三通转换器(Single Incision Laparoscopic Surgery Port,SILS PORT),三通道内分别插入3个软性器械套管建立防止漏气的通道,充气后首先于SILSPORT6点位通道进入腹腔镜探查腹盆腔情况,并监视硬质弯曲操作器械通过3点及9点位的通道到达胆囊区。分离出胆囊管及胆囊动脉,置入钛夹,分别夹闭胆囊管及胆囊动脉,常规切除胆囊,电凝胆囊床,将胆囊从阴道取出体外。结果胆囊切除时间39min,出血量2mL,未放引流,术后无阴道分泌物、无出血、胆漏等并发症,几乎无腹部疼痛,恢复快,术后第3天康复出院。结论 PURE NOTES经阴道腹腔镜胆囊切除术技术可行,操作安全,相比传统腹腔镜手术有明显优势,是目前开展PURE NOTES的较好方法 。     

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

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

Transanal radical endoscopic resection of the rectum on a swine model: a surviving model

INTRODUCTION: This multimedia video is the second part of our study on transanal endoscopic radical resection of the rectum, which we have previously described (http://links.lww.com/DCR/A4). In this present study, we hypothesized that this procedure is not only technically feasible but also safe. MATERIALS AND SURGICAL TECHNIQUE: This procedure was performed on two swine as a surviving model. After radical resection of the rectum and primary anastomosis, the two swine were monitored in an animal holding area for a period of 1 week, and the anastomoses were inspected after that period. The lower rectum was transected, and retroperitoneal dissection was performed transanally using flexible endoscopic equipment to achieve high ligation of the caudal mesenteric vessels. After rectal resection, hand-sewn coloanal anastomosis was performed. DISCUSSION: Both swine had good postoperative outcomes, and the postoperative period was captured on video. Transanal radical endoscopic resection of the rectum is not only technically feasible, but it can can be safely performed on swine.     

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

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

Chemically assisted peroral endoscopic myotomy with submucosal mesna injection in a porcine model

Background: Peroral endoscopic myotomy (POEM) is a less invasive alternative to standard surgery for the treatment of achalasia. Previous studies have demonstrated that submucosal injections of mesna soften tissues and facilitate endoscopic submucosal dissection. Material and methods: We studied the technical feasibility of a chemically assisted POEM procedure with mesna injection (CA-POEM) in ten pigs compared with POEM with saline injection in five pigs. We also compared two dissection techniques in CA-POEM, diathermy needle knife dissection (n = 5) and balloon mechanical dissection (n = 5). A 10 cm esophageal submucosal tunnel was created with a needle knife or with balloon mechanical dissection following mesna or saline submucosal injection. Approximately 5 cm of inner circular muscle was then dissected within the tunnel. The tunnel was closed with endoclip application at the mucosal endoscopic entry point. Pigs were sacrificed one week post procedure. Results: All procedures were successful and all pigs survived for one week. Submucosal tunneling time was significantly shorter in the mesna group (363.8 sec for needle knife dissection and 294.2 sec for balloon dissection) than in the saline group (640 sec), regardless of the dissection method (p < 0.05). Conclusions: Our study demonstrated the technical feasibility of CA-POEM.     

Clinical experience with a simple retraction device in single-port laparoscopic cholecystectomy: Technical description and initial results

Abstract

Background: Performing single-port laparoscopic cholecystectomy (SPLC) is challenging as triangulation is limited and the critical view is difficult to obtain. We present our initial experience using a simple retraction device to reduce these problems. Material and methods: In January 2012 a novel lifter was introduced at our department and subsequently used in SPLC for suspension of the gallbladder. Perioperative data were collected prospectively. In addition, all videos were reviewed to assess any adverse events caused by the lifter. Results: Thirty (20 female and 10 male) patients at a median age of 48.4 years (range: 23–83) were operated using this novel retraction device. Median BMI accounted for 26.0 kg/m² (median; range: 14.0–36.9). Retraction of the gallbladder using the lifter was possible in all patients. In four cases (13.3 %) spillage of bile caused by the lifter was recorded. In addition, perforation of the gallbladder was seen once (3.3 %), caused by electrocautery. No inflammation, induration or visible scars were seen in the right upper quadrant at six weeks postoperatively in any patient. Conclusions: Gallbladder retraction in SPLC using this novel device is feasible and safe without leaving any apparent scar. Rate of bile spillage is (at least) comparable to that reported for conventional laparoscopic cholecystectomy.     

复杂胆囊患者行腹腔镜下逆行和次全胆囊切除术效果比较

目的 比较腹腔镜下逆行和次全胆囊切除对复杂胆囊病例的治疗效果.方法 回顾性分析2008年至2009年我院对39例复杂胆囊病例实施腹腔镜逆行切除术(21例)和腹腔镜次全胆囊切除术(18例)的治疗效果.结果 腹腔镜次全胆囊切除术手术时间[(88.89±18.11)min]相对短于腹腔镜逆行胆囊切除术[(109.52±21.79)min],差异有统计学意义(P<0.05);前者术中出血量[(82.78±44.96)ml]和所需补液量[(847.22±169.32)ml]也少于后者[(116.67±53.23)ml和(964.29±147.60)ml],差异有统计学意义(P均<0.05);患者术后恢复平稳,术后住院时间与腹腔镜逆行胆囊切除术无明显差异[(5.56±1.20)d与(5.29±1.38)d],P>0.05.结论 对于复杂胆囊病例,合理实施腹腔镜胆囊次全切除术有助于简化手术操作,缩短手术时间,提高手术操作的安全性,而手术效果与腹腔镜逆行胆囊切除术无明显差异.     

Internal retraction in single-port laparoscopic cholecystectomy: Initial experience and learning curve

Abstract

Introduction: We report our experience and learning curve in single-port laparoscopic cholecystectomy (SPLC) using an internal anchored retraction system. Methods: Usefulness of the retraction system was analysed in 18 SPLC. The first eight, the following ten SPLC and 20 consecutive four-port laparoscopic cholecystectomies (4PLC) were compared. Duration of operation, burns on nontarget tissue and gallbladder perforations were assessed by reviewing videotapes recorded during the procedures. Results: Use of the retraction system failed in three out of five patients (60%) with intraoperative signs of chronic inflammation and in one out of 13 (7.1%) without such signs (p = 0.0441). Median operation time was 90 (45–120) in the first eight and 55 (40–180) minutes in the following ten SPLC (p = 0.0361). Whereas the first eight SPLC lasted longer compared to 4PLC (70 (40–140) minutes, p = 0.0435) the difference disappeared after eight procedures (p = 0.2076). Median number of burns to nontarget tissue was seven (1–16) in the first eight and one (0–8) in the following ten SPLC (p = 0.0049). There was no difference in perforation of the gallbladder. Discussion: Internal retraction enables a safe exposure of the Calot triangle avoiding bile spillage in cholecystectomies without intraoperative signs of inflammation. Familiarisation with SPLC was rapidly achieved. Operation time and dexterity were equal to 4PLC after eight SPLC.     

Delivery of the gall bladder after laparoscopic cholecystectomy using a condom

Summary

Gall bladder retrieval through a port site is often associated with wound contamination and the loss of stones. The use of a condom as a protective sheath for the gall bladder prevents spillage and infection and aids retrieval.     

猪经脐经肛直肠肿瘤切除的杂交NOTES手术模型建立简

目的：建立猪经脐经肛直肠肿瘤切除的杂交NOTES手术模型。方法选择健康普通家猪7只,气管插管,异氟烷吸入麻醉。造气腹后,经脐单切口分别置入5 mm、10 mm及12 mm Trocar各1支,腹腔镜下游离、切断肠系膜血管及肠管,经肛将远断端结、直肠拖出肛门外,预定平面切断并移除标本,腔镜直视下CDH25吻合器完成吻合。结果所有手术均顺利完成,手术时间38～57 min,平均（44.83±7.47）min;术中出血量5～24 ml、平均（10.62±8.24）ml;切除肠管长度7.8～11.3 cm,平均（8.76±1.11）cm;吻合口均完整。结论猪经脐经肛直肠肿瘤切除的杂交NOTES手术可行,可作为过渡至临床常规应用前训练模型。     

急性胆囊炎早期治疗及推迟行腹腔镜胆囊切除的比较

目的：比较急性胆囊炎症状早期行腹腔镜胆囊切除和待急性期后再行手术的安全性及可行性。方法：将有症状的急性胆囊炎患者随机分为两组,一组在入院72h内行腹腔镜胆囊切除,另一组则行保守治疗待症状缓解消失后3个月返院行手术治疗。结果：并未发现早期行胆囊切除术组相对推迟后手术组的中转开腹率、术后疼痛处理技术后并发症有显著区别,但在手术时间相对增加,而住院时间则缩短。结论：在出现症状72h内急诊行腹腔镜胆囊切除在医疗及社会经济效益上具有较大优势,但手术需要更有经验的医师执行。     

腹腔镜B超在腹腔镜胆囊切除术中的应用

目的探讨腹腔镜B超在腹腔镜胆囊切除术中的作用，利用腹腔镜B超，对肝胆系统进行探查，代替术中胆道造影，以降低手术难度及风险，减少漏诊及胆道损伤。方法收集并分析2002年6月-2003年6月间69例LC中应用腹腔镜B超进行检查的病例。结果手术过程均顺利，轻易找到胆总管位置及其病变，其中1例发现胆总管变异，1例胆总管癌变，2例胆总管结石，无中转开腹及术后并发症。结论腹腔镜B超对肝外主胆管能作出准确的术中定位，避免术中胆道损伤，也可判断胆总管内有无结石，对指导LC手术和提高诊断准确率有实用价值，可代替术中胆道造影。     

Cystic artery pseudoaneurysm as a complication of laparoscopic cholecystectomy

A 39-year-old man presented with a subhepatic fluid collection 3 weeks after undergoing a laparoscopic cholecystectomy. This was mistakenly thought to represent an abscess, and a drainage catheter was placed at an outside institution. Upon transfer, the collection was diagnosed as a pseudoaneurysm by spiral computed tomography (CT) and angiography. This is the first report of a pseudoaneurysm complicating laparoscopic cholecystectomy.     

经自然腔道完全腹腔镜超低位直肠癌保肛根治术疗效分析

目的探讨经自然腔道完全腹腔镜超低位直肠癌保肛根治术的可行性及安全性。方法经肛门直视下在距癌灶最下缘1.5～2.0 cm处对肿瘤远端肠管缝合、切断,经肛门将肿瘤拖出切除,近端肠管置入吻合器钉座,缝合关闭远端肠管,术中冰冻病理检查确认远端切缘无癌细胞残留,再经肛门置入管状吻合器进行肠管端端吻合或手工吻合。结果 7例手术均获成功。手术时间145～265 m in,平均190 m in;术中出血45～95 m l,平均65 m l,术中无肠管、输尿管及邻近器官损伤。吻合口距齿状线1.0～2.0 cm,术后无吻合口漏及吻合口狭窄等并发症。术后3个月排便次数4～6次/d,随访3～16个月,未发现吻合口复发及穿刺孔种植转移。结论经自然腔道完全腹腔镜超低位直肠癌保肛根治术既能保证肿瘤远端肠管有足够的切除范围,又能避免腹部辅助切口,减少腹腔镜手术难度,在临床上具有一定的应用价值。     

老年人腹腔镜胆囊切除术治疗体会

目的探讨老年人腹腔胆囊切除术(LC)的麻醉及手术方法。方法在全麻和CO2气腹下，老年人106例LC术，中转开腹6例，3例术中经胆管造影。结果全部患者完成麻醉及手术，无严重手术并发症及死亡病例。结论老年人多伴有其他慢性器官疾病，术前应严格选择手术适应证，充分准备，术中加强监测及管理，术中相对放宽中转开腹指征，是预防和减少并发症的关键。     

一日腹腔镜胆囊切除术护理管理方法探讨

目的 探讨安全且有效的一日腹腔镜胆囊切除术护理管理模式.方法成立一日手术小组,制订工作流程,实施手术前后护理管理.结果 一日腹腔镜胆囊切除术患者平均住院日为(2.85±0.56) d、住院费用为(8 650.12±311.61)元、术后满意度为98.32%,无一例并发症发生.结论 一日腹腔镜胆囊切除术护理管理流程是一套...     

肺部并存病患者腹腔镜与开腹胆囊切除术的对比观察

目的　探讨肺部并存病患者腹腔镜胆囊切除术的安全性。方法　 2 0 0 3年 1月 36例伴肺部合并病的患者行胆囊切除术 ,其中LC组 16例 ,OC组 2 0例。对比分析两组患者术后恢复活动时间、住院时间、恢复饮食时间和腹胀发生率、伤口及肺部并发症发生率。结果　两组均无手术死亡。术后恢复活动时间分别为(2 4± 6 .8)h和 (6 8± 16 .3)h ,恢复饮食时间分别为 (2 6± 8.4 )h和 (6 8± 2 2 .4 )h ,住院时间分别为 (4.4± 2 .2 5 )d和 (10 .6± 5 .38)d。腹胀发生率分别为 6 .7% (1/ 16 )和 35 .0 % (7/ 2 0 ) ,切口感染 (和 /或裂开 )率分别是 0和15 .0 % ,肺部感染率分别为 6 .6 %和 2 5 .0 %。结论　肺部并存病患者行腹腔镜胆囊切除术是安全可行的 ,具有并发症发生率低、术后恢复快、住院时间短的特点。