Colorectal natural orifice transluminal endoscopic surgery (NOTES) and transvaginal/transrectal specimen extraction

Advancements in minimally invasive surgery have both revolutionized laparoscopy and set the stage for the advancement of endoscopic surgery to the forefront of modern medicine. Natural orifice transluminal endoscopic surgery (NOTES) has now become a subject of great interest to surgeons worldwide who wish to reduce the morbidity associated with abdominal operations. However, the application of NOTES to colorectal surgery has thus far been limited due to the complex dissection, anastomosis and specimen extraction typically required when operating on the large bowel. For this reason, laparoscopic-assisted natural orifice surgery has been the means by which most surgeons have begun to incorporate natural orifice surgery into their established practices. Transanal endoscopic surgery, transvaginal-assisted laparoscopy and transrectal specimen extraction are all emerging techniques that may be currently employed, in a hybrid manner, with traditionally accepted laparoscopic operations in order to transition toward less invasive surgery and even pure NOTES. To this end, the vagina appears to be the most practical and widely used site of specimen extraction and adjunct access site for laparoscopic hybrid operations. An accompanying video demonstrates the authors’ preferred technique for transvaginal and transrectal specimen extraction.     

An experimental study of betadine irrigation for preventing infection during the natural orifice transluminal endoscopic surgery (NOTES) procedure

OBJECTIVE: To study the effect and feasibility of using betadine irrigation of the gastrointestinal tract for preventing infection during the natural orifice transluminal endoscopic surgery (NOTES) procedure. METHODS: Twelve sows were used in this study. Four sows in the control group were lavaged with 500 mL saline. The eight sows in the experimental group were first lavaged with 500 mL saline and then irrigated with 200 mL betadine. A total of 5 mL of gastrointestinal (GI) tract fluid was collected before and after lavage, respectively, and 5 mL of peritoneal fluid was collected at the end of the NOTES procedure. A follow‐up endoscopic examination of the GI tract was performed 24 h after NOTES. The animals were killed and necropsied after 3 weeks. RESULTS: Irrigation with betadine of the GI tract significantly reduced the bacterial load of GI fluid. One sow died of diaphragmatic injury. No inflammation, ulcer or bleeding were observed in the experimental group by endoscopy after 24 h. More adhesions and abscesses were found in the control group than in the experimental group after 3 weeks. Only one case of adhesion was observed in the experimental group using the transcolonic approach. CONCLUSIONS: Betadine irrigation of the GI tract is effective and feasible for preventing infection during the NOTES procedure. Further studies are needed for assessing the effectiveness and safety of betadine irrigation in the clinical application of NOTES.     

Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video)

BACKGROUND: The ability to access the abdominal cavity though a direct (modified-PEG type) gastric incision to perform natural orifice transluminal endoscopic surgery (NOTES) has been demonstrated in the literature. However, the optimal technique to access the abdomen remains unknown. OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of a transgastric approach to the abdominal cavity through an extended submucosal tunnel. DESIGN: Animal feasibility study. INTERVENTIONS: Transgastric endoscopic peritoneoscopy was performed in 7 anesthetized swine, including 2 acute and 5 survival animals. After the creation of a 10-cm to 12-cm tunnel in the gastric submucosal plane, the peritoneal cavity was accessed by needle-knife puncture through the gastric wall near the greater curvature. The peritoneal cavity was examined before the gastric mucosal incision was closed with endoclips. Survival animals were euthanized two weeks after the procedure, and a necropsy was performed. RESULTS: The abdominal cavity was successfully entered without complication in all 7 animals. The mucosal incisions were able to be closed by endoscopy. In the survival experiments, all animals recovered and gained weight. Two animals experienced clinically unapparent infectious complications. LIMITATIONS: Small sample size. CONCLUSIONS: A peroral transgastric approach to the abdominal cavity through an extended submucosal tunnel is technically feasible and allows safe abdominal access and reliable closure with currently available technology. It has potential benefits as an alternative to direct transgastric access for NOTES procedures.     

经胃、结肠联合路径腹腔内镜探查术的实验研究

目的初步探讨经胃（口）和经结肠（肛）双路径经自然孔道内镜外科学（NOTES）技术的可行性和利弊。方法采用雌性猪模型。先经口路径用针刀在胃前壁穿透切开，用扩张球囊扩大通道，将胃镜送入腹腔，在经胃路径的内镜监视下，再经肛路径用针刀穿透结肠壁，用弓刀扩大肠壁切口，将内镜送入腹腔。两条内镜先分别单独寻找胆囊和输卵管，然后相互配合共同寻找和观察胆囊和输卵管。胃肠切口分别用止血夹闭合。术后立即剖腹探查，观察腹腔内脏器损伤及胃肠壁切口闭合情况。结果胃肠壁通过球囊和弓刀扩大切口均无出血。经胃壁穿透切开时损伤肝脏表面。在经胃路径的内镜监视下完成结肠壁切开，避免了临近脏器的损伤。单内镜寻找胆囊和输卵管困难，时间较长。而双内镜配合寻找胆囊和输卵管相对容易，时间缩短，视野暴露好。用止血夹封闭胃壁切口比结肠切口困难。结论经胃与经结肠联合路径腹腔内镜探查术是可行的，可能比单路径更容易完成NOTES操作。     

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra‐abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra‐abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES‐related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES‐related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.     

Early clinical experience with a new flexible endoscopic suturing method for natural orifice transluminal endoscopic surgery and intraluminal endosurgery (with videos)

BACKGROUND: To perform advanced endoscopic treatments, one has to be able to close defects and perforations. Many devices have been constructed to perform endoscopic suturing, but all are rather complicated, expensive, and difficult to use. OBJECTIVE: To develop and use a new simple stitching technique at intraluminal flexible endoscopy. DESIGN: A flexible 19-gauge needle, loaded with a metal tag attached to a 3-0 polypropylene thread is passed down the working channel of a conventional endoscope. Two tags are placed into the stomach or the intestinal wall, 1 on each side of the defect. The threads are then locked together and cut. Precise stitch positioning is possible. Multiple stitches can be placed quickly, without removal of the endoscope. SETTING: Surgical department at Sahlgrenska University Hospital in G?teborg, Sweden. PATIENTS: Three patients in whom other conventional treatments had failed. INTERVENTIONS: Initially, survival studies in pigs were performed, and full-thickness resections, pyloroplasty, and gastrojejunostomies could be completed. The technique was subsequently used in patients when surgery was not feasible and when other endoscopic interventions had failed. MAIN OUTCOME MEASUREMENTS: Clinical evaluation; successful sealing of defects, leaks, or a bleeding vessel. RESULTS: We present 3 human cases and describe endoluminal closure of a perforated duodenal ulcer, a leaking gastroenteroanastomosis after gastroplasty, and successful treatment of upper-GI bleeding by oversewing a bleeding vessel. CONCLUSIONS: This stitching technique is easy to use and makes endoscopic suturing possible for closure of perforations and tissue approximation almost anywhere in the GI tract that can be reached by a flexible endoscope.