Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery

Background Natural orifice translumenal endoscopic surgery (NOTES), a recent development in the field of minimally invasive surgery, may offer advantages over open and laparoscopic surgery. Most investigations to date have focused on small end-organ resections, and none have described en bloc regional lymphadenectomy. This study aimed to describe a method of anal transcolonic sigmoid colon resection. Methods A fresh frozen then thawed cadaver model was used. Three male human cadavers were subjected to transanal sigmoid colon mobilization, high vascular ligation, en bloc lymphadenectomy, and stapled end-to-end anastomosis performed by a single operator using transanal endoscopic microsurgery instrumentation. Results The findings showed that NOTES sigmoid colon resection with en bloc lymphadenectomy and primary anastomosis can be performed successfully. The critical steps of the procedure were (1) luminal suture occlusion of the sigmoid colon, (2) transrectal bowel division, (3) entry through the mesorectum into the presacral space, (4) en bloc mobilization of the sigmoid colon mesentery off of the retroperitoneum, (5) high ligation of the superior hemorrhoidal artery, (6) transanal delivery of the intact sigmoid colon specimen, (7) extracorporeal division of the colon, and (8) creation of a stapled end-to-end colorectal anastomosis. Postprocedure laparotomy confirmed adequate lymphadenectomy and anastomosis with no untoward events. Conclusions It is possible to complete the critical steps of a NOTES sigmoid resection, en bloc lymphadenectomy, primary anastomosis, and retrieval of an intact specimen without any incisions using transanal endoscopic microsurgery instrumentation.     

Comparison of anterior transgastric access techniques for natural orifice translumenal endoscopic surgery

Background  

The advancement of natural orifice translumenal endoscopic surgery (NOTES) into clinical practice is dependent on its safety, efficacy, and efficiency. Access is the obligatory first step in NOTES and serves as a surrogate to technical difficulties associated with this novel surgical approach. This study aimed to compare endoscopic transgastric access techniques in terms of safety, reproducibility, and efficiency.     

NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance

Background  

The feasibility and safety of Natural Orifice Translumenal Endoscopic Surgery (NOTES) transanal endoscopic rectosigmoid resection using transanal endoscopic microsurgery (TEM) was previously demonstrated in human cadavers and a porcine survival model. We report the first clinical case of a NOTES transanal resection for rectal cancer using TEM and laparoscopic assistance, performed by a team of surgeons from Barcelona and Boston with extensive experience with NOTES and minimally invasive approaches to colorectal diseases.     

Evaluation for transvaginal and transgastric NOTES cholecystectomy in human and animal natural orifice translumenal endoscopic surgery

Background/purpose  Natural orifice translumenal endoscopic surgery (NOTES) is a novel concept using an endoscope via a translumenal access for abdominal surgery. This study was designed to evaluate the feasibility and technical aspects of NOTES cholecystectomy from our experience on humans and animals. Methods  NOTES cholecystectomies were performed in 12 animal experiments, including 8 pigs (6 by transgastric and 2 by transvaginal accesses) and 4 dogs (4 transvaginal accesses), and a human female cadaver. Results  The entire gallbladder could be removed under direct vision in all experiments. The average time was 60 min by transgastric and 40 min by transvaginal in animals. It was 87 min for human transvaginal cholecystectomy. In all animal and human procedures, there was no major complication concerning the operation. Discussion  The transvaginal route may be the easiest route for abdominal NOTES. Percutaneous endoscopic gastrostomy (PEG) allowed the safe performance of a controlled gastric perforation and shortened the time. The hybrid method allowed performance of a safe procedure and shortened the time. Conclusions  Transvaginal and transgastric NOTES cholecystectomy is technically feasible and safe in both humans and animals. New instrumentation needs to be developed to perform a pure NOTES cholecystectomy without transabdominal assistance.     

Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series

Background

The authors’ group has previously described successful transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) in both porcine and cadaveric models using the transanal endoscopic microsurgery platform. This report describes the largest cadaveric series to date as optimization of this approach for clinical application continues.

Methods

Between December 2008 and September 2011, NOTES transanal rectosigmoid resection with total mesorectal excision (TME) was successfully performed in 32 fresh human cadavers using transanal dissection alone (n = 19), with transgastric endoscopic assistance (n = 5), or with laparoscopic assistance (n = 8). The variables recorded were gender, body mass index (BMI), operative time, length of the mobilized specimen, integrity of the mesorectum and the resected specimen, and complications. Univariate statistical analysis was performed.

Results

Of the 32 cadavers, 22 were male with a mean BMI of 24 kg/m² (range 16.3–37 kg/m²). The mean operative time was 5.1 h (range 3–8 h), and the mean specimen length was 53 cm (range 15–91.5 cm). After the first five cadavers, specimen length significantly improved, and a trend toward decreased operative time was demonstrated. The mesorectum was intact in 100 % of the specimens. In nine cadavers, endoscopic dissection was complicated by organ injury. Evaluation by the operative approach demonstrated a significantly longer specimen with laparoscopic assistance (67.7 cm) than with transgastric assistance (45.4 cm) or transanal dissection alone (49.2 cm) (p = 0.013). Comparison of the technique used for inferior mesenteric pedicle division demonstrated both significantly decreased operative time (4.8 vs 6 h; p = 0.024) and increased specimen length (57.7 vs 39.6 cm; p = 0.025) when a stapler was used in lieu of a bipolar cautery device.

Conclusion

Transanal NOTES rectosigmoid resection with TME is feasible and demonstrates improvement in specimen length and operative time with experience. Transitioning to clinical application requires laparoscopic assistance to overcome limitations related to NOTES instrumentation, as well as procedural training with fresh human cadavers.     

Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)

Background  

Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting in-line endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access.     

Single-port surgery and NOTES: from transanal endoscopic microsurgery and transvaginal laparoscopic cholecystectomy to transanal rectosigmoid resection

Two different ways have been developed to perform endoscopic surgery. The standard way is multiport laparoscopic surgery. When entering through a natural orifice, we use single-port surgery for transanal work (transanal endoscopic microsurgery). In clinical routine, we moved from intralumenal surgery toward surgery in the perirectal area and finally the free abdomen. In the context of natural orifice translumenal endoscopic surgery, we have modified the length and diameter of optics and tube and developed new mechanisms for steering long curved instruments. This technology is then used for transvaginal cholecystectomy and transanal rectosigmoid resection. Global clinical application of transanal endoscopic microsurgery has proven superiority in preciseness and clinical results for adenomas and early cancer. The initial clinical study for transvaginal cholecystectomy is successfully performed in 6 female patients with an average operation time of 80 minutes and without major complication. Feasibility of transanal rectosigmoid resection is demonstrated in an ex vivo experimental model.     

Perioperative inflammatory response in natural orifice translumenal endoscopic surgery

Background

Natural orifice translumenal endoscopic surgery (NOTES) could offer multiple advantages compared with the laparoscopic approach. One such potential advantage, not yet proven, is the inferior inflammatory response, which translates into less significant operative stress. This study aimed to compare the immuno-inflammatory response between transgastric NOTES and laparoscopy for simple surgical procedures (oophorectomy) with reference to the cytokine levels.

Methods

For this study, 20 female pigs were randomly assigned to either NOTES or laparoscopic oophorectomy. Seven animals were used as a control group and received only general anesthesia, with no other procedure performed. Blood samples were obtained before surgery, 1 h after the start of the procedure, and at the end of the intervention. The serum levels of IL1β and IL6 were determined using a porcine enzyme-linked immunosorbent assay (ELISA) kit. The mean operative time, intraoperative incidents, and postoperative complications were recorded. On postoperative day 14, the animals were killed, and gastric leak tests were performed.

Results

Both the NOTES and laparoscopic procedures were successfully completed. No gastric leaks were observed during necropsy. The transgastric oophorectomy required a significantly longer time to perform than the laparoscopic surgery. Compared with the NOTES procedures, laparoscopic oophorectomy resulted in significantly higher levels of interleukin-1β (IL1β) (42.34 ± 5.26 ng/ml with NOTES vs 46.93 ± 4.79 ng/ml with laparoscopy; p = 0.028) and IL6 (66.95 ± 7.29 ng/ml with NOTES vs 71.75 ± 4.76 ng/ml with laparoscopy, p = 0.049) during the postoperative phase. No statistical difference was detected between the pre- and postoperative cytokine levels in the NOTES group.

Conclusion

The study findings suggest that pure transgastric endoscopic surgery is a safe approach resulting in less perioperative inflammatory response than laparoscopy in the early postoperative phase.     

Preoperative ultrasound measurements predict the feasibility of gallbladder extraction during transgastric natural orifice translumenal endoscopic surgery cholecystectomy

Background  

Extraction of a gallbladder through an endoscopic overtube during natural orifice translumenal endoscopic surgery (NOTES^?) transgastric cholecystectomy avoids potential injury to the esophagus. This study examined the rate of successful gallbladder specimen extraction through an overtube and hypothesized that preoperative ultrasound findings could predict successful specimen passage.     

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.     

A novel percutaneous insufflating guidewire system for transgastric natural orifice translumenal endoscopic surgery (NOTES) (with video)

Background

A modified percutaneous endoscopic gastrostomy (PEG) technique has been widely used as a safe alternative for gaining peritoneal access in transgastric (TG) natural orifice translumenal endoscopic surgery (NOTES). The authors developed a novel insufflating guidewire (IGW) system, which further maximizes the safety of the modified PEG technique by preparation of a preliminary pneumoperitoneum (PP) before TG route creation. This study aimed to assess the feasibility and safety of the modified PEG technique under PP using the IGW system.

Methods

The IGW system was evaluated in porcine models (n = 5). The process of PP creation was monitored with either laparoscopy or real-time magnetic resonance imaging. The times required to create PP and to establish the TG route were prospectively registered. The animals were killed at the end of each experiment for evaluation of any injuries to adjacent organs.

Results

Preliminary pneumoperitoneum was successfully created in all the animals (median procedural time, 240 s) in rapid and highly reproducible fashion. The creation of the TG route also was quick and straightforward (median procedural time, 100 s). No injuries to the adjacent organs were noted at necropsy.

Conclusions

The establishment of the TG route under PP is feasible and safe with the authors’ newly developed IGW system. The device seems to be advantageous because the entire session is endoscopically controlled. The device may become one of the useful alternatives for adopting TG NOTES in daily practice. Further assessment with human subjects is necessary to make this system practical and universal.     

A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer

Background

The objective of this pilot study was to evaluate the feasibility and safety of natural orifice endoscopic transanal total mesorectal excision (TME) with laparoscopic assistance in a cohort study of five patients with stage I and IIA rectal cancer.

Methods

Five eligible patients with node-negative rectal cancer located 4–12 cm from the anal verge were enrolled in an IRB-approved pilot study. All patients underwent transanal endoscopic TME with laparoscopic assistance, hand-sewn coloanal anastomosis, and a diverting loop ileostomy. Primary and secondary end points included adequacy of the mesorectal excision and 30-day postoperative complications, respectively.

Results

Between November 2011 and May 2012, three males and two females underwent transanal endoscopic TME with laparoscopic assistance. Patient mean age and BMI were 48.6 ± 9.8 years and 25.7 ± 2.3 kg/m², respectively. Tumors were located an average of 5.7 ± 2.4 cm from the anal verge and preoperatively staged as T1N0M0 (2), T2N0M0 (1), and T3N0M0 (2). Mean operative time was 274.6 ± 85.4 min with no intraoperative complications. Partial intersphincteric resection was performed in conjunction with transanal endoscopic TME in three patients. Pathologic examination of TME specimens demonstrated complete mesorectal excision in all cases with negative proximal, distal, and radial margins. Mean length of hospital stay was 5.2 ± 2.6 days and three minor complications occurred, including one ileus and two cases of transient urinary dysfunction. At a mean early follow-up of 5.4 ± 2.3 months, all patients remain disease-free.

Conclusions

In this pilot study of five patients with rectal cancer, transanal endoscopic TME with laparoscopic assistance is feasible and safe, and is a promising alternative to open and laparoscopic TME. Evaluation of long-term functional and oncologic outcomes of this approach is needed before widespread adoption can be recommended.     

Transvesical thoracoscopy: A natural orifice translumenal endoscopic approach for thoracic surgery

Background Recently there has been an increasing enthusiasm for using natural orifices translumenal endoscopic surgery (NOTES) to perform scarless abdominal procedures. We have previously reported the feasibility and safety of the transvesical endoscopic peritoneoscopy in a long-term survival porcine model as useful for those purposes. Herein, we report our successful experience performing transvesical and transdiaphragmatic endoscopic approach to the thoracic cavity in a long-term survival study in a porcine model. Methods Transvesical and transdiaphragmatic endoscopic thoracoscopy was performed in six anesthetized female pigs. A 5 mm transvesical port was created on the bladder wall and an ureteroscope was advanced into the peritoneal cavity. After diaphragm inspection, we introduced through the left diaphragmatic dome a ureteroscope into the left thoracic cavity. In all animals, we performed thoracoscopy as well as peripheral lung biopsy. Animals were sacrificed by day 15 postoperatively. Results We easily introduced a 9.8 Fr ureteroscope into the thoracic cavity that allowed us to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. Postmortem examination revealed complete healing of vesical and diaphragmatic holes, whereas no signs of infection or adhesions were observed in the peritoneal or thoracic cavities. Conclusion This study demonstrates the feasibility of transvesical thoracoscopy in porcine model. However, although this study extends the potential applications of NOTES to the thoracic cavity, new instruments and further work are needed to provide evidence that this could be translated to humans and with advantages for patients.     

Translumenal esophageal anastomosis for natural orifice translumenal endoscopic surgery: an ex vivo feasibility study

Abstract Aim: This study aimed to develop a novel procedure for esophagoesophageal anastomosis for natural orifice translumenal endoscopic surgery (NOTES). Materials and Methods: An ex vivo feasibility study was performed in eight porcine models. The procedure was as follows: (1) A BraceBar? (Olympus Medical Systems Corp., Tokyo, Japan), a double T-bar suturing device, was placed endoscopically at the blind end of the upper esophagus (UE). (2) The blind end was incised, and the scope was advanced out of the esophagus. (3) A balloon catheter was inserted into the lower esophagus (LE). (4) The catheter and a thread on the BraceBar were withdrawn so that the end of the UE was inverted, and the LE was pulled into the UE. (5) After the catheter was removed, a short tube was placed inside the duplicated part of the esophagus via the transgastric route. (6) A double ligature was performed using a ligating device over the tube. A liquid leak test was performed after the procedure. Results: All steps in this procedure were technically successful under the endoscopic visualization without any assistance from outside of the esophagus. The median time of this procedure was 31 (23-66) minutes. The median internal pressure of the UE was 122 (82-142) mm Hg when the anastomosed esophagus was separated into two specimens during the leak test. Conclusions: Translumenal esophagoesophageal anastomosis was feasible. The duration of the procedure was short, and the anastomoses appear to have sufficient strength for use in clinical practice. An in vivo survival study is needed to confirm the safety and reliability of this NOTES procedure.     

Current status and prerequisites for natural orifice translumenal endoscopic surgery (NOTES)

Natural orifice translumenal endoscopic surgery (NOTES) is a sophisticated form of endoscopic surgery whose use has recently spread rapidly around the world. Although hundreds of reports of animal studies and clinical cases about NOTES have been published since 2004, NOTES is still in the experimental phase. The formation of an iatrogenic incision in the lumenal wall of intraperitoneal organs is a major disadvantage of NOTES. No reliable technique for complete closure has yet been established, and this problem must be resolved before NOTES can be adopted as a routine clinical practice. Several devices for the closure of lumenal incisions in the stomach or colorectum have been developed, and their safety and usefulness have been examined in animal studies and clinical cases. Kyushu University has been involved in furthering the adoption of NOTES as a routine clinical practice, and the Kyushu University Training Center for Minimally Invasive Surgery holds training sessions on endoscopic surgical techniques for surgeons from all over Japan. Studies to develop a navigation system and robotic technology for use with NOTES are also in progress at Kyushu University. The further development of endoscopy-related technologies and equipment, such as robotic technology, is therefore essential to allow the safe, widespread adoption of pure NOTES.     

Natural orifice translumenal endoscopic surgery (NOTES): creation of a gastric valve for safe and effective transgastric surgery in humans

Introduction  

NOTES has become a clinical reality. There remain, however, many challenges that need to be addressed in order to refine the technique. One of the most feared potential complications of transgastric surgery is a leak from the port of entry into the peritoneum. When withdrawing the endoscope into the gastric lumen it is difficult to make a secure closure due to the loss of pneumogastrium. We present a novel and safe technique for creating a gastrotomy developed in our animal laboratory and applied in all of our human NOTES cholecystectomies.     

A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery

Background Natural orifice translumenal endoscopic surgery (NOTES) provides surgical access to the peritoneal cavity without skin incisions. The NOTES procedure requires pneumoperitoneum for visualization and manipulation of abdominal organs, similar to laparoscopy. Accurate measurement of the pneumoperitoneum pressure is essential to avoid potentially deleterious effects of intraabdominal compartment syndrome. A reliable method for monitoring pneumoperitoneum pressures during NOTES has not been identified. This study evaluated several methods of monitoring intraabdominal pressures with a standard gastroscope during NOTES. Methods Four female pigs (25 kg) were sedated, and a single-channel gastroscope was passed transgastrically into the peritoneal cavity. Pneumoperitoneum was achieved via a pressure insufflator through a percutaneous, intraperitoneal 14-gauge catheter. Three other pressures were recorded via separate catheters. First, a 14-gauge percutaneous catheter passed intraperitoneally measured true intraabdominal pressure. Second, a 14-gauge tube attached to the endoscope was used to measure endoscope tip pressure. The third pressure transducer was connected directly to the accessory channel of the endoscope. The abdomen was insufflated to a range of pressures (10–30 mmHg), and simultaneous pressures were recorded from all three pressure sensors. Results Pressure correlation curves were developed for all animals across all intraperitoneal pressures (mean error, –4.25 to –1 mmHg). Endoscope tip pressures correlated with biopsy channel pressures (R ² = 0.99). Biopsy channel and endoscope tip pressures fit a least-squares linear model to predict actual intraabdominal pressure (R = 0.99 for both). Both scope tip and biopsy channel port pressures were strongly correlative with true intraabdominal pressures (R ² = 0.98 and R ² = 0.99, respectively). Conclusion This study demonstrates that monitoring pressure through an endoscope is reliable and predictive of true intraabdominal pressure. Gastroscope pressure monitoring is a useful adjunct to NOTES. Future NOTES procedures should incorporate continuous intraabdominal pressure monitoring to avoid the potentially deleterious effects of pneumoperitoneum during NOTES. This can be achieved by the integration of pressure-monitoring capabilities into gastroscopes. Presented at the 2006 Scientific Session of Society of American Gastrointestional and Endoscopic Surgeons (SAGES), April 2006, Dallas, TX, USA