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.     

Changes in abdominal wall thickness during laparoscopy: implications for the use of magnetic assisted surgery

Abstract

Introduction: Recently, magnetic solutions have been proposed to minimize surgical invasiveness. These are comprised of deployable instruments containing magnets which are inserted into the abdominal cavity through a single access point. The manipulation of the internal elements occurs via magnets held on the external surface of the abdominal wall. This technology relies on the magnetic force between the magnets, which is inversely related to the abdominal wall thickness (AWT). The aim of this study was to establish the expected change in AWT from before and after initiation of pneumoperitoneum.

Material and methods: Patients scheduled for laparoscopic procedures were assessed by ultrasound for AWT immediately before and during laparoscopy. Change of AWT during laparoscopy was calculated. Statistical analysis was performed using Student’s t-test.

Results: Thirty-two patients undergoing various laparoscopic procedures were included. Twenty patients were male (62.5%) and ten were morbidly obese (31%). Mean age was 51?years (range 18–76) and average BMI was 28.1?kg/m² (range 19.0–41.0). AWT decreased on average by 15.6% once pneumoperitoneum was initiated in both obese and non-obese patients (p?=?.01).

Conclusion: Our data suggest that following preoperative assessment of AWT with abdominal wall ultrasound, more patients than expected might be candidates for the use of trans-abdominal magnetic devices.     

Surgical robots for SPL and NOTES: A review

Introduction: Single port laparoscopy (SPL) and natural orifice transluminal endoscopic surgery (NOTES) are next-generation minimally invasive surgery (MIS) procedures which could further reduce patient trauma. Robotic assistance shows great potential in providing augmented motion precision and manipulation dexterity. This article reviews the robotic systems recently developed for SPL and NOTES. Material and methods: A literature search was conducted based on Science Citation Index, Engineering Index, Medline, and PubMed databases. Results: Eleven robotic systems for SPL and six robotic systems for NOTES were identified. Structures and performances of these systems were reported. Special attention was directed to the systems using continuum mechanisms. Discussion and conclusion: Regarding the structure aspect, the reviewed systems for SPL and NOTES all deploy a vision unit and at least two manipulation arms for surgical interventions through an access channel. To date, the smallest diameter of such a channel is 12 mm. Regarding the functionality aspect, only a few systems demonstrated results promising enough for animal or clinical studies in the near future. Surgical robots using dual continuum mechanisms achieved both design compactness and functional versatility. The characteristics suggest that the use of continuum mechanisms is worth exploring through future developments of surgical robots.     

NOViSE: a virtual natural orifice transluminal endoscopic surgery simulator

Purpose

Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique in minimally invasive surgery whereby a flexible endoscope is inserted via a natural orifice to gain access to the abdominal cavity, leaving no external scars. This innovative use of flexible endoscopy creates many new challenges and is associated with a steep learning curve for clinicians.

Methods

We developed NOViSE—the first force-feedback-enabled virtual reality simulator for NOTES training supporting a flexible endoscope. The haptic device is custom-built, and the behaviour of the virtual flexible endoscope is based on an established theoretical framework—the Cosserat theory of elastic rods.

Results

We present the application of NOViSE to the simulation of a hybrid trans-gastric cholecystectomy procedure. Preliminary results of face, content and construct validation have previously shown that NOViSE delivers the required level of realism for training of endoscopic manipulation skills specific to NOTES.

Conclusions

VR simulation of NOTES procedures can contribute to surgical training and improve the educational experience without putting patients at risk, raising ethical issues or requiring expensive animal or cadaver facilities. In the context of an experimental technique, NOViSE could potentially facilitate NOTES development and contribute to its wider use by keeping practitioners up to date with this novel surgical technique. NOViSE is a first prototype, and the initial results indicate that it provides promising foundations for further development.

     

Development of advanced endoscopes for Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Natural orifice transluminal endoscopic surgery (NOTES) is a hybrid procedure which uses flexible endoscopic technology to perform laparoscopic surgical procedures within the abdominal cavity. Initial reports of animal studies describe the use of standard endoluminal endoscopes to accomplish intra‐abdominal surgeries. Current flexible scopes suffer from several deficiencies which make them unlikely to be able to be used for large scale human NOTES experiences. This review analyzes the deficiencies of current endoscopes, discuses the requirements of the ideal NOTES endoscope and reviews some of the possible “endoscopes of the future” that are being developed for the next generation of surgery. Discussion focuses on the “R” scope (Olympus, Tokyo, Japan) and the Transport and Cobra scopes (USGI Medical, San Capistrano, CA).     

ELITE -The ex vivo training unit for NOTES: Development and Validation

Abstract

Skill training is an essential part of surgical education. Every physician has to get familiar with the various operation techniques and needs to handle the different instruments. However, mechanical and computer-based VR-simulators offer only one specific procedure, either laparoscopic or endoscopic. We designed the universal training system ELITE (endoscopic-laparoscopic interdisciplinary training entity) which is a new full synthetic ex vivo surgical training model for laparoscopic surgery, combined endoluminal/endocavitary procedures (“hybrid surgery”) and NOTES. The aim of the current investigation was to integrate respiration and electro dissection into the model, and the evaluation of both innovations. The ELITE is a full-size replica of a human female torso including a gas-tight abdominal wall and offering various accesses to the abdomen. A complete organ package including liver, gallbladder, spleen, gastrointestinal tract, including the mesentery and omentum is available for this system. Cholecystectomy and appendectomy can be simulated realistically with this new training system. For more realistic conditions during operations breathing-induced organ motion could be integrated into this system. Two latex balloons were inserted into the system to imitate the function of the diaphragm. They are inflated and deflated according to the respiration cycle and move the artificial organs in a natural way. Physicians, including endoscopic/laparoscopic novices and experts, were asked to train different NOTES procedures on the model. Performance of their training and subjective appraisal of the model itself were evaluated. The opportunity of electrodissection of the gallbladder and appendix and simulation of breath excursion of the diaphragm could successfully be implemented into the training system. One recently published study showed that ELITE is a suitable tool to train different surgical procedures. All subjects (novices and endoscopic/laparoscopic experts) showed a significant learning curve during the assessment. Experts could be reliably differentiated from novices. The actual evaluation of the model showed that 97% of the subjects considered the ELITE as a useful simulator for NOTES. ELITE was validated to be a suitable tool to train different NOTES procedures. As a step by step training of NOTES is highly recommended, this training system offers the opportunity by degrees that animal experiments can be replaced, especially, for learning of basic techniques and thus costs can be significantly reduced.     

Flexible endoscopic robot

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical procedure during which abdominal operations can be performed with an endoscope passed through a natural orifice through an internal incision in the stomach, vagina, bladder or colon. NOTES is still evolving and many barriers stand on its way before it can gain acceptance in modern surgical practice. Effective access to the peritoneal cavity, closure techniques of the natural orifice access sites, development of a multitasking platform to accomplish procedures and support for special orientation are only a handful of its known limitations. Although the endoscope and conventional tools are useful for simple procedures, many important and complicated procedures are currently not possible due to limitation of degree of freedom (DOF) of the end effectors. We have developed a Master and Slave Transluminal Endoscopic Robot (MASTER) with nine degrees of freedom (DOF) in end effectors, which are long and flexible so as to enhance endoscopic procedures and NOTES. Using MASTER we have successfully performed endoscopic sub-mucosal dissections (ESD) to segmental hepatectomies in animal models. Thus, the MASTER robotic system shows great potential to perform new surgical procedures that are otherwise not possible with conventional endoscopic tools.     

Possibilities of lasers within NOTES

Abstract

Lasers possess unique properties that render them versatile light sources particularly for NOTES. Depending on the laser light sources used, diagnostic as well as therapeutic purposes can be achieved. The diagnostic potential offered by innovative concepts such as new types of ultra-thin endoscopes and optical probes supports the physician with optical information of ultra-high resolution, tissue discrimination and manifold types of fluorescence detection. In addition, the potential 3-D capability promises enhanced recognition of tissue type and pathological status. These diagnostic techniques might enable or at least contribute to accurate and safe procedures within the spatial restrictions inherent with NOTES. The therapeutic potential ranges from induction of phototoxic effects over tissue welding, coagulation and tissue cutting to stone fragmentation. As proven in many therapeutic laser endoscopic treatment concepts, laser surgery is potentially bloodless and transmits the energy without mechanical forces. Specialized NOTES endoscopes will likely incorporate suitable probes for improving diagnostic procedures, laser fibres with advantageous light delivery possibility or innovative laser beam manipulation systems. NOTES training centres may support the propagation of the complex handling and the safety aspects for clinical use to the benefit of the patient.     

NOTES: past,present and future

Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about that field. Natural Orifices Translumenal Endoscopic Surgery (NOTES) has the potential to break the physical barrier between bodily trauma and surgery. At the dawn of surgery, excellence was associated with big incisions: “big scar ‐ big surgeon”. In the 80s, minimally invasive surgery was born representing one of the greatest surgical evolutions of the 20th century. After Kalloo's first report in 2004 on transgastric peritoneoscopy in a porcine model, the interest in natural orifice transluminal endoscopic surgery (NOTES) has blossomed. Theoretically the same operation performed laparoscopically could be carried out through natural orifices without any abdominal incision avoiding pain and scarring. The lesson learned from the advent of laparoscopic surgery, thought us that we could be witnessing the birth of another surgical revolution. Since 2004 many abdominal procedures that use a NOTES approach have been successfully performed in animal models. However, the initial excitement for NOTES has been somewhat tempered by the reality that a NOTES procedure in human without laparoscopic assistance has not been performed by most groups. Indeed, a major issue is the lack of stable operative platform and flexible instruments that allow retraction and exposure of the organs, such as appendix or gallbladder. Will this issue change the future of NOTES?     

Nouvelles frontières de la chirurgie bariatrique : chirurgie endoluminale et laparoscopie par une seule incision

Since the introduction of the natural orifices transluminal endoscopic surgery (NOTES) in bariatric surgery, a development of new endoluminal devices for primary and revisional surgery invested the last years. Contemporaly, the tendency to reduce abdominal trauma, especially to improve the cosmetic results, induced the realization of laparoscopic procedures through a single abdominal incision. The authors report an overview of the actual endoluminal procedures (primary, revisional), the different endoscopes developed or under research, and the state-of-the-art single incision laparoscopy in bariatric surgery.     

Five millimetre-instruments in paediatric robotic surgery: Advantages and shortcomings

Purpose: The study was designed to assess the utility and controversies surrounding the usage of 5-mm instruments in paediatric robotic surgery. Adequate, delicate instruments for surgery in very narrow spaces are still lacking. Material and methods: Thirty children underwent elective abdominal robotic surgery. Working sites, assembly and operative time, hospital stay, advantages, complications and shortcomings are reported. Results: Interventions were performed in the following anatomical sites: 11 upper abdominal, nine pelvic, ten renal procedures. The majority of procedures required two operative trocars. A 2–3 mm accessory port was necessary for operations in the renal area and upper abdomen. The ports had to be placed at least 3 cm from the costal margins and superior iliac spines and at an angle of at least 130° with respect to the camera trocar. This configuration allowed intra-corporal knotting, vessel ligation and dissection with instruments in the inverted position. Operative times and hospital stays were similar to those reported for 8 mm-instruments. Conclusion: The use of 5-mm instruments was advantageous in renal and pelvic sites. The benefits in upper abdominal surgery need further evaluation, particularly in patients weighing <10 kg. Smaller sized instruments with high endowrist dexterity would resolve the problems encountered in paediatric robotic-assisted surgery using 5-mm instruments.     

Submucosal endoscopy, a new era of pure natural orifice translumenal endoscopic surgery (NOTES)

Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional perforation of the viscera with an endoscope to access the abdominal cavity and perform an intraabdominal operation. In a brief time period, NOTES has been shown to be feasible in laboratory animal and human studies. Easy access to the peritoneal cavity and complete gastric closure should be secured before NOTES can be recommended as an acceptable alternative in clinical practice. The concept of submucosal endoscopy has been introduced as a solution to overcome these two primary barriers to human NOTES application. Its offset entry/exit access method effectively prevents contamination and allows the rapid closure of the entry site with a simple mucosal apposition. In addition, it could be used as an endoscopic working space for various submucosal conditions. Herein, the detailed procedures, laboratory results and human application of the submucosal endoscopy will be reviewed.     

Entrance barriers and integration obstacles of NOTES

Abstract

Natural orifice transluminal endocopic surgery (NOTES) changes the paradigm of endoscopy and even surgery. The artificial perforation of abdominal hollow organs is now welcome and no longer avoided under all circumstances. Surgeons as well as gastroenterologists face a lot of problems, barriers and integration obstacles. The interdisciplinary approach for the introduction of a new technique appears promising and opens a lot of perspectives. This paper illustrates and discusses medical, technical, financial and professional barriers and integration obstacles for the introduction of NOTES into clinical practice.     

Successful removal of two magnets in the small intestine by laparoscopy and colonoscopy: A case report

BACKGROUNDIngestion of multiple magnets can cause serious gastrointestinal complications, such as obstruction, fistulae, and perforation. When multiple magnets traverse the stomach, coordination between pediatric gastroenterologists and pediatric surgeons is recommended, and ultimate management is required dependent on clinical concerns.CASE SUMMARYA 5-year-old girl swallowed 2 small magnets that then remained in the right lower quadrant (RLQ) of the abdomen for 3 d; this required endoscopic and laparoscopic intervention. Abdominal X-ray and computed tomography revealed high-density objects in the RLQ area. Colonoscopy after proper bowel preparations on the third day of ingestion revealed no foreign body in the colonic area or the end of the ileum. The two magnets were removed via colonoscopy with laparoscopic intervention.CONCLUSIONIt is important to establish effective coordination between pediatric gastroenterologists and pediatric surgeons when using a non-invasive procedure to remove magnets.     

Endoluminal minirobots for transgastric peritoneoscopy

The performance of surgeries through small incisions or natural orifices minimizes the invasiveness to the patient as compared to open procedures. However, the constraints on visual feedback and dexterity limit the scope of these procedures. Recent robotic technologies attempt to mitigate these constraints for flexible endoscopy and laparoscopy. Much of the current work in flexible endoscopy is in the development of a fully autonomous endoscope capable of providing the surgeon with better control. Advancements in laparoscopic technologies have demonstrated abilities to improve visualization and dexterity through telerobotics and in vivo robotics. The application of new robotic technologies in flexible endoscopy and laparoscopy to natural orifice surgery promises to further benefit the patient by eliminating abdominal incisions, scarring, and the pain associated with these incisions. The safety and feasibility of such robotic technology has been successfully demonstrated for natural orifice transluminal endoscopic surgery (NOTES) in animal models.     

EUS-guided NOTES interventions

Entering the peritoneal cavity with the echoendoscope has been avoided because this endoscope is rather rigid and difficult to handle and maneuver in a limited space. Endoscopic ultrasound may be of help, however, to guide natural orifice translumenal endoscopic surgery (NOTES) procedures. This article provides an overview of the potential benefit and the few endoscopic ultrasound-based natural NOTES procedures performed to date.     

Establishment of pure NOTES procedure using a conventional flexible endoscope: review of six cases of gastric gastrointestinal stromal tumors

An increasing number of reports have recently been published on hybrid natural orifice transluminal endoscopic surgery (NOTES). These reports do not address how to complete an operation with a flexible endoscope alone (pure NOTES), but rather how to combine use of an endoscope and a laparoscope. Surgical procedures using flexible and rigid endoscopes have been developed using different processes and concepts. Recognizing this conceptual difference, we conducted a study to address how to establish a pure NOTES procedure. Six patients with gastric gastrointestinal stromal tumors (GISTs) underwent hybrid NOTES. Each case was retrospectively reviewed to determine the appropriateness of the treatment and the usefulness of the endoscopic submucosal dissection (ESD) method, double-scope method, spaced perforation method, duodenal balloon occlusion method, and loop clip technique. The development of operative procedures that take advantage of the characteristics of flexible endoscopes, even with conventional flexible endoscopic devices and conventional endoscopes alone, may contribute to the realization of pure NOTES.     

Endoscopic repair of delayed stomach perforation caused by penetrating trauma: A case report

BACKGROUNDPrimary endoscopic closure of a perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are very few studies on the efficacy of endoscopic management of delayed traumatic gastric perforation. Herein, we report a novel case of a patient who was successfully treated for delayed traumatic stomach perforation using an alternative endoscopic modality.CASE SUMMARYA 39-year-old woman presented with multiple penetrating traumas in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and peri-splenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suturing of the lacerated lung was performed; however, delayed free perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for the primary repair of the gastric wall, re-perforation was noted 15 d postoperatively. The high risk associated with re-surgery prompted an endoscopic intervention using 2 endoloops and 11 endoscopic clips using a novel modified purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications.CONCLUSIONEndoscopic closure with endoloops and clips can be a useful therapeutic alternative to re-surgery for delayed traumatic gastric perforation.     

NOTES: human experience

Human natural orifice translumenal endoscopic surgery (NOTES) is already being reported from numerous centers, and the results seem promising. There are key issues to be addressed and benefits over traditional safe procedures need to be demonstrated. Interestingly, however, human NOTES seem to be progressing at a fast pace compared with the evolution of surgical procedures or techniques described previously. This article examines the current status of NOTES in humans, the challenges, and the implications on the future of minimal access surgery.     

NOTES: a surgeon's perspective

Natural orifice transluminal endoscopic surgery (NOTES) is an exciting concept gaining national attention as a novel and minimally invasive approach to gastrointestinal surgery and endoscopy. The hope of combining the talents and experience of surgeons and gastrointestinal endoscopists with emerging technologies has created enthusiasm for developing this approach as a specialty itself. Upon initial review, many procedures seem to naturally lend themselves to this approach and include endoscopic mucosal resection, small tumor excision, and access to the peritoneum. The main question to be answered in this short article is: What is gained and what is lost with NOTES?