单孔腹腔镜结直肠癌手术研究进展

正近年来,随着腹腔镜手术在结直肠外科的广泛开展以及微创理念的延伸,许多单位着手"无痕"结直肠外科手术的研究,以进一步减少创伤,减轻术后疼痛,提高美容效果。这些研究主要包括经自然腔道内镜外科手术(NOTES)和单孔腹腔镜手术(LESS)。由于NOTES在伦理学、胃肠道吻合、预防感染、操作平台及器械研发等多方面     

完全经脐单孔腹腔镜阑尾切除术30例报告

经脐单孔腹腔镜手术（transumbilical laparoendoscopic single site surgery．TU—LESS）利用人体天然的瘢痕——脐进行手术，术后瘢痕隐蔽，手术创伤小而且美观．是对传统腹腔镜技术的进一步发展和补充，是现阶段最可行的经自然孔道内镜外科技术（NOTES）。苏州大学附属第二医院于2009年11月至2010年9月实施了30例完全经脐单孔腹腔镜阑尾切除术．取得了良好效果．现总结报告如下、     

循自然腔道内镜手术临床应用现状

循自然腔道内镜手术（natural orifice transluminal endoscopic surgery,NOTES）的概念由Kalloo等于2004年正式提出。NOTES是以内镜为治疗工具,经自然腔道（食管、胃、阴道、膀胱、结直肠等）而非皮肤切口．对腹腔脏器疾病进行治疗的微创外科治疗方法,其作为新型腹壁无瘢痕手术比腹腔镜手术更为微创。NOTES从概念的提出到动物实验及临床应用,发展迅速。     

单孔腔镜技术及其在泌尿外科的应用

以尽可能小的创伤和尽可能美容的切口完成手术,是每个外科医师的美好愿望。自1987年Mouret等完成了世界首例电视腹腔镜胆囊切除术后^[1],外科学便进入了一个全新的微创外科时代。随后于1991年Clayman等^[2]。首次应用腹腔镜技术完成了肾切除术,在此之后泌尿外科医师在微创外科的道路上不断探索,并逐渐成为了应用微创技术解决患者病痛的先行者。随着科学技术的进步,加之外科医师创造性的不断展现,单孔腔道腹腔镜内镜手术（1aparo endoscopicsingle sitesurgery,LESS）和经自然腔道内镜手术（naturalorificetransluminalendoscopicsurgery,NOTES）技术应运而生,使微创外科的发展再次向前迈进了一大步,很有可能给外科领域带来革命性的突破。LESS手术理论上的优势在于隐藏瘢痕而达到美容效果、减轻患者术后疼痛、缩短术后恢复时间和减少手术切口相关并发症等方面,目前该技术已经得到外科医师的认可并得以应用于临床。本文就LESS技术及其在泌尿外科的临床应用现状加以论述。     

腹腔镜结直肠手术进展及展望（2000-2020）

自20世纪90年代至今,腹腔镜结直肠手术技术经历了突飞猛进的发展,安全性逐渐得到广泛认可,已经成为结直肠癌的重要手术方式。与传统的开放结直肠手术对比,腹腔镜结直肠手术创伤更小,降低了术后的应激和炎症反应,使病人的免疫状态得到改善;腹腔镜结直肠手术可获得更好的近期疗效和相当的远期疗效。近年来相继报道腹腔镜结直肠手术安全性、有效性研究证据,NCCN指南中腹腔镜结直肠手术的指征也不断拓展。如今在完整系膜切除（CME）、全系膜切除（TME）原则的指导下,已发展出诸多腹腔镜结直肠手术术式。未来,在5G通信技术的支持下,在越来越多中国学者的多中心RCT研究结果揭晓后,腹腔镜结直肠手术必将迎来空前发展。     

腹腔镜直肠全系膜切除术在中低位直肠癌手术中的应用现状与展望

腹腔镜在结直肠癌手术中的应用已在世界范围内获得较为广泛的开展，其手术安全性、可行性、肿瘤根治性及近、远期疗效部分已得到前瞻性随机对照临床研究（RCT）结果的证实。基于此，腹腔镜结直肠手术已经与Heald等提出的直肠全系膜切除（total mesorectal excision，TME）原则一起被认为是近20年来结直肠肿瘤手术发展历程中两次具有重大意义的变革。而腹腔镜中低位直肠癌手术由于技术要求更高，因此，单纯针对腹腔镜中低位直肠癌手术的临床研究与腹腔镜结肠手术相比，开展较少。但国内外已有关于腹腔镜直肠癌TME手术临床研究的初步结果，为该手术在中低位直肠癌中的应用提供了不少临床依据。     

腹腔镜结直肠手术减孔技术及经验分享

1 微创结直肠手术的选择 回顾腹腔镜结直肠手术的历史,自从腹腔镜手术问世以来,勇于进取的外科医师们便在不同的领域进行了相关的尝试,如今腹腔镜技术已经广泛应用于结直肠手术中。     

2013年国家级继续医学教育项目“泌尿外科LESS和NOTES技术的临床应用”学习班通知

国家级继续医学教育项目--“泌尿外科NOTES和LESS的临床应用”【编号2013—04—05—010（国）】学习班，经全国继续医学教育委员会批准，定于2013年12月13～15日在赣南医学院第一附属医院举办。学习班邀请了著名泌尿外科专家学者前来讲学，将展示NOTES、LESS及3D腹腔镜等微创泌尿外科前沿技术最新进展，并安排精彩的相关手术演示。     

“泌尿外科LESS和NOTES技术的临床应用”学习班通知（2013年国家级继续医学教育项目）

国家级继续医学教育项目一“泌尿外科NOTES和LESS的临床应用”【编号,2013—04—05—010（国）】学习班经全国继续医学教育委员会批准,定于2013年12月13-15日在赣南医学院第一附属医院举办。学习班邀请了著名泌尿外科专家学者前来讲学,将展示NOTES、LESS及3D腹腔镜等微创泌尿外科前沿技术最新进展,并安排精彩的相关手术演示。     

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。     

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.     

单孔腹腔镜技术在胃肠外科手术中应用的问题与决策

经脐单孔腹腔镜外科技术足现阶段最为町行的“无瘢痕”手术．国内外均已将该技术应用于胃肠外科于术一本文结合作者的经验,就经脐单孔腹腔镜外科技术任胃肠外科领域的应用现状、所而临问题和相应对策进行探讨．直线视野、器械难以彤成三角关系及Trocar与器械手柄仡腹腔外部分的拥挤等是单孔腹腔镜外科技术的操作难点,单孔条件下进行胃或结直肠手术时上述难点更为凸硅提高手术技能、选择合适的单孔腔镜器械、相对同定单孔腹腔镜手术同队以及灵活的暴露方法等可以保证单孔胃或结区肠手术的安全进行为了保证单孔腹腔镜技术被大家所接受并坚持开展,胃肠道恶性肿瘤手术的安全性和彳丁效性峨需评价,单孔腹腔镜技术作为一种新兴的外科技术．住初涉胃肠道肿瘤治疗领域后的进一步发展离不开理念的认同、技术瓶颈的突破及器械的更新,     

单孔腹腔镜手术在消化外科的应用

Although natural orifice transluminal endoscopic surgery provides excellent cosmesis,it is not being widely accepted because of the restriction in aspects of technology,instruments and ethics.As a bridge,laparoendoscopic single site surgery(LESS)has been widely applied in digestive surgery,including bariatric,gastric,hepatobiliary and colorectal surgery.Although LESS provides excellent cosmetic results,and its safety and feasibility seems similar to conventional laparoscopy in most procedures,its effectiveness in the treatment of malignant tumors still needs to be proved. Compared with conventional laparoscopy,LESS has the drawbacks of longer operation time and higher demand in experience.Besides,because digestive tract reconstruction is often needed after resection,more convenient and applicable instruments need to be invented for the development of LESS.     

单孔腔镜技术发展带给我们的思考

经自然孔道内镜外科（natural orifice transluminal endoscopic surgery, NOTES）经过近10年的研究,已经由一个理想中的概念走向初步的临床应用。由于其尚存在诸多较难克服的技术瓶颈,现阶段仍无法广泛开展。经脐单孔腔镜手术是目前最现实可行的“无瘢痕”技术。该技术近年来在国内外进展迅速,但是仍然存在许多亟待改进的方面,包括操作技巧的进步、器械设备的研发和手术观念的提高。该技术的临床应用和适应证的拓展将为NOTES手术提供有益的技术准备,若与内镜相结合,则可发挥各自的优势,使病人得到更为安全、有效、微创的治疗。由此可见,腔镜医生的培养需要辅以内镜技术的培训,这样才能造就技术全面的微创外科医生。     

Single-incision laparoscopic surgery - current status and controversies

Scarless surgery is the Holy Grail of surgery and the very raison d'etre of Minimal Access Surgery was the reduction of scars and thereby pain and suffering of the patients. The work of Muhe and Mouret in the late 80s, paved the way for mainstream laparoscopic procedures and it rapidly became the method of choice for many intra-abdominal procedures. Single-incision laparoscopic surgery is a very exciting new modality in the field of minimal access surgery which works for further reducing the scars of standard laparoscopy and towards scarless surgery. Natural orifice translumenal endoscopic surgery (NOTES) was developed for scarless surgery, but did not gain popularity due to a variety of reasons. NOTES stands for natural orifice translumenal endoscopic surgery, a term coined by a consortium in 2005. NOTES remains a research technique with only a few clinical cases having been reported. The lack of success of NOTES seems to have spurred on the interest in single-incision laparoscopy as an eminently doable technique in the present with minimum visible scarring, rendering a 'scarless' effect. Laparo-endoscopic single-site surgery (LESS) is, a term coined by a multidisciplinary consortium in 2008 for single-incision laparoscopic surgery. These are complementary technologies with similar difficulties of access, lack of triangulation and inadequate instrumentation as of date. LESS seems to offer an advantage to surgeons with its familiar field of view and instruments similar to those used in conventional laparoscopy. LESS remains a evolving special technique used successfully in many a centre, but with a significant way to go before it becomes mainstream. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery. This article outlines the development of LESS giving an overview of all the techniques and devices available and likely to be available in the future.     

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.     

LESSons in minimally invasive urology

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. LaparoEndoscopic Single Site (LESS) surgery potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. Technological developments in instrumentation, access and optics devices are overcoming some of the challenges that are raised when operating through a single site. Further advances in the technique have included the incorporation of robotics (R-LESS), which exploit the ergonomic benefits of ex vivo robotic platforms in an attempt to further improve the implementation of LESS procedures. In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of tissue from internal repositionable platforms. The use of magnetic anchoring and guidance systems (MAGS) might allow the external manoeuvring of intra-corporeal instruments to reduce clashing and facilitate triangulation. However, the final promise in minimally invasive surgery is natural orifice transluminal endoscopic surgery (NOTES), with its scarless technique. It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical utility over standard laparoscopic methods.     

Laparo‐endoscopic single‐site surgery: preliminary advances in renal surgery

We reviewed the preliminary advances in laparo‐endoscopic single‐site surgery (LESS) as applied to renal surgery, and analyzed current publications based on animal models and human patients. We searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Keyword searches included: ‘scarless’, ‘scar free’, ‘single port/trocar/incision’, ‘intraumbilical’, and ‘transumbilical’, ‘natural orifice transluminal endoscopic surgery’ (NOTES), ‘SILS’, ‘OPUS’ and ‘LESS’. The lessons learnt from the studies using the porcine model are that further advances in instrumentation are essential to achieve optimum results, and that testing survival in animals is also necessary to further expand the NOTES and LESS techniques. Further advances in instrument technology together with increasing experience in NOTES and LESS approaches have driven the transition from porcine models to human patients. In the latter, studies show that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills, and optimal instrumentation, are available. The next step towards minimal access/minimally invasive urological surgery is NOTES and LESS. It is inevitable that LESS will be extended to involve more complex and technically demanding procedures such as laparoscopic radical prostatectomy and partial nephrectomy.     

Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML)

Introduction

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches.

Objective

To present LESS and NOTES in its historical context and to clarify the associated terminology.

Method

Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT).

Results

The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4?years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that ‘laparoendoscopic single-site surgery’ (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy.

Discussion

The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.