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Muhammad S, Gao Y, Guan X, QingChao T, Fei S, Wang G, Chen Y, Liu Z, Jiang Z, Kaur K, Tatiana K, Ul Ain Q, Wang X, He J. Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients. J Int Med Res 2022; 50:3000605221134472. [PMID: 36440806 PMCID: PMC9712411 DOI: 10.1177/03000605221134472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 10/05/2022] [Indexed: 03/27/2024] Open
Abstract
OBJECTIVE To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction. METHODS Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction. RESULTS The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient. CONCLUSION The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.
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Affiliation(s)
- Shan Muhammad
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - YiBo Gao
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
| | - Tang QingChao
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Shao Fei
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
| | - Guiyu Wang
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Yinggang Chen
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
| | - Kavanjit Kaur
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | | | - Qurat Ul Ain
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences & Peking Union Medical College, Beijing 100021,
China
- Department of Colorectal Surgery, the Second Affiliated Hospital
of Harbin Medical University, Harbin 150086, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/National
Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing 100021, China
- Laboratory of Translational Medicine, National Cancer
Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese
Academy of Medical Sciences and Peking Union Medical College, Beijing 100021,
China
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Mann J, Rolinger J, Axt S, Kirschniak A, Wilhelm P. Novel box trainer for taTME - prospective evaluation among medical students. Innov Surg Sci 2019; 4:116-120. [PMID: 31709303 PMCID: PMC6817727 DOI: 10.1515/iss-2019-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/12/2019] [Indexed: 12/24/2022] Open
Abstract
Background Transanal total mesorectal excision (taTME) has been subject to extensive research and increasing clinical application. It allows further reduction of trauma by accessing via a natural orifice. Manifold platforms and instruments have been introduced and heterogeneity in surgical techniques exists. Because of the technique’s complexity there is a persistent need for dedicated training devices and concepts. Materials and methods The key steps of taTME were analyzed and a box trainer with three modules resembling these steps was designed and manufactured. Twenty-one surgically inexperienced medical students performed five repetitions of the three tasks with the new box trainer. Time and error count were analyzed for assessment of a learning curve. Results A significant reduction of processing time could be demonstrated for tasks 1–3 (p < 0.001; p < 0.001; p = 0.001). The effect size was high for comparison of repetition 1 and 5 and decreased over the course (task 1: r = 0.88 vs. r = 0.21; task 2: r = 0.86 vs. r = 0.23; task 3: r = 0.74 vs. r = 0.44). Also, a significant reduction of errors was demonstrated for tasks 1 and 2. The decrease of effect size was analogously demonstrated. Conclusions The trainer might help to reduce the use of animal models for testing of platforms and instruments as well as gaining first-hand experience in transanal rectal resection.
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Affiliation(s)
- Jakob Mann
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Henriettenstift Hospital, Hannover, Germany
| | - Jens Rolinger
- Department of Surgery and Transplantation, University of Tuebingen, Tuebingen, Germany
| | - Steffen Axt
- Department of Surgery and Transplantation, University of Tuebingen, Tuebingen, Germany
| | - Andreas Kirschniak
- Department of Surgery and Transplantation, University of Tuebingen, Tuebingen, Germany
| | - Peter Wilhelm
- Department of Surgery and Transplantation, University of Tuebingen, Tuebingen, Germany
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Roodbeen SX, lo Conte A, Hirst A, Penna M, Bemelman WA, Tanis PJ, Hompes R. Evolution of transanal total mesorectal excision according to the IDEAL framework. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2019; 1:e000004. [PMID: 35047772 PMCID: PMC8749305 DOI: 10.1136/bmjsit-2019-000004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/21/2019] [Accepted: 06/06/2019] [Indexed: 12/28/2022] Open
Abstract
Tremendous innovations have taken place in surgical procedures, but contrary to drug development, this process has been unregulated in the past. IDEAL promotes a structured framework for the safe implementation and assessment of a new surgical technique or intervention, by describing five stages for evaluating and reporting of innovations: Idea, Development, Exploration, Assessment and Long term. Transanal total mesorectal excision (TaTME) is a relatively new technique in rectal cancer surgery that has attracted huge interest and increasing adoption worldwide. This review article aims to provide an overview of the evolution of TaTME, according to the IDEAL framework, which guides us in the difficult yet exciting process of surgical innovation.
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Affiliation(s)
| | | | - Allison Hirst
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Marta Penna
- Surgery, Churchill University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Willem A Bemelman
- Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roel Hompes
- Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Oliveira ALA, Zorron R, Oliveira FMMDE, Santos MBD, Scheffer JP, Rios M, Antunes F. Transcolonic Perirectal NOTES Access (PNA): A feasibility study with survival in swine model. AN ACAD BRAS CIENC 2018; 89:685-693. [PMID: 28562823 DOI: 10.1590/0001-3765201720160541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 01/23/2017] [Indexed: 12/22/2022] Open
Abstract
Transrectal access still has some unsolved issues such as spatial orientation, infection, access and site closure. This study presents a simple technique to perform transcolonic access with survival in a swine model series. A new technique for NOTES perirectal access to perform retroperitoneoscopy, peritoneoscopy, liver and lymphnode biopsies was performed in 6 pigs, using Totally NOTES technique. The specimens were extracted transanally. The flexible endoscope was inserted through a posterior transmural incision and the retrorectal space. Cultures of bacteria were documented for the retroperitoneal space and intra abdominal cavity after 14 days. Rectal site was closed using non-absorbable sutures. There was no bowel cleansing, nor preoperative fasting. The procedures were performed in 6 pigs through transcolonic natural orifice access using available endoscopic flexible instruments. All animals survived 14 days without complications, and cultures were negative. Histopathologic examination of the rectal closure site showed adequate healing of suture line and no micro abscesses. The results of feasibility and safety of experimental Transcolonic NOTES potentially brings new frontiers and future wider applications for minimally invasive surgery. The treatment of colorectal, abdominal and retroperitoneal diseases through a flexible Perirectal NOTES Access (PNA) is a promising new approach.
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Affiliation(s)
- André L A Oliveira
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
| | | | | | - Marcelo B Dos Santos
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
| | - Jussara P Scheffer
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
| | - Marcelo Rios
- Clínica Veterinária-Gávea, Rio de Janeiro, RJ, Brazil
| | - Fernanda Antunes
- Departamento de Cirurgia Veterinária, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, RJ, Brazil
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Wilhelm P, Axt S, Storz P, Wenz S, Müller S, Kirschniak A. Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a new elongated, curved Transanal Endoscopic Operation (TEO) device for rectosigmoid resection: a survival study in a porcine model. Tech Coloproctol 2016; 20:273-278. [PMID: 26940219 DOI: 10.1007/s10151-016-1446-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/13/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection. METHODS Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1-112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation. RESULTS Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14-23 cm). Mean operating time was 124 min (SD 35.7 min, range 70-166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site. CONCLUSIONS Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.
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Affiliation(s)
- P Wilhelm
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - S Axt
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - P Storz
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - S Wenz
- Department of Pathology, Tübingen University Hospital, Tübingen, Germany
| | - S Müller
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - A Kirschniak
- Department of General, Visceral and Transplant Surgery, Tübingen University Hospital, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany.
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Motson RW, Whiteford MH, Hompes R, Albert M, Miles WFA. Current status of trans-anal total mesorectal excision (TaTME) following the Second International Consensus Conference. Colorectal Dis 2016; 18:13-8. [PMID: 26400670 DOI: 10.1111/codi.13131] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 09/10/2015] [Indexed: 12/12/2022]
Abstract
This article documents the consensus of an expert group of surgeons from the Second International Trans-anal Total Mesorectal Excision (TaTME) Conference held in Paris in July 2014. It outlines three facets of the TaTME procedure: (i) the technique and its indications, (ii) training and adoption, and (iii) data collection and the TaTME registry.
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Affiliation(s)
- R W Motson
- The ICENI Centre, Colchester University Hospital and Anglia Ruskin University, Colchester, Essex, UK
| | - M H Whiteford
- Oregon Clinic and Providence Cancer Centre, Portland, Oregon, USA
| | - R Hompes
- Oxford University Hospitals NHS Trust, Headington, Oxford, UK
| | - M Albert
- Florida Hospital, Altamonte Springs, Florida, USA
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Lee GC, Sylla P. Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery. Clin Colon Rectal Surg 2015; 28:181-93. [PMID: 26491411 DOI: 10.1055/s-0035-1555009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.
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Affiliation(s)
- Grace Clara Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Patricia Sylla
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Kim MJ, Park JW, Ha HK, Jeon BG, Shin R, Ryoo SB, Choi SJ, Park BK, Park KJ, Jeong SY. Initial experience of transanal total mesorectal excision with rigid or flexible transanal platforms in cadavers. Surg Endosc 2015; 30:1640-7. [PMID: 26169645 DOI: 10.1007/s00464-015-4398-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 06/28/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) is expected to provide benefits in the removal of the complete mesorectum for low rectal lesions, and several clinical studies regarding this technique have been reported. However, a transanal platform has not yet been standardized, and diverse transanal endoluminal surgery access devices have been used, based on individual surgeon preferences. In the present study, we performed laparoscopy-assisted taTME in cadavers and compared the characteristics of four different platforms. METHODS Between January 2013 and April 2015, laparoscopy-assisted taTME was performed on six fresh cadavers. Flexible [SILS™ Port (Covidien), GelPOINT(®) Path Transanal Access Platform (Applied Medical)] and rigid [TEO(®) (Karl Storz Endoskope), TEM (Richard Wolf)] transanal access platforms were used on three cadavers each. RESULTS All cadavers were male, with a mean age of 69.2 (range 57-86) years. The mean operation time was 146.3 (range 140-155) min with flexible platforms and 206.7 (range 150-260) min with rigid platforms. The mean specimen length was 23 (range 18-26) cm. Complete or nearly complete mesorectal specimens were obtained in all cases, except for one case using the TEM platform. Flexible platforms (SILS and GelPOINT) provided a short set-up time, relatively atraumatic retraction, and easy application of familiar laparoscopic instruments; a narrow operative field was its limitation. The rigid platforms (TEO and TEM) enabled larger and more stable operative fields and space than did the SILS platform, but they were limited by a narrow view, prolonged set-up time, rigidity, and long channels relative to the short distance from the anus to the rectal closure site. CONCLUSION In this preliminary study, laparoscopy-assisted taTME was a feasible and safe procedure using both rigid and soft platforms, despite some limitations of each platform.
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Affiliation(s)
- Min Jung Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Gyeonggi, Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
| | - Heon-Kyun Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Geon Jeon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Rumi Shin
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-ji Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Kwan Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
- Cancer Research Institute, Seoul National University, Seoul, Korea.
- Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea.
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Elmore U, Fumagalli Romario U, Vignali A, Sosa MF, Angiolini MR, Rosati R. Laparoscopic anterior resection with transanal total mesorectal excision for rectal cancer: preliminary experience and impact on postoperative bowel function. J Laparoendosc Adv Surg Tech A 2015; 25:364-9. [PMID: 25918836 DOI: 10.1089/lap.2014.0435] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIM Transanal total mesorectal excision (TME) and the "down-to-up" mobilization concept might be possible alternatives to the standard TME, particularly in cases of narrow pelvis or bulky tumors in obese patients. Our aim was to test the feasibility and safety of transanal TME and to evaluate its impact on short-term functional outcome. SUBJECTS AND METHODS Six consecutive patients with histologically proven low/middle rectal adenocarcinoma were prospectively enrolled. All patients underwent laparoscopic anterior resection with transanal TME. Intraoperative complications, postoperative morbidity, and oncologic adequacy of the surgical specimen were evaluated in all patients. A bowel function questionnaire using information from the Wexner's score continence grading scale was administered to all patients 1 week before surgery and 6 months following operation. RESULTS Laparoscopically assisted transanal TME was successful in all patients. Mean operative time was 236 minutes (range, 200-270 minutes). There were no intraoperative complications. The anastomotic leak rate was 16.6%. Clear distal and circumferential margins and proper lymphadenectomy were obtained in all surgical specimens (mean number of nodes harvested, 32; range, 19-68). In no patients was a major incontinence observed; the median (range) Wexner score at 6 months after surgery was 3 (1-7). CONCLUSIONS Transanal TME is safe and feasible. Preliminary outcomes meet oncologic criteria. Moreover, the transanal approach does not have an adverse impact on functional outcome. Further long-term evaluation of results and clinical trials should be performed.
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Affiliation(s)
- Ugo Elmore
- 1 Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, University Vita Salute , Milan, Italy
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Patel N, Darzi A, Teare J. The endoscopy evolution: 'the superscope era'. Frontline Gastroenterol 2015; 6:101-107. [PMID: 25878767 PMCID: PMC4392308 DOI: 10.1136/flgastro-2014-100448] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/20/2014] [Indexed: 02/04/2023] Open
Abstract
Developments to the design of the flexible endoscope are transforming the field of gastroenterology. There is a drive to improve colonic adenoma detection rates leading to advancements in the design of the colonoscope. Novel endoscopes now allow increased visualisation of colonic mucosa, including behind colonic folds, and aim to reduce pain associated with the procedure. In addition, a shift in surgical paradigm towards minimally invasive endoluminal surgery has meant innovations in flexible platforms are being sought. There are a number of limitations of the basic endoscope. These include a lack of stability and triangulation of instruments. Modifications to the flexible endoscope design form the basis of a number of newly developed and research platforms, some of which are discussed in this review.
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Affiliation(s)
- Nisha Patel
- Department of Surgery and Cancer , Imperial College London , London , UK
| | - Ara Darzi
- Department of Surgery and Cancer , Imperial College London , London , UK
| | - Julian Teare
- Department of Surgery and Cancer , Imperial College London , London , UK
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Daher R, Chouillard E, Panis Y. New trends in colorectal surgery: Single port and natural orifice techniques. World J Gastroenterol 2014; 20:18104-18120. [PMID: 25561780 PMCID: PMC4277950 DOI: 10.3748/wjg.v20.i48.18104] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/28/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of “pure” NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal “down-to-up” total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.
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Totally laparoscopic resection with natural orifice specimen extraction for carcinoma of sigmoid colon and rectum: a feasible and innovative technique. J Clin Gastroenterol 2014; 48:e57-61. [PMID: 24440933 DOI: 10.1097/mcg.0000000000000038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
GOALS To testify the feasibility and safety of an innovative technique we performed. BACKGROUND An abdominal incision is required to extract a specimen for laparoscopic-assisted colorectal operation, and the incision brings some disadvantages for surgeons and patients. Natural orifice specimen extraction (NOSE) is developed to avoid these disadvantages. STUDY Between May 2012 and March 2013, we attempted to perform totally laparoscopic resection with NOSE in 27 patients with sigmoid colon cancer or rectal cancer. Procedure of this technique was described and clinic data of all 27 patients were collected and analyzed. RESULTS We successfully completed the technique of NOSE in 24 of these patients. Mean operation time was 110.0 minutes and mean intraoperative blood loss was 69.1 mL in 23 patients (not including one patient who received additional bilateral oophorectomy) who underwent NOSE. Of these 24 patients, the mean time to passing of first flatus was 3.1 days, the mean postoperative hospital stay was 9.2 days, and 2 patients used analgesics after operation; 22 patients were able to walk in first 2 days, 2 patients had postoperative complications. CONCLUSIONS Totally laparoscopic resection with NOSE is suited for selected patients with sigmoid colon cancer or rectal cancer, and this technique is worth to recommend and spread.
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Zorron R, Phillips HN, Wynn G, Neto MPG, Coelho D, Vassallo RC. "Down-to-Up" transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients. J Minim Access Surg 2014; 10:144-50. [PMID: 25013331 PMCID: PMC4083547 DOI: 10.4103/0972-9941.134878] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 07/26/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND: Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde (“Down-to-Up”) total mesorectal excision for rectal cancer. MATERIALS AND METHODS: Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis. RESULTS: Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients. CONCLUSION: This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.
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Affiliation(s)
- Ricardo Zorron
- Innovative Surgery Division, Klinikum Bremerhaven Reinkenheide, Germany ; Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Henrique N Phillips
- Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Greg Wynn
- ICENI Centre, Colchester, United Kingdom
| | | | - Djalma Coelho
- Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Ricardo C Vassallo
- Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
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Zorron R, Phillips HN, Wynn G, Neto MPG, Coelho D, Vassallo RC. "Down-to-Up" transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients. J Minim Access Surg 2014. [PMID: 25013331 DOI: 10.4103/0972-9941.134878jmas-10-144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde ("Down-to-Up") total mesorectal excision for rectal cancer. MATERIALS AND METHODS Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis. RESULTS Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients. CONCLUSION This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.
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Affiliation(s)
- Ricardo Zorron
- Innovative Surgery Division, Klinikum Bremerhaven Reinkenheide, Germany ; Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Henrique N Phillips
- Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Greg Wynn
- ICENI Centre, Colchester, United Kingdom
| | | | - Djalma Coelho
- Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Ricardo C Vassallo
- Department of Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
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Patel N, Seneci C, Yang GZ, Darzi A, Teare J. Flexible platforms for natural orifice transluminal and endoluminal surgery. Endosc Int Open 2014; 2:E117-23. [PMID: 26135256 PMCID: PMC4423273 DOI: 10.1055/s-0034-1377171] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The flexible endoscope is playing an increasingly pivotal role in minimally invasive transluminal and endoluminal surgery. Whilst the flexible nature of the platform is desirable in order to navigate through the abdominal cavity or through a lumen, there are a number of issues with using the platform for this purpose. The challenges associated with using flexible endoscopes such as a lack of triangulation of instruments and force transmission, which is often inadequate for endoscopic surgery are discussed in this review. As a result of these difficulties, a number of mechanically and robotically driven devices based upon the flexible endoscope are emerging. The design of these devices and potential problems are also reviewed. Finally, future robotic systems which are still in the development and validation stage are briefly discussed. The field of gastroenterology is diverging. The narrowing divide between minimally invasive and endoluminal surgery has led to a surge of innovative and novel devices which may in the future enable precise, seamless and scar less surgery.
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Affiliation(s)
- Nisha Patel
- St. Mary’s Hospital, Imperial – Gastroenterology, London, United Kingdom,Hamlyn Centre – Robotics and Engineering, London, United Kingdom,Corresponding author Nisha Patel, BSc (Hons), MBBS (Hons), MRCP St. Mary’s Hospital – GastroenterologyPraed St, Paddington, London W2 1NYUnited Kingdom0797167931307971679313
| | - Carlo Seneci
- Hamlyn Centre – Robotics and Engineering, London, United Kingdom
| | - Guang-Zhong Yang
- Hamlyn Centre – Robotics and Engineering, London, United Kingdom
| | - Ara Darzi
- St. Mary’s Hospital, Imperial – Gastroenterology, London, United Kingdom,Hamlyn Centre – Robotics and Engineering, London, United Kingdom
| | - Julian Teare
- St. Mary’s Hospital, Imperial – Gastroenterology, London, United Kingdom,Hamlyn Centre – Robotics and Engineering, London, United Kingdom
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Emhoff IA, Lee GC, Sylla P. Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery. COLORECTAL CANCER 2014. [DOI: 10.2217/crc.14.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.
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Affiliation(s)
- Isha Ann Emhoff
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Grace Clara Lee
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Patricia Sylla
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
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Advanced laparoscopic surgery for colorectal disease: NOTES/NOSE or single port? Best Pract Res Clin Gastroenterol 2014; 28:81-96. [PMID: 24485257 DOI: 10.1016/j.bpg.2013.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 11/23/2013] [Indexed: 01/31/2023]
Abstract
Laparoscopic surgery for colorectal disease is an evolving, dynamic subject undergoing constant adaptation. Hence there are significant ongoing advances in technique and technology as has been seen with the emergence of single port and Natural Orifice Transluminal Endoscopic operations with already considerable ramifications for many aspects of minimal access surgery. Most recently single port technologies and expertise have synergized with Transanal Endoscopic (TEM/TEO) experience to allow their convergence out of their respective niches so that pelvic surgery can be laparoendoscopically performed from both its abdominal and perineal aspects. Distinct from wound-related benefits, such capacity for high resolution and multi-dimensional imaging relates significant benefit to the operating team and patient. This state of the art review demonstrates the crucial perspective that advanced practices and performance capabilities are intrinsically complimentary rather than competitive. All surgeons need therefore to participate in adapting their practice styles to allow technical step-advance across the discipline.
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Emhoff IA, Lee GC, Sylla P. Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES). Dig Endosc 2014; 26 Suppl 1:29-42. [PMID: 24033375 DOI: 10.1111/den.12157] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/08/2013] [Indexed: 02/08/2023]
Abstract
The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.
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Affiliation(s)
- Isha Ann Emhoff
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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19
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Transanal NOTES Applications. CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nishimura A, Kawahara M, Honda K, Ootani T, Kakuta T, Kitami C, Makino S, Kawachi Y, Nikkuni K. Totally laparoscopic anterior resection with transvaginal assistance and transvaginal specimen extraction: a technique for natural orifice surgery combined with reduced-port surgery. Surg Endosc 2013; 27:4734-40. [PMID: 23949481 PMCID: PMC3830205 DOI: 10.1007/s00464-013-3120-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 07/17/2013] [Indexed: 12/13/2022]
Abstract
Background Natural orifice specimen extraction (NOSE) has been developed as a means of decreasing the incidence of surgical wound complications. However, NOSE performed using a conventional multiport technique has been reported previously. The current authors performed totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) using the reduced-port surgery (RPS) technique. The Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) and Free Access (Top Corporation, Tokyo, Japan) were attached to the transvaginal route for transvaginal assistance and smooth specimen extraction. The authors documented this simple and safe technique and its short-term results. Methods Data were prospectively collected for five patients who underwent totally laparoscopic anterior resection with TVSE for colorectal cancer between June 2012 and December 2012. A multiport access device (GelPOINT advanced-access platform; Applied Medical) was inserted into the navel, and a 5-mm port was inserted into the right lower quadrant to be used as a drain site. Transverse transvaginal posterior colpotomy then was performed. One ring of an Alexis ring pair was inserted into the peritoneal cavity through the vagina. The other white ring was placed outside of the vagina and then covered with a Free Access to maintain the pneumoperitoneum for insertion of a 12-mm port. Lymph node dissection and transection of the distal colon were performed with transvaginal assistance. The specimen then was extracted transvaginally. After the Alexis had been removed, the vaginal incision was closed transvaginally. End-to-end colorectal anastomosis was performed using the double-stapling technique. Results Transvaginal extraction was completed in all five cases. The median operation time was 235 min. One case was complicated by chyloperitoneum. The median hospital stay was 6 days. Only one patient required intravenous analgesics once on postoperative day 1. All the patients remained disease free. Conclusion Totally laparoscopic anterior resection using TVSE with RPS appears to be feasible, safe, and oncologically acceptable for selected cases.
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Affiliation(s)
- Atsushi Nishimura
- Department of Surgery, Institute of Gastroenterology, Nagaoka Chuo General Hospital, 2041 Kawasaki-cho, Nagaoka, Niigata, 940-8653, Japan,
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Park SJ, Lee KY, Choi SI, Kang BM, Huh C, Choi DH, Lee CK. Pure NOTES rectosigmoid resection: transgastric endoscopic IMA dissection and transanal rectal mobilization in animal models. J Laparoendosc Adv Surg Tech A 2013; 23:592-5. [PMID: 23755854 DOI: 10.1089/lap.2012.0551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND We report a pure natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and the Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) rectosigmoidectomy in animal models using transgastric endoscopic inferior mesenteric artery (IMA) dissection and transanal rectal mobilization. MATERIALS AND METHODS Ten live animals (2 pigs weighing 35-40 kg each and 8 dogs weighing 25-30 kg each) were used. A gastrotomy was made using a needle-knife puncture and the balloon dilatation technique or following the creation of a submucosal tunnel. A circular stapler shaft was transanally inserted up to the sigmoid colon for spatial orientation and traction of the mesocolon. The IMA was endoscopically dissected using a Coagrasper™ (Olympus, Tokyo, Japan) and then clipped. Endoscopic division of the sigmoid mesocolon was conducted laterally toward the marginal artery. Transanal full-thickness circumferential rectal and mesorectal dissections were performed, and a colorectal anastomosis was performed using a circular stapler with a single stapling technique. During the transanal approach, the gastrotomy was closed using four endoscopic clips. RESULTS Endoscopic dissection of the IMA was successful in all cases, but minor bleedings occurred in 3 cases. The mean time from dissection and clipping to division of the IMA was 36.7 minutes (range, 25-45 minutes). The mean operation time was 180.5 minutes (range, 145-210 minutes). There were no intraoperative complications or hemodynamic instability. The mean length of the resected specimen was 11.2 cm (range, 9-17 cm). CONCLUSIONS A pure NOTES approach to rectosigmoid resection using transgastric endoscopic IMA dissection is technically feasible in animal models.
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Affiliation(s)
- Sun Jin Park
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
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van den Boezem PB, Velthuis S, Lourens HJ, Samlal RAK, Cuesta MA, Sietses C. Hybrid transvaginal cholecystectomy, clinical results and patient-reported outcomes of 50 consecutive cases. J Gastrointest Surg 2013; 17:907-12. [PMID: 23475630 DOI: 10.1007/s11605-013-2175-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 02/17/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to report the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC). BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has been developed as a minimal invasive alternative for conventional laparoscopic cholecystectomy. Although transvaginal NOTES procedures are becoming increasingly popular, data focussing on body image, cosmesis and sexual recovery are rare. METHODS Our clinic started to perform the TVC in the beginning of 2011. Female patients with symptomatic gallstone disease that were treated between January 2011 and April 2012 with TVC were entered in a prospective database. All patients received a survey postoperative with questions about recovery, cosmesis and body image. RESULTS Fifty consecutive patients were treated with a TVC. There were no major complications. Mean operative time was 61 min. In five patients (10 %), a conversion to another type of cholecystectomy was necessary. None of the sexually active women observed dyspareunia postoperative. The results for cosmesis and body image after the transvaginal approach were excellent. CONCLUSIONS TVC is a safe and feasible procedure when performed on selected patients. The transvaginal route seems to result in excellent cosmetic outcomes without gynaecologic complications after short-term follow up. Randomised trials are needed to specify the role of TVC in the treatment of patients with symptomatic gallstone disease and to detect differences in cosmetic outcomes.
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Affiliation(s)
- Peter B van den Boezem
- Department of Surgery, Gelderse Vallei Hospital, Willy Brandtlaan 10, Postbus 9025, 6710 HN, Ede, the Netherlands.
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Fuchs KH, Meining A, von Renteln D, Fernandez-Esparrach G, Breithaupt W, Zornig C, Lacy A. Euro-NOTES Status Paper: from the concept to clinical practice. Surg Endosc 2013; 27:1456-67. [PMID: 23543284 DOI: 10.1007/s00464-013-2870-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 02/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures. METHODS After the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed. RESULTS The statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections. CONCLUSIONS NOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.
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Affiliation(s)
- K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Wilhelm-Epstein-Str. 4, Frankfurt, Germany.
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The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report. Surg Endosc 2013; 27:3073-84. [PMID: 23519494 DOI: 10.1007/s00464-013-2908-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 02/12/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND The EURO-NOTES Clinical Registry (ECR) was established as a European database to allow the monitoring and safe introduction of Natural Orifice Transluminal Endoscopic Surgery (NOTES). The aim of this study was to analyze different techniques applied and relative results during the first 2 years of the ECR. METHODS The ECR was designed as a voluntary database with online access. All members of the European Society for Gastrointestinal Endoscopy and the European Association for Endoscopic Surgery were requested to participate in the registry. Demographic and therapy data as well as data on the postoperative course are recorded in the ECR in an anonymous way. RESULTS A total of 533 patients who underwent NOTES procedures were included in the study. Four different hybrid techniques for 435 cholecystectomies were described, registering postoperative complications in 2.8% of patients, addition of a single trocar in 5.3%, and conversions to laparoscopy in 0.5%. Both flexible endoscopic and rigid laparoscopic cholecystectomy techniques proved to be safe and effective with minor differences. There was a shorter operative time in the rigid laparoscopic group. Thirty-three appendectomies were reported by transgastric and transvaginal techniques, with transvaginal techniques scoring shorter operative time and hospital stay, but with a frequent need to add more trocars. Overall complications occurred in 14.7% of patients but they did not differ significantly among the different techniques. One transvaginal and 31 transanal sigmoidectomies were included for prolapse and diverticulitis, with four postoperative complications (12.5%), but none needing further treatment. Twenty peroral esophageal myotomies were included with three postoperative complications (15.0%), but none needing further treatment. CONCLUSIONS Five years since the introduction of NOTES into clinical practice, hybrid techniques have gained considerable clinical application. Several NOTES hybrid cholecystectomy and appendectomy techniques are practicable and safe alternatives to laparoscopic procedures. Also, sigmoidectomies and peroral esophageal myotomies were described, proving feasibility and safety. Nevertheless, the real benefit of NOTES for patients still needs to be assessed.
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Marks JH, Mullen MG, McKeever DN, Benchimol D. The Future of Minimally Invasive Colorectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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George V. Single-Port Laparoscopy: Market-Driven or True Advancement. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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de Montbrun S, MacRae H. Simulation and Minimally Invasive Colorectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Minimal-invasive chirurgische Behandlung der Sigmadivertikulitis. COLOPROCTOLOGY 2013. [DOI: 10.1007/s00053-012-0334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fuchs KH, Breithaupt W, Varga G, Schulz T, Reinisch A, Josipovic N. Transanal hybrid colon resection: from laparoscopy to NOTES. Surg Endosc 2012; 27:746-52. [PMID: 23052514 DOI: 10.1007/s00464-012-2534-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 07/30/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Reducing access size and trauma are important issues in natural orifice transluminal endoscopic surgery (NOTES). The combination of experience with laparoscopic colorectal surgery and transanal endoscopic microsurgery has helped in the use of the transanal approach as a realistic option of NOTES techniques to introduce transanal hybrid laparoscopic-assisted colon resection into clinical practice. The purpose of this study was to assess the clinical introduction of transanal hybrid colon resection in terms of feasibility and patient safety. METHODS Patients with pelvic floor disorders, prolapse, and slow-transit constipation in whom a colon resection was indicated were recruited. Patients were followed prospectively with a postoperative well-being score, a pain score, and a quality-of-life score. All complications were prospectively documented. The essential change was the reduction of the number and size of ports by using the transanal route. A camera and two 5-mm ports for grasping forceps and delivering ultrasonic energy were the laparoscopic components. All tasks requiring a port diameter of >5 mm were applied via the transanal route, such as positioning of the proximal stapler anvil, application of linear stapling for resection, specimen retrieval, stapler anastomosis, and closing the bowel. RESULTS Fifteen patients with benign colorectal disease underwent transanal hybrid colon resection, and 11 had additional rectopexy. All patients were women with a mean age of 61 (range, 28-86) years and a body mass index of 26 kg/m(2). One patient was converted to full laparoscopy. One complication--bleeding that required no reintervention--was recorded. The procedure lasted a mean of 131 (range, 55-184) min. The Gastrointestinal Quality of Life Index was 96 before surgery and 117 after surgery. CONCLUSIONS From this initial experience, transanal hybrid colon resection seems a feasible and safe hybrid NOTES procedure that can be usefully introduced into clinical practice.
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Affiliation(s)
- Karl-Hermann Fuchs
- Department of General, Visceral, and Thoracic Surgery, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein-Str. 4, 60431 Frankfurt, Germany.
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Takayama S, Hara M, Sato M, Takeyama H. Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection. World J Gastrointest Surg 2012. [PMID: 22408718 DOI: 10.4240/wjgs.v4.i2.41.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Although laparoscopic colectomy is commonly performed around the world, an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery. Thus, a certain sized skin incision is required to remove the resected colon. Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction. We present a case characterized by a laterally spreading type of tumor of the cecum. We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy. Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction. The patient was discharged without complications on postoperative day 4. Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique. Although our method is restricted to flat or small lesions, we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.
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Affiliation(s)
- Satoru Takayama
- Satoru Takayama, Masayasu Hara, Mikinori Sato, Hiromitsu Takeyama, Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
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Leroy J, Diana M, Barry B, Mutter D, Melani AGF, Wu HS, Marescaux J. Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESSS): a feasibility study for a new NOTES approach in a swine model. Surg Innov 2012; 19:345-52. [PMID: 22751618 DOI: 10.1177/1553350612452346] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model. MATERIALS AND METHODS Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the "Holy" plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization. RESULTS The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach. CONCLUSIONS Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.
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Affiliation(s)
- Joël Leroy
- IRCAD-EITS, University of Strasbourg, Strasbourg, France.
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Alba Mesa F, Amaya Cortijo A, Romero Fernandez JM, Komorowski AL, Sanchez Hurtado MA, Fernandez Ortega E, Sanchez Margallo FM. Transvaginal sigmoid cancer resection: first case with 12 months of follow-up--technique description. J Laparoendosc Adv Surg Tech A 2012; 22:587-90. [PMID: 22690651 DOI: 10.1089/lap.2011.0469] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Several minimally invasive techniques using natural orifices as an entrance site to the peritoneal cavity have been described recently. Pure natural orifice translumenal endoscopic surgery (NOTES) techniques have been mainly implemented to perform cholecystectomies and appendectomies, while more complex operations like colon resections have been described in a hybrid setting and with the use of the transumbilical approach. Here we describe the technique of transvaginal sigmoid colon resection for cancer with standard laparoscopy equipment. MATERIALS AND METHODS After developing the transvaginal technique of sigmoid colon resection in an experimental sheep model, we have performed this operation in a human patient for cancer. Twelve months of follow-up is reported. RESULTS A totally transvaginal R0 resection of the sigmoid colon for adenocarcinoma has been successfully performed in a female patient with laparoscopy equipment. The specimen included 13 lymph nodes, all of which were free of metastasis. Twelve months after surgery the patient is alive with no evidence of disease. CONCLUSION A pure transvaginal NOTES approach to sigmoid colon cancer is feasible in human patients.
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Affiliation(s)
- Francisco Alba Mesa
- Public Health Consortium of Aljarafe, Hospital San Juan de Dios, Bormujos, Sevilla, Spain
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Barry BD, Leroy J, Mutter D, Wu HS, Marescaux J. Minimally invasive surgical treatment of sigmoid diverticulitis. Langenbecks Arch Surg 2012; 397:1035-41. [PMID: 22644602 DOI: 10.1007/s00423-012-0965-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 05/20/2012] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications. METHODS A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis. RESULTS In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning. CONCLUSION Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.
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Affiliation(s)
- B D Barry
- Department of General, Digestive and Endocrine Surgery, IRCAD/EITS, University Hospital of Strasbourg, 1 Place de l'Hôpital, 67091 Strasbourg, France
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Outcomes for consecutive patients undergoing single-site laparoscopic colorectal surgery. J Gastrointest Surg 2012; 16:849-56. [PMID: 22125171 DOI: 10.1007/s11605-011-1783-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 11/11/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Single-site laparoscopy (SSL) represents an innovation whose wider adoption may be limited by technical challenges and a current dearth of outcomes data. METHODS A retrospective review of prospectively collected data was performed on all consecutive laparoscopic colorectal resections, including elective and emergent surgeries. Patient demographics and operative details were collected, and outcomes were analyzed for 30 days following surgery. RESULTS Forty-one single-site laparoscopic procedures were performed, with 12 (29%) being nonelective. Surgeries included seven right colectomies, eight sigmoidectomies, four ileocolectomies, five total colectomies, two low anterior resections, and two abdominoperineal resections. The most frequent indication for surgery was inflammatory bowel disease (31.7%), followed by cancer (24.4%) and diverticular disease (24.4%). Thirty-seven percent of the patients had undergone previous abdominal surgery, with 64% of these having undergone previous laparotomy. One (2.5%) patient required conversion to multiple trocar laparoscopy, and five (12%) required conversion to laparotomy. Mean length of hospital stay was 4.2 days for SSL without a conversion. There was one anastomotic leak, no postoperative bleeding, no surgical site infections, and no deaths. The readmission rate was 14%. CONCLUSIONS SSL is safe when applied to unselected patients undergoing colorectal surgery, including those patients who have undergone a previous laparotomy.
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Bona S, Molteni M, Montorsi M. Minilaparoscopic colorectal resections: technical note. Minim Invasive Surg 2012; 2012:482079. [PMID: 22548166 PMCID: PMC3323854 DOI: 10.1155/2012/482079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 01/23/2012] [Indexed: 12/21/2022] Open
Abstract
Laparoscopic colorectal resections have been shown to provide short-term advantages in terms of postoperative pain, general morbidity, recovery, and quality of life. To date, long-term results have been proved to be comparable to open surgery irrefutably only for colon cancer. Recently, new trends keep arising in the direction of minimal invasiveness to reduce surgical trauma after colorectal surgery in order to improve morbidity and cosmetic results. The few reports available in the literature on single-port technique show promising results. Natural orifices endoscopic techniques still have very limited application. We focused our efforts in standardising a minilaparoscopic technique (using 3 to 5 mm instruments) for colorectal resections since it can provide excellent cosmetic results without changing the laparoscopic approach significantly. Thus, there is no need for a new learning curve as minilaparoscopy maintains the principle of instrument triangulation. This determines an undoubted advantage in terms of feasibility and reproducibility of the procedure without increasing operative time. Some preliminary experiences confirm that minilaparoscopic colorectal surgery provides acceptable results, comparable to those reported for laparoscopic surgery with regard to operative time, morbidity, and hospital stay. Randomized controlled studies should be conducted to confirm these early encouraging results.
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Affiliation(s)
- S. Bona
- Department of General Surgery, IRCCS Istituto Clinico Humanitas, University of Milan School of Medicine, Via Manzoni 56, 20089 Rozzano, Milano, Italy
| | - M. Molteni
- Department of General Surgery, IRCCS Istituto Clinico Humanitas, University of Milan School of Medicine, Via Manzoni 56, 20089 Rozzano, Milano, Italy
| | - M. Montorsi
- Department of General Surgery, IRCCS Istituto Clinico Humanitas, University of Milan School of Medicine, Via Manzoni 56, 20089 Rozzano, Milano, Italy
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Takayama S, Hara M, Sato M, Takeyama H. Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection. World J Gastrointest Surg 2012; 4:41-4. [PMID: 22408718 PMCID: PMC3297667 DOI: 10.4240/wjgs.v4.i2.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 10/31/2011] [Accepted: 11/10/2011] [Indexed: 02/06/2023] Open
Abstract
Although laparoscopic colectomy is commonly performed around the world, an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery. Thus, a certain sized skin incision is required to remove the resected colon. Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction. We present a case characterized by a laterally spreading type of tumor of the cecum. We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy. Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction. The patient was discharged without complications on postoperative day 4. Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique. Although our method is restricted to flat or small lesions, we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.
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Affiliation(s)
- Satoru Takayama
- Satoru Takayama, Masayasu Hara, Mikinori Sato, Hiromitsu Takeyama, Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601 Aichi, Japan
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Leroy J, Perretta S, Diana M, Wall J, Lindner V, Harrison M, Marescaux J. An original endoluminal magnetic anastomotic device allowing pure NOTES transgastric and transrectal sigmoidectomy in a porcine model: proof of concept. Surg Innov 2011; 19:109-16. [PMID: 22143749 DOI: 10.1177/1553350611429029] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION While experimental natural orifice transluminal endoscopic surgery (NOTES) sigmoid colectomies have been reported, pure NOTES anastomoses are restricted by the limited reach of commercially available circular staplers. MAGNAMOSIS is a set of self-orienting magnetic rings that can be delivered endoluminally throughout the colon to generate a compression anastomosis. Aim. To assess the feasibility of a pure NOTES transrectal (TR) and transgastric (TG) approach to perform any segmental colectomy. MATERIALS AND METHODS One pig (50 kg) underwent the experimental procedure as follows: (a) creation of the TG access to the peritoneal cavity, (b) precise transluminal placement of the proximal MAGNAMOSIS ring, (c) creation of the TR access with the TEO and transrectal dissection of the sigmoid mesentery, (d) resection of the surgical specimen, (e) transrectal extraction of the specimen, (f) delivery and mating of the distal MAGNAMOSIS ring, and (g) closure of the TG and TR viscerotomies. The animal survived for 14 days at which time burst pressure and histology were performed. RESULTS A pure NOTES TR and TG segmental colectomy was performed in 139 minutes. The postoperative course was uneventful. The animal had a formed bowel movement including the magnetic rings on postoperative day 5. Endoscopic examination at postoperative day 14 revealed a patent anastomosis. Necropsy revealed no abscess or signs of peritonitis. Burst pressure was >198 mm Hg. The histology showed a sealed anastomosis with mild inflammation. CONCLUSIONS MAGNAMOSIS enabled a totally NOTES partial colectomy with combined TG and TR access. The flexible delivery options and low cost of manufacturing could make MAGNAMOSIS an attractive alternative to circular staplers.
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Affiliation(s)
- Joël Leroy
- IRCAD/EITS Institute, University Hospital of Strasbourg, Strasbourg, France.
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Rieder E, Whiteford MH. Transrectal natural orifice translumenal endoscopic surgery (NOTES) for colorectal resection. Colorectal Dis 2011; 13 Suppl 7:51-4. [PMID: 22098519 DOI: 10.1111/j.1463-1318.2011.02780.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) is a new surgical paradigm involving performance of intra-abdominal surgery via a natural orifice and thereafter peritoneal access through an intentionally created hole in a hollow viscus. The vast majority of research in this rapidly evolving field had involved access via an oral or vaginal route. Access via a transanal route, other than the obvious concern over contamination, has many appealing attributes. In addition, transanal surgery has long been a common procedure lending a valuable clinical experience to the foundation of this field of research. Examples of preclinical and clinical research on transanal NOTES colorectal resections are here presented and discussed.
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Affiliation(s)
- E Rieder
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, Oregon 97210, USA
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Cahill RA, Hompes R, Cunningham C, Mortensen NJ. Sealed Orifice Laparoscopic or Endoscopic (SOLE) Surgery: technology and technique convergence for next-step colorectal surgery. Colorectal Dis 2011; 13 Suppl 7:3-7. [PMID: 22098509 DOI: 10.1111/j.1463-1318.2011.02771.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The new avenue of minimally invasive surgery, referred to as single-incision/access laparoscopy, is often presented as an alternative to standard multiport approaches, whereas in fact it is more usefully perceived as a complementary modality. The emergence of the technique can be of greater use both to patients and to the colorectal specialty if its principles can be merged into next-stage evolution by synergy with more conventional practice. In particular, rather than device specificity, what is needed is convergence of capability that can be applied by the same surgeon in differing scenarios depending on the individualized patient and disease characteristics. We detail here the global applicability of a simple access device construct that allows the provision of simple and complex single-port laparoscopy as well as contributing to multiport laparoscopic and transanal resections in a manner that is reliable, reproducible, ergonomical and economical.
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Affiliation(s)
- R A Cahill
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.
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Abstract
AIM SILS is an area of growing interest in colorectal surgery. We report our preliminary experience of 13 consecutively selected patients undergoing colonic surgery using SILS. METHOD From July 2009 to January 2010, 13 patients (five men) of median age 56 (23-82) years and a body mass index (BMI) of 23.5 (18-30) kg/m(2) underwent colonic surgery. Procedures included subtotal colectomy (1), ileocolic resection (2), right colectomy (4) and sigmoidectomy for benign disease (6). Three instruments (including camera) were introduced through a single 2.5-cm port (SILS™ Port Multiple Instrument Access Port; Covidien Inc., Norwalk, Connecticut, USA) inserted at the umbilicus. RESULTS The median operating time was 150 (100-240) min, and the median size of the umbilical port incision was 32 (25-50) mm. There was no postoperative mortality and morbidity, and the median hospital stay was 6 (4-10) days. The cosmetic result was judged to be excellent in 12 of 13 patients who felt it to be better than expected. CONCLUSION This preliminary experience shows that SILS is technically feasible and safe for colonic resection.
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Affiliation(s)
- S Gaujoux
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Clichy, France
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Minimally invasive surgery for colorectal cancer: past, present, and future. Int J Surg Oncol 2011; 2011:490917. [PMID: 22312511 PMCID: PMC3263673 DOI: 10.1155/2011/490917] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Accepted: 06/20/2011] [Indexed: 12/12/2022] Open
Abstract
A rapid progression from conventional open surgery to minimally invasive approaches in the surgical management of colorectal cancer has occurred over the last 2 decades. Initial concerns that this new approach was oncologically inferior to open surgery were ultimately refuted when several prospective randomized trials concluded that laparoscopic colectomy could achieve similar oncologic outcomes to open surgery. On the contrary, level 1 data has not yet matured regarding the oncologic safety of minimally invasive approaches for rectal cancer. We review the published literature pertaining to the evolution of minimally invasive techniques used to treat colorectal cancer surgery, including barriers to adoption, and the prospects for future advances related to innovative techniques.
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Lamadé W, Rieber F, Friedrich C, Basar T, Ulmer C, Bannier O, Thon KP. Sashimi NOTES--extraction of bulky specimens in no-scar operations. MINIM INVASIV THER 2011; 20:247-52. [PMID: 21793781 DOI: 10.3109/13645706.2010.541707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A major obstacle in no-scar surgery is the extraction of large, bulky or rigid specimen. Thus, a method is needed that allows for extraction of large specimens without situs contamination in women and men. It should enable safe treatment of infectious or malignant disease while preserving pathologic workup. Five patients suffering from diverticulitis with expected bulky and rigid specimen were enrolled into this early series. Preparation was performed transumbilically in single-port technique. To prevent new scar formation, the incision was limited to the base of the umbilicus without extension onto the sound abdominal skin. A functionally and topologically extracorporeal compartment was created within the abdomen by introduction and insufflation of a tear-proof impermeable retrieval bag. The specimen was sliced in a controlled fashion inside the compartment along a pre-marked geometry. Controlled specimen dissection in a dedicated intraabdominal resection compartment was feasible. The dissected specimen could be retrieved through the 1.5 cm umbilical incision without spillage of material. The geometry of the extracted organ was reconstructed in detail allowing for uncompromised pathological workup. Extraction of bulky and rigid specimen is possible through natural orifices by the proposed controlled dissection method enabling the pathologist to reconstruct anatomical affiliation.
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Affiliation(s)
- Wolfram Lamadé
- Department of Surgery, Dr. Margarete Fischer-Bosch-Institute for Clinical Pharmacology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
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Dhumane PW, Diana M, Leroy J, Marescaux J. Minimally invasive single-site surgery for the digestive system: A technological review. J Minim Access Surg 2011; 7:40-51. [PMID: 21197242 PMCID: PMC3002006 DOI: 10.4103/0972-9941.72381] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 08/02/2010] [Indexed: 12/13/2022] Open
Abstract
Minimally Invasive Single Site (MISS) surgery is a better terminology to explain the novel concept of scarless surgery, which is increasingly making its way into clinical practice. But, there are some difficulties. We review the existing technologies for MISS surgery with regards to single-port devices, endoscope and camera, instruments, retractors and also the future perspectives for the evolution of MISS surgery. While we need to move ahead cautiously and wait for the development of appropriate technology, we believe that the “Ultimate form of Minimally Invasive Surgery” will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery, complimented by technological innovations from the fields of robotics and computer-assisted surgery.
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Affiliation(s)
- Parag W Dhumane
- IRCAD/EITS, Hôpitaux Universitaires, 1 Place de l'Hôpital, 67091 Strasbourg Cedex, France
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Zorron R, Phillips HN, Coelho D, Flach L, Lemos FB, Vassallo RC. Perirectal NOTES access: "down-to-up" total mesorectal excision for rectal cancer. Surg Innov 2011; 19:11-9. [PMID: 21742663 DOI: 10.1177/1553350611409956] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Clinical natural orifice surgery has been applied for abdominal surgery in recent years, mostly by vaginal and oral access. The study describes preliminary successful human applications of transcolonic natural orifice transluminal endoscopic surgery (NOTES), using a new transrectal total mesorectal excision procedure for rectal cancer. METHODS Institutional review board approval was obtained for the study. In 2 patients with rectal adenocarcinoma, total mesorectal resection and rectosigmoidectomy with lymphadenectomy was performed using a low NOTES transcolonic access. "Down-to-up" mesorectal dissection was achieved either using a flexible scope or a transrectal single port device. The specimens were extracted transanally, and transorificial low anastomosis was performed. RESULTS Operative time was 350 and 360 minutes, respectively; no complications occurred and patients were discharged after 6 days. CONCLUSION Successful human reports on transcolonic NOTES suggest potential applications. The treatment of colorectal diseases through transorificial single port or flexible perirectal NOTES access are promising new approaches besides current methods to improve patient care.
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Affiliation(s)
- Ricardo Zorron
- University Hospital Teresopolis HCTCO FESO, Rio de Janeiro, Brazil.
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Leroy J, Diana M, Perretta S, Wall J, De Ruijter V, Marescaux J. Original technique to close the transrectal viscerotomy access in a NOTES transrectal and transgastric segmental colectomy. Surg Innov 2011; 18:193-200. [PMID: 21727099 DOI: 10.1177/1553350611411490] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NOTES). Transanal endoscopic approaches have enabled rectosigmoid colectomy through a viscerotomy that is resected with the specimen. To extend NOTES segmental colectomy to the entire colon and beyond, a rectal viscerotomy will have to be safely and effectively closed at the end of the procedure. A new technique for rectal viscerotomy closure using a circular EEA hemorrhoid and prolapse stapler with DST series technology (Covidien) is described.
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Sun Z, Ang RY, Lim EW, Wang Z, Ho KY, Phee SJ. Enhancement of a Master-Slave Robotic System for Natural Orifice Transluminal Endoscopic Surgery. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2011. [DOI: 10.47102/annals-acadmedsg.v40n5p223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: A novel robotic platform for Natural Orifice Transluminal Endoscopic Surgery (NOTES) is presented in this paper. It aims to tackle two crucial technical barriers which hinder its smooth transition from animal studies to clinical trials: providing effective instrumentations to perform complex NOTES procedures and maintaining the spatial orientation for endoscopic navigation. Materials and Methods: The technical barriers are overcome by the design of the robotic system considering size, triangulation, dexterity, maneuverability and complexity. It is also shown that haptic feedback and interventional navigation system could solve the problem of off-axis manipulation of the camera angle and loss of spatial orientation upon entering the peritoneal cavity in transgastric NOTES procedure, respectively. Results: Successful ESD (endoscopic submucosal dissection) and wedge hepatic resection have been performed on live pigs with our Master And Slave Transluminal Endoscopic Robot (MASTER) system, showing its capability to perform advanced endoscopic surgical and NOTES procedures. It is found that the MASTER exhibited good grasping and cutting efficiency. And the lesion resection time could be significantly reduced with more practice between the endoscopist and the robot operator. Conclusion: This study evaluates the feasibility of MASTER system as a platform overcoming the barriers to NOTES. It is also demonstrated that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures.
Key words: Haptic feedback, Instrumentation design, Interventional Navigation System (INS), Tracking
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Affiliation(s)
| | | | - Ed Wyn Lim
- Nanyang Technological University, Singapore
| | - Zheng Wang
- Nanyang Technological University, Singapore
| | - Khek Yu Ho
- Nanyang Technological University, Singapore
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Rieder E, Spaun GO, Khajanchee YS, Martinec DV, Arnold BN, Smith Sehdev AE, Swanstrom LL, Whiteford MH. A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy. Surg Endosc 2011; 25:3357-63. [PMID: 21556994 DOI: 10.1007/s00464-011-1726-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 04/02/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP). METHODS Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP. RESULTS Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p < 0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min). CONCLUSION Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.
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Affiliation(s)
- Erwin Rieder
- Minimally Invasive Surgery Program, Legacy Health, Portland, OR, USA
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Nishimura A, Kawahara M, Suda K, Makino S, Kawachi Y, Nikkuni K. Totally laparoscopic sigmoid colectomy with transanal specimen extraction. Surg Endosc 2011; 25:3459-63. [PMID: 21553173 DOI: 10.1007/s00464-011-1716-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 03/28/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Conventional techniques for laparoscopic-assisted colectomy (LAC) require abdominal minilaparotomy for extraction of the specimen. Abdominal wound complications often increase the invasiveness of LAC. To decrease the incidence of wound complications, natural orifice specimen extraction (NOSE) has been reported. However, only a few devices that allow smooth extraction and reduced intracorporeal contamination have been reported previously. We performed totally laparoscopic sigmoid colectomy using transanal specimen extraction (TASE) and the Alexis(®) wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA). We document this simple and safe technique and its short-term results. METHODS We prospectively collected data on 18 patients who underwent totally laparoscopic sigmoid colectomy with TASE from April 2009 to July 2010. Lymph node dissection and transection of proximal and distal colon were performed in conventional manner. The transected rectal stump was opened transversely, and a long Babcock grasper was inserted transanally through the opened rectal stump. One of a pair of Alexis rings was held and pulled out of the anus. The other ring was placed in the opened rectal stump. The specimen was then extracted transanally through the Alexis. After the Alexis had been removed, the rectal opening was reclosed with a linear stapler. End-to-end colorectal anastomosis was then performed using the double-stapling technique. RESULTS Transanal extraction was achieved in 17 cases. We switched to conventional LAC in a case involving a bulky specimen. In 16 cases not including the combined cholecystectomy case, mean operation time was 241 min. One case was complicated by anastomotic leakage and wound infection, while another had enterocolitis. Median hospital stay was 6 days. All patients remained disease free. Mean Wexner score at 12 months after operation was 2.3. CONCLUSION Totally laparoscopic sigmoid colectomy using TASE and the Alexis appears to be feasible, safe, and oncologically acceptable for selected cases.
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Affiliation(s)
- Atsushi Nishimura
- Department of Surgery, Institute of Gastroenterology, Nagaoka Chuo General Hospital, Nagaoka, Japan.
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Schoenberg MB, Ströbel P, von Renteln D, Eickhoff A, Kähler GF. Absorbable ligation loops for flexible endoscopy: a necessary tool for natural orifice transluminal endoscopic surgery. Gastrointest Endosc 2011; 73:791-7. [PMID: 21288519 DOI: 10.1016/j.gie.2010.11.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 11/29/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND One of the main challenges of natural orifice transluminal endoscopic surgery (NOTES) remains the development of safe and reliable tools. In this study, we introduce the first absorbable ligatures specifically designed for NOTES. OBJECTIVE To determine the feasibility of a new absorbable ligation loop (NOTES loop) and to compare this new type of suture with the nonabsorbable loop (Endoloop) most commonly used until now. DESIGN Prospective, comparative animal trial/survival animal study (observation period 21 days) with subsequent histopathological assessment (blinded observer design). SETTING Veterinarian center. SUBJECTS This study used 12 female domestic piglets. INTERVENTION Every pig underwent two transgastric uterine horn ligations, one with an absorbable loop and one with a nonabsorbable loop. Additional uterine horn resections on both sides were done on 6 pigs. MAIN OUTCOME MEASUREMENTS Intervention success, loop reliability, foreign-body reaction, extent of inflammatory response (μm). RESULTS Transgastric flexible intra-abdominal ligation of the uterine horns was performed safely with both loops in all cases. During a 3-week observation period, 11 of 11 NOTES loops and 10 of 11 Endoloops were reliable. Microscopically, foreign-body reaction was minimal around both sutures (P = .303). The overall inflammatory response was larger around the Endoloops (P = .046). Uterine horn resection had an influence on the extent of inflammation. LIMITATIONS Animal study. CONCLUSION Ligation was feasible with both loops. The absorbable loops were reliable during a 3-week observation period and can be recommended for use during NOTES appendectomies.
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Affiliation(s)
- Markus B Schoenberg
- University Hospital Complex Mannheim, Central Interdisciplinary Endoscopy, Theodor-Kutzer-Ufer 1-3, Mannheim, Germany
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