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Totally transvaginal resection of the descending colon in an experimental model
Abstract
Natural orifice translumenal endoscopic surgery (NOTES), although in its embryonic phase, is currently experiencing important developments. The technique has been successfully applied for cholecystectomies and appendectomies. However, several doubts exist as to the technical limitations and feasibility of NOTES in other clinical settings.
The authors have performed totally transvaginal colon resections in a sheep model. Although completion of the surgery was possible through the transvaginal route, the addition of a transumbilical laparoscope was used as an added safety measure.
Totally transvaginal resection of the sigmoid colon was performed for two sheep with no intra- or postoperative complications.
Totally transvaginal resection of the colon (pure NOTES) is feasible in a sheep model.
... The rise of minimally invasive procedures has increased the interest of many surgeons in laparo-and endoscopy training models that use live animal. As a result, pigs have been frequently used as a model for colorectal laparoscopic surgery (1), sheep as a gynecologic and transvaginal NOTES model (2) and rabbit as a pediatric thoracoscopy model (3). Indeed, the introduction of a new technique based on animal experiment can lead to steeper learning curve (1) and finally to less complications in humans after clinical application of the technique (4). ...
... More advanced students go for more sophisticated simulators with the help of laparoscopy instructors, however the need for constant instructor feedback has been recently put in doubt (12). Cadaveric and live animal models are probably the models that let the trainee get as close to the real laparoscopy experience as possible (2,13). There have been multiple approaches to use pigs as an experimental animal for surgical procedures. ...
The aim of the study was to evaluate the possibility to use live anesthetized pigs as a model for laparoscopic liver resection. During two days laparoscopy course two trainees were operating on two live animals performing exposure of the liver, Pringle manoeuver, division of liver ligaments, dissecting of the structures inside the hepatoduodenal ligament, dissection of the hepatic veins and left lateral liver sectionectomy. Exposure of the liver and Pringle manoeuver were performed correctly within 50 and 35 minutes. Left lateral sectionectomy has been performed correctly within 2 hours. The full dissection of the hepatoduodenal ligament and exposure of the hepatic veins were judged as insufficient by experienced laparoscopic tutors. There was one injury to the suprahepatic vena cava that was managed laparoscopically. The porcine model can be used as an advanced training for laparoscopic liver surgery.
... There are much less reports on the use of sheep as a model for advanced surgical training [12]. It is however known to be an interesting model for advanced colon resections [13]. ...
... Hybrid Tv resection of descending colon was feasible on animal model. Only one 5-mm transumbilical port was added for safety [133]. Long-segment Hirschsprung's disease was managed by NOTES. ...
Abstract: Research Focus - NOTES is a new technique that faces numerous challenges. Current technology, training and research activities are conducted to make it a safe and effective minimal access technique.Research Methods Used - This chapter is based on the current evidence of published NOTES studies. Medline search is conducted through November to December 2014, including English literatures only. The search words are NOTES, natural orifice translumenal endoscopic surgery, hybrid NOTES and hybrid natural orifice translumenal endoscopic surgery; additional search words are specific for the titles like NOTES gastric, NOTES oesophageal, NOTES biliary, NOTES cholecystectomy, NOTES pancreatic, NOTES small bowel, NOTES colorectal and NOTES appendicectomy. Animal and human studies are selected after 2008. Small studies are excluded unless they report a novel approach or a new procedure.Results/Findings of the Research - There is development in the technology by installing new platforms, instruments and closure devices to add more safety and security. There is also development in training and research activities across the continents; a number of NOTES procedures are performed safely on human beings including cholecystectomy, appendicectomy, peritoneoscopy, POEM and other procedures. Feasibility studies are conducted on animal and human cadaver models including numbers of complex procedures.Main Conclusions and Recommendations - NOTES is evolving and gaining popularity. The growth rate however is slowed by challenges of the need for an ideal working platform and closure devices that are easy to use, cheap and time effective, in addition to the dedicated effective training.
Keywords: Upper GI NOTES, Lower GI NOTES, Oesophageal NOTES, Gastric NOTES, Duodenal NOTES, Liver NOTES, Pancreatic NOTES, Splenic NOTES
... Values are expressed as percent (number) Grade I any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions; Grade II requiring pharmacological treatment; Grade III requiring surgical, endoscopic, or radiological intervention; Grade IV life-threatening complication requiring IC/ICU-management; Grade V death of a patient p=0.998 (chi-square test for trend) been published [11,12]. However, the more complex the procedure, the more difficult the technical execution of a pure NOTES procedure without percutaneous trocars, regardless of the access route [13][14][15]. Our analysis of the colon procedures from the GNR showed that only hybrid procedures were performed, using either a transvaginal or a transrectal access and one or more percutaneous trocars. ...
The German NOTES registry (GNR) is the largest published database for natural orifice transluminal endoscopic surgery (NOTES) worldwide. Although transvaginal cholecystectomy is the most frequent procedure in the GNR, the number of colorectal resections is increasing. The objective of this study was to analyze the first 139 colonic procedures of the GNR.
All colonic procedures from the GNR were analyzed regarding patient- and therapy-related parameters. A multivariate analysis was conducted for transvaginal sigmoid resections regarding procedural time, hospital stay, conversion rate, and rate of complications.
From October 2008 to January 2013, 139 colon NOTES procedures (12 male, 127 female) were registered. Main diagnoses were sigmoid diverticulitis (85.6 %), colon carcinoma (9.4 %), and ulcerative colitis (3.6 %). Sigmoid resections (87.1 %), proctocolectomies (3.6 %), right-sided resections (2.9 %), left-sided resections (3.6 %), segmental resections (2.2 %), and 1 ileocecal resection (0.7 %) were performed. All procedures were conducted in transvaginal (87.8 %) or transrectal (12.2 %) hybrid technique, with a median of 3 percutaneous trocars. Conversions to laparoscopic technique were necessary in 3.6 % (none to conventional technique). Intraoperative complications were recorded in 2.9 % and postoperative complications in 12.2 %. The institutional case number in transvaginal sigmoid resections correlated negatively with procedural time (p = 0.041) and the number of percutaneous trocars (p = 0.002).
The analysis of the first 139 colon NOTES operations of the GNR shows the feasibility of colon operations in hybrid technique, especially for transvaginal sigmoid resection as the most frequent procedure.
The aim of the study was to evaluate early (the first 30 days) postoperative complications after transvaginal resection of the sigmoid colon.
A total of 23 laparoscopy-assisted transvaginal resections of the sigmoid colon and 1 NOTES transvaginal sigmoid resection were performed in the course of 3 years. Postoperative complications were recorded in a prospective manner.
In the group of 24 patients operated on using the transvaginal approach, 6 (25%) complications were recorded, including 3 urinary tract infections, 2 vaginal bleedings, and 1 abdominal trocar site hernia.
Early postoperative complication rate after transvaginal resection of the sigmoid colon is relatively low and the clinical complications are not severe.
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.
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.
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.
A pure transvaginal NOTES approach to sigmoid colon cancer is feasible in human patients.
The aim of the present study was to use a porcine model to compare one- and two-port transvaginal natural orifice transluminal endoscopic surgery (NOTES) with single-port laparoscopic surgery (SPLS) for sentinel node basin dissection.
Three groups (n=3 per group) of healthy female pigs were subjected to lymph node dissection. For hybrid NOTES, an endoscope was inserted via the transvaginal route. For SPLS, a 5-mm 30° telescope with two-port laparoscopic instrument was inserted via the transumbilical port. The three methods were used to dissect the regions of the pig stomach that corresponded to four lymph node areas on the lesser curvature of the anterior wall and greater curvatures in humans.
For two-port NOTES, SPLS, and one-port NOTES, the overall rates of complete dissection of the lymph node stations were 91.6 %, 83%, and 50%, respectively (P>.05). The mean resected tissue weights were 49.3, 37.9, and 22.5 g, respectively (P=.03). The mean operation times for two-port NOTES (69.9 minutes) and SPLS (68 minutes) were shorter than that for one-port NOTES (99 min) (P>.05).
Two-port NOTES and SPLS are more feasible than one-port NOTES for sentinel node basin dissection in a porcine model. One-port NOTES is difficult to perform and requires long operation times; however, we foresee this operation as becoming more common in the future.
Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience.
Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance.
Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred.
The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.
Natural orifice transluminal endoscopic surgery (NOTES) is usually performed by using a flexible endoscope. However, this instrument shows several limitations in the manipulation of intra-abdominal organs. Using the laparoscope instead of the flexible endoscope eliminates the need for new instruments and technical skills. We used conventional laparoscopic instruments for improving operative efficiency and single-port access (SPA) to prevent air leakage from the vaginal port. A 54-year-old female patient was admitted to our hospital with uterine prolapse and symptomatic gallstones. She underwent a transvaginal laparoscopic cholecystectomy. The transvaginal hysterectomy was performed after the cholecystectomy by a gynecologist. The operative time for the cholecystectomy was 86 minutes. She was discharged on postoperative day 8. This technique combines the advantages of NOTES and SPA surgery. We think that this technique can be easily performed from using laparoscopic instruments.
Enthusiasm for natural orifice transluminal endoscopic surgery (NOTES) has been partly tempered by the reality that most NOTES procedures to date have been laparoscopically assisted. After safely performing transvaginal cholecystectomy in an IACUC-approved porcine model, the authors embarked on an institution review board (IRB)-approved protocol for ultimate performance of pure NOTES cholecystectomy in humans. They describe their experience performing a true NOTES transvaginal cholecystectomy after safely accomplishing three laparoscopically assisted or hybrid procedures in humans. One of the patients was a 35-year-old woman presenting with symptoms of biliary colic. Ultrasound confirmed gallstones, and her liver enzymes were normal. Pneumoperitoneum to 15 mmHg was obtained via a transvaginal trocar placed through a colpotomy made under direct vision. A double-channel endoscope then was advanced into the abdomen. To overcome the retracting limitations of currently available endoscopes, the authors used an extra-long 5-mm articulating retractor placed into the abdomen via a separate colpotomy made under direct vision using the flexible endoscope in a retroflexed position. Endoscopically placed clips were used for control of both the cystic duct and the artery. These techniques obviated the need for any transabdominally placed instruments or needles. This patient was the first to undergo a completely NOTES cholecystectomy at the authors' institution, and to their knowledge, in the United States. She was discharged on the day of surgery and at this writing has not experienced any complication after 1 month of follow-up evaluation. Performance of NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe for humans. Additional experience with this technique are required before studies comparing it with standard laparoscopy and hybrid techniques are appropriate.
Transumbilical single-port access (SPA) surgery is a rapidly evolving field that combines in part the cosmetic advantage of natural orifice transluminal endoscopic surgery (NOTES) with the ability to perform the operation with standard laparoscopic instruments. We report our experience with the first transumbilical single-port access radical left colectomy conforming to surgical oncologic principle and minimally invasive colectomy technique.
Umbilical single-port access (embryonic natural orifice transluminal endoscopic surgery) left colectomy was performed in a patient with sigmoid colon adenocarcinoma in situ. During the same procedure, a single-port access cholecystectomy was performed for chronic cholecystitis.
Transumbilical single-port access radical left colectomy was feasible with conventional laparoscopic instruments. A 39-cm pathologic specimen with sufficient surgical margins and lymph nodes (34) was resected. Final diagnosis revealed an adenocarcinoma in situ. Operative time for left colectomy and cholecystectomy was 213 minutes. No intraoperative or postoperative complications were recorded.
Single-port access radical left colectomy is feasible when performed by experienced laparoscopic surgeons. Carcinologic surgical principles can be respected using this colectomy technique. Single-port access left colectomy may have a clinical advantage over natural orifice transluminal endoscopic surgery in offering the safety of laparoscopic colectomy. It has yet to be determined whether or not this approach would offer patient benefits, except in cosmesis, compared with standard laparoscopic left colectomy.
Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.
Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m(2)) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization.
Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery.
Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.
Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single-port laparoscopic colorectal surgery using a Uni-X Single-Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi-channel cannula and specially designed curved laparoscopic instrumentation.
The abdomen was approached through a 3.5 cm incision via the umbilicus and a single-port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis.
The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae.
Single-port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient's umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.
With available laparoscopic and endoscopic instruments/technology a standard radical sigmoid resection is feasible and safe using transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS).
The intervention was a transvaginal MA-NOS sigmoidectomy in a 78-year-old woman with a sigmoid adenocarcinoma. Maintaining triangulation the surgeon positioned himself at the right side of the patient and used the transvaginal trocar for dissection and stapling of both the inferior mesenteric vessels and the upper rectum. The colonic resection was performed extracorporeally in the conventional fashion and was followed by an intra-abdominal endoscopically assisted stapled anastomosis.
Advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All oncological principles governing resection and management were accomplished and the pathology examination confirmed a T3N1 lesion. The patient was discharged on the fourth postoperative day.
Transvaginal MA-NOS radical sigmoidectomy is a feasible and oncologically safe procedure. MA-NOS is a realistic option for avoiding the need of assisting incisions and related morbidity in the laparoscopic resection of large intra-abdominal lesions. Combined hybrid laparoscopic NOS in humans (MA-NOS) currently provides a safe and reliable way of defining future clinical applications and advantages of NOS and NOTES. Additionally, it stimulates the active development and evaluation of the underpinning technologies and instrumentation.
A new ovine model of hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy (abstract no. 6)
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Postoperative pain after laparoscopic assisted transvaginal resection of rectal cancer (abstract no. 385)
- Alba Mesa
- Romero Fernandez
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A new ovine model of hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy (abstract no
- F M Sanchez Margallo
- Perez Duarte
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- FM Sanchez Margallo