Developments in flexible endoscopic surgery: a review

EUS and natural orifice transluminal endoscopic surgery

Objective To investigate value of embryonic natural orifice transluminal endoscopic surgery (ENOTES) in the treatment of patients with abdominal compartment syndrome (ACS) complicated by severe acute pancreatitis.Methods The patients with ACS complicated by SAP were,randomly divided into two groups,Group ENOTES and Group surgical operation.On the base of routine therapy the embryonic natural orifice transluminal endoscopic surgery with flexible endoscope was performed for 32 patients with ACS complicated by SAP during 4 hr of admission,whereas,surgical operation was carried out for 28patients with ACS complicated by SAP during 4 hr of admission.Intra-abdominal pressure,changes of APACHE Ⅱ scores,cure rate,and complications between Group ENOTES and Group surgical operation were compared.Results There was no significant difference between Group ENOTES and Group surgical operation in intra-abdominal pressure at admission with (22.57 ± 7.48) cmH2O vs.(24.000 ± 5.62)cmH 2O,(P ＞0.05).Intra-abdominal pressure in Group ENOTES was (12.09 ±5.23) cmH 2O,(9.41±3.12) cmH 2O,(7.87 ±2.24) cmH 2O and (7.15 ± 1.34) cmH 2O at 1st,3rd,5th and 7th day after ENOTES.Compared with Group ENOTES,intra-abdominal pressure in Group surgical operation was (12.55±2.88) cmH 2O,(8.82±4.14) cmH2O,(7.45 ±2.38) cmH 2O,and (7.54±3.18) cmH2O at 1st,3rd,5th and 7th day after surgical operation.There was no statistical differences in intraabdominal pressure after operations between two groups (p ＞ 0.05).At admission there was no significant differences between Group ENOTES and Group surgical operation in the scre of APACHE Ⅱ [(14.82 ± 4.00) vs (17.00 ± 6.78),P ＞ 0.05].The scores of APACHE Ⅱ in Group ENOTES were (10.05 ±2.43),(8.74 ± 2.48),(7.18 ± 2.72) and (6.35 ± 2.78) at 1 st,3rd,5th and 7th day after ENOTES.Compared whth Group ENOTES,the scores of APACHE in Group surgical operation were (13.38 ±3.12),(12.92±4.03),(10.08 ±3.30) and (9.54 ±3.18) at 1st,3rd,5th and 7th day after surgical operation.There was significant differences between two groups in the scores of APACHE after operations (P ＜0.05).The cure rate was 96.8％ in ENOTES group and 78.5％ in surgical operation group.The difference between ENOTES group and surgical operation group in cure rate had significant (P ＜ 0.05).The complications accounted for 12.5％ in ENOTES group and 50.0％ in surgical operation group.There was significantly different between ENOTES group and surgical operation group in the complications.(P ＜0.01).Conclusions Emergency ENOTES with flexible endoscope is a safe,effective,minimal invasive and fewer complication method for patients with ACS associated with severe acute pancreatitis. Key words: Embryonic natural orifice transluminal endoscopic surgery; Abdominal cavity lavage; Peritoneal dialysis; Severe acute pancreatitis; Abdominal compartment syndrome; Inflammatory mediator; Systemic inflammatory response syndrome; Multiple organ dysfunction syndrome; Capillary leak

Research confirms that surgeons experience physical symptoms due to the unfavorable ergonomics of laparoscopy. The physical effects of performing Natural Orifice Transluminal Endoscopic Surgery (NOTES)-potentially the next evolutionary surgical step-are only now being quantitatively and systematically assessed. This study investigates NOTES- and laparoscopy-related physical workloads through biomechanical analyses. Fourteen surgeons with varying laparoscopic experience were recruited. Each participant completed ring transfer and triangle transfer tasks using two surgical platforms: laparoscopy and NOTES. Motion capture and electromyography (EMG) systems recorded biomechanical data for quantitative physical workload assessment. The normalized cumulative muscular workload (NCMW) and mean muscular workload (MMW) were obtained from EMG data. Then normalized performance time (NPT) was compared between the two surgical platforms. The overall NCMW was considerably greater when participants performed tasks using the NOTES platform (1315.8±116.9%) compared with traditional laparoscopy (153.9±18.8%). Performing NOTES required eight to nine times higher muscular workload (NCMW: NOTES 1315.8%, laparoscopy 153.9%, p<0.05) when compared with traditional laparoscopy. This result was shown to be caused by the following: (1) six to eight times longer NPT with NOTES (p<0.05) and (2) higher average activation levels shown in regard to biceps, extensor digitorum communis, and thenar compartment (p<0.05), the muscles responsible for specific joint movements to hold and operate the scope. This study demonstrated that performing NOTES is significantly more challenging for surgeons than laparoscopy. The greater amount of muscular exertion required is linked to higher ergonomic risks. Based on the depth and strength of our results, we propose that an alternative NOTES platform be designed, one that overcomes the awkward operational mechanism of the dual-working-channel flexible endoscope.

To review the current state of natural orifice surgery and examine the concerns, challenges, and opportunities presented by translumenal research. Translumenal endoscopic procedures have been the focus of extensive research. Researchers have reported natural orifice translumenal endoscopic surgery in a swine model in several areas involving the abdominal cavity. Diagnostic procedures have included endoscopic peritoneoscopy, liver biopsy, lymphadenectomy, and abdominal exploration. Several gynecologic procedures including tubal ligation, oophorectomy, and partial hysterectomy have been demonstrated using current commercial endoscopes. Gastrointestinal surgical procedures, including gastrojejunostomy, cholecystectomy, splenectomy, and distal pancreatectomy have been performed successfully via transgastric and/or transcolonic approaches. There have been no studies of natural orifice translumenal endoscopic surgery procedures published in humans. While fundamental questions about the emerging technology have not been scrutinized, limitations of the large animal model will pose a challenge to the development of large randomized trials. While natural orifice translumenal endoscopic surgery may represent a paradigm shift and may offer significant benefits to patients, rigorous testing of the techniques is lacking and current data have been drawn from case series.

Effect of transgastric natural orifice transluminal endoscopic surgery peritoneoscopy on abdominal organ microcirculation: an experimental controlled study

The advancement of natural orifice translumenal endoscopic surgery (NOTES) depends on the availability of a suitable platform. A 2008 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) Working Group identified access, navigation, maneuverability, and stability to withstand instrument forces as the essential requirements for a successful NOTES platform [1]. No single NOTES platform can adequately achieve all four of these key capabilities. In this study, the authors tested a novel flexible endoscopic robotic platform in a cadaver to determine how it performs with respect to these specific requirements. A highly maneuverable multichannel flexible robotic endoscopic platform developed for NOTES was used transgastrically in an adult cadaver to test the platform's ability to reach multiple intraabdominal targets. The device was under the control of the surgeon throughout the test. The surgeon was blinded to a control laparoscopic view. At each target organ, the platform was maneuvered via a joystick to provide different camera views and tool access orientation appropriate for the surgical tasks of each procedure. Standard endoscopic tools were used in the platform's two working channels to demonstrate the platform's ability to withstand the forces generated during tissue manipulation and clipping. The platform reached each target organ site without difficulty, relying on the endoscopic view only. The platform's unique ability to maintain stability in two- and three-dimensional space resisted forces exerted by tools in the tool channels used for tissue manipulation and clipping. Endoscopic visualization allowed the surgeon to reposition the platform easily to gain a different camera view or tool access orientation about an organ (see video in Supplementary material). The authors demonstrated that the four capabilities identified by NOSCAR can be provided by the flexible robotic endoscopic platform. These essential capabilities for the clinical implementation of NOTES were addressed specifically by this platform. The provision of these capabilities in a single device may further the advancement and adoption of NOTES.

Natural orifice transluminal endoscopic surgery proceeding to clinical (NOTES). Eliminate natural (NOTES) first gained notoriety with the initial orifice transluminal endoscopic surgery. laboratory report of transgastric peritoneoscopy in Since then the medical community and the SOME ADVANTAGES general public has been captivated with the idea of “no-scar” abdominal surgery. In animal models, There are many potential advantages of NOTES over translumenal organ resections have been shown to conventional surgery. Much like laparoscopy has be feasible and an unpublished clinical case series demonstrated less physiologic impact than of transgastric appendectomies has been discussed laparotomy, NOTES may cause less physiologic across the world. However, as data accumulate we insult than either laparoscopy or laparotomy. are learning that NOTES techniques requir Laboratory studies are underway investigating substantial refinement before achieving clinical cytokine levels with NOTES in comparison to conventional operations. Furthermore, natural orifice surgery may negate the possibility of wound complications and reduce the formation of intraabdominal adhesions. Natural orifice transluminal endoscopic surgery (NOTES) involves accessing the abdominal cavity via Given the portability of NOTES equipment, natural one of the bodies’ natural orifices (mouth, anus, vagina orifice surgery is suited for an intensive care unit. or urethra). A flexible endoscope is advanced into the Moving the equipment to the patient, rather than peritoneal cavity after puncturing one of the viscera vice versa, might reduce the resource requirements 2004.

Background and Objectives:Natural orifice translumenal endoscopic surgery (NOTES) is a development of recent origin. In 2004, Kalloo et al first described NOTES investigation in an animal model. Since then, several investigators have pursued NOTES study in animal survival and nonsurvival models. Our objectives for this project included studying NOTES intervention in a laboratory environment using large animal (swine) models and learning to do so in a safe, controlled manner. Ultimately, we intend to introduce NOTES methodology into our surgical residency training program. The expertise of an experienced laparoscopic surgeon, fellowship-trained laparoendoscopic surgeon, and veterinarian along with a senior surgical resident was utilized to bring the input of several disciplines to this study. The Institutional Animal Care and Use Committee (IACUC) of Northeastern Ohio Universities College of Medicine and Pharmacy (NEOUCOM/COP) approved this study.Methods:A series of 5 laboratory sessions using mixed breed farm swine varying in weight from 37 kg to 43.1 kg was planned for the initial phase of NOTES introduction into our residency program. Animals were not kept alive in this investigation. All animals were anesthetized using a standard swine protocol and euthanized following guidelines issued by the American Veterinary Medical Association Panel on Euthanasia. Equipment included a Fujinon EVE endoscope 0.8 cm in diameter with a suction/irrigation channel and one working channel. Initially, a US Endoscopy gastric overtube, 19.5 mm OD and 50 cm in length, was used to facilitate passage of the endoscope. However, this device was found to have insufficient length. Subsequently, commercially available 5/8” diameter clear plastic tubing, 70 cm to 80 cm in length, was adapted for use as an overtube. Standard endoscopic instruments included Boston Scientific biopsy forceps, needle-knife, papillotome, endoscopic clip applier, and Valley Lab electrosurgical unit. A Karl Storz laparoscope and tower were used for laparoscopic observation of NOTES maneuvers. Necropsy was performed to determine specific details of surgical intervention.Results:NOTES intervention is feasible in an animal model. Insight into the potential of NOTES was obtained in this investigation.Conclusions:NOTES investigation in a controlled, laboratory setting using an animal model proved to have value for our program. A steep learning curve was encountered despite the availability of an investigator familiar with elementary NOTES procedures. The authors strongly suggest investigators adopt the ASGE/SAGES working group recommendations for a multidisciplinary team possessing advanced therapeutic endoscopic and advanced laparoscopic skills to study NOTES before human investigation. Animal laboratory facilities to perform research and training should be available to the multidisciplinary team for exploration of NOTES techniques and procedures. Institutional Review Board (IRB) approval must be obtained before introduction of NOTES procedures in human patients.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a potential paradigm shift of Minimally Invasive Surgery that makes use of natural orifices to access the peritoneum for surgery without leaving visible scars. With NOTES, there are various benefits for patients such as fewer complications, improved precision, and faster recovery. In NOTES, the endoscope needs to be sufficiently flexible to go through the tortuous paths inside the human body to reach the target therapeutic site; once at the target site, the endoscope needs to be stiff enough to withstand external payloads as a stable platform during tissue manipulation without unwanted bending of the endoscope tip. Thus, an endoscope whose stiffness can be adjusted on command is desired. This thesis presents a novel variable-stiffness manipulator/endoscope and its application in NOTES. Two main objectives are identified: (𝑖) design, testing, and modeling of a novel approach for variable-stiffness manipulators, for proof of concepts, using a thermoplastic material whose stiffness is tunable through temperature. The temperature is adjusted through the joule heat generated by applying electric current into flexible metal coils inside the manipulator. A model that represents the relationship between the stiffness and the variables like dimensions of the design, heating time, and applied current will be studied and verified with experiments; and (𝑖𝑖) design, testing, and modeling of a variable-stiffness manipulator by considering critical requirements on sizes, and efficiency of real surgeries in flexible endoscopy and NOTES. Driven by 8 tendons, the robot has two bending sections and can be bent into “S” shapes. The active cooling mechanism is designed to shorten the activation time. The thermal insulation is also included to keep the temperature of the outer surface in the safe range. The comparisons in terms of the stiffness changing ratio and stiffness itself between the proposed design and the commercial endoscopes are shown along with extensive experiments. In particular, the manipulator has a high stiffness-changing ratio (22) between rigid and flexible states while that of its commercial Olympus counterpart is only 1.59. Heating and cooling mathematical models are also derived and evaluated using the experimental data. The cooling time with the active cooling mechanism is 11.9s while that of passive ambient cooling is 100.3s. The thermal insulation layer keeps the temperature of the outer surface within the safe range (below 41˚C) during operation. The results confirm the feasibility of developing a compact variable-stiffness endoscopic manipulator with significantly high stiffness-changing ratio (low stiffness in the flexile mode and high stiffness in the rigid mode), shortened time for switching the modes, and safe thermal insulation. The proposed manipulator may be used as a stable endoscopic platform in general flexible endoscopy and key-hole surgery.

Objective Since the first report of transgastric peritoneoscopic surgery in 2004, minimal invasive surgery (MIS) including conventional laparoscopy, natural orifice transluminal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), and robotic surgery have gained traction in general and visceral surgery. While laparoscopic surgery is now the gold standard in many institutions, other MIS approaches lag behind in spite of the enthusiasm of few promoters. The present study investigates the current role of NOTES and SILS in Switzerland. Methods All Swiss surgical departments where queried. Heads of department were asked to complete a detailed questionnaire regarding the use of NOTES and SILS techniques, reminders were sent twice. Results Of 93 departments queried, 63 (68%) answered the survey and most were public hospitals (92%). One third of general surgery departments and 46% of visceral surgery departments had the highest accreditation level A and V1, respectively. While up to 27% of the responding hospitals had performed NOTES in the past, only about 9% still use the technique today. Since January 2019, only two departments performed NOTES cholecystectomy, one department NOTES colectomy and three departments NOTES total mesorectal excision. The main reasons for not performing NOTES anymore were lack of perceived benefits, higher costs, increased morbidity in routine procedures, no patient demand, and the lack of surgical expertise. A similar picture was found regarding the use of SILS, with 37% of hospitals having past experience with SILS and only 13% still performing SILS procedures. Yet, significantly more institutions performed a broader range of SILS procedures today: SILS appendectomy (n = 2), SILS cholecystectomy (n = 4), SILS thyroidectomy (n = 1), SILS small bowel resection (n = 2), SILS colonic resection (n = 5), and SILS rectal resection (n = 2). The main reasons for not performing routinely SILS were similar to the rationale against NOTES. Conclusion Due to technical limitations and lack of perceptible benefits, NOTES and SILS are less frequently performed nowadays than they were in the past. Only a minority of departments are still performing NOTES and SILS, including cholecystectomies, appendectomies, thyroidectomies, and bowel resections. Whether the rise in use of robotic techniques correlates with the decrease of NOTES and SILS needs further investigation.

Postoperative outcomes and quality of life following hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) compared to laparoscopy in women with a non-prolapsed uterus and benign gynaecological disease: a systematic review and meta-analysis

The ergonomics of natural orifice translumenal endoscopic surgery (NOTES) navigation in terms of performance, stress, and cognitive behavior

BACKGROUND: As an emerging surgical paradigm, NOTES is currently performed using conventional flexible endoscopes. Gastroenterologists are experts in handling this instrument; however, NOTES involves manipulation of the endoscope outside the lumen of the gastrointestinal tract. Surgeons are used to operating within the spatial environment of the peritoneal cavity. The aim of this study was to investigate whether either surgeons or gastroenterologists are superior at navigating the endoscope in a NOTES environment using the Imperial College Natural Orifice Simulated surgical Environment (NOSsE) as an assessment tool. METHODS: Nine novices, 5 gastroenterologists and 4 laparoscopic surgeons were recruited to navigate through a series of targets in the NOSsE phantom. End-points were time taken to complete the course and number of targets successfully visualised. RESULTS: Gastroenterologists and surgeons completed the course faster (p < 0.001) and revealed more targets than novices (p < 0.001). Overall, surgeons completed the course in less time than gastroenterologists (mean time 228 sec vs. 134 sec; p = 0.172) and visualised more targets (mean 8.83 vs. 7.53; p = 0.217) although neither reached statistical significance. CONCLUSIONS: The results of this pilot study suggest that surgeons are not disadvantaged when it comes to navigating an endoscope within a simulated NOTES environment compared to gastroenterologists. Therefore, as appears to be the current practice, it is acceptable for surgical teams to perform initial NOTES studies, provided they possess adequate skill, appropriate laboratory experience and ethical review board approval. With the evolution in surgical tools, we are likely to see improved instrumentation to aid in navigation in NOTES.

Since its introduction in 2000, natural orifice translumenal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world. In this article, we will review the progress in the field of NOTES and present the latest publications that provide some answers and solutions to the barriers suggested by the Natural Orifice Surgery Consortium for Assessment and Research white paper. Because of the first human NOTES procedure by Rao and Reddy, more pioneering procedures, including transgastric and transvaginal cholecystectomies, appendectomies, and hernia repairs, have been performed. Although NOTES researchers continue to experiment with new innovative equipment and procedures in the lab, more structured work, including randomized controlled trials, has been published. In the last several years, there has been growing interest in NOTES, which has translated into exciting animal research work and publication of randomized controlled trials. Additionally, preliminary NOTES human procedures have been successfully performed. When suitable instruments become available, the subsequent step should be comparing NOTES with current laparoscopic approaches. Superiority or even equality of NOTES to laparoscopic surgery would be the best argument for advancing and integrating implementation into clinical practice.

Recent decades have seen remarkable progress in medicine as minimally invasive procedures have replaced radical surgical resections. Natural orifice translumenal endoscopic surgery (NOTES) is an evolving minimally invasive technique that has the potential to break the physical barrier between incisions and surgery. The present-day concept of NOTES was articulated by Kalloo et al. in 2004, who challenged surgeons and endoscopists to focus research on finding the best translumenal endoscopic access to the peritoneal cavity, with the utmost attention to safety, including the reliable closure of the entry point. The justifications for this technique are as follows: the reduction or absence of postoperative pain; the ease of access to some organs; the absence of trauma to the abdominal wall; ideal cosmetic results; and the psychological advantages of eliminating the trauma caused by transabdominal surgery. Both transvaginal and transgastric cholecystectomies have been translated from research into clinical applications, attracting an explosion of interest. Since the first report from Marescaux et al. and Bessler et al. in 2007, over 500 NOTES cholecystectomies have been reported in Europe, mostly using a hybrid approach between NOTES and laparoscopy. With the goal of tracking the evolution of new techniques, a global European NOTES activity registry, the Euro-NOTES Registry (www.euronotes.world.it), was created among ten centers. An independent nationwide German registry was also established as an outcome database to allow the monitoring and safe introduction of NOTES. Both registries invite surgeons who performed NOTES procedures to voluntarily contribute. Despite the fact that NOTES has just recently been introduced, the technique has already gained considerable clinical application in Europe, and it appears to be well accepted by patients. According to the registries, cholecystectomies account for 89 % of all NOTES procedures in Europe. NOTES cholecystectomies have been described in Europe using the transvaginal approach with rigid in-line instruments, and through both the transvaginal and transgastric approaches with a flexible platform.