Higher physical workload risks with NOTES versus laparoscopy: a quantitative ergonomic assessment

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

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: 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.

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.

Scarlesss Intra-Retroperitoneoscopy in Human and Animal NOTES® Translumenal Cholecystectomy, Appendectomy and GI Anastomosis

A Randomized Comparison of Laparoscopic, Flexible Endoscopic, and Wired and Wireless Magnetic Cameras on Ex Vivo and In Vivo NOTES Surgical Performance

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.

The application of flexible endoscopy tools for Natural Orifice Translumenal Endoscopic Surgery (NOTES) is constrained due to limitations in dexterity, instrument insertion, navigation, visualization, and retraction. Miniature endolumenal robots can mitigate these constraints by providing a stable platform for visualization and dexterous manipulation. This video demonstrates the feasibility of using an endolumenal miniature robot to improve vision and to apply off-axis forces for task assistance in NOTES procedures. A two-armed miniature in vivo robot has been developed for NOTES. The robot is remotely controlled, has on-board cameras for guidance, and grasper and cautery end effectors for manipulation. Two basic configurations of the robot allow for flexibility during insertion and rigidity for visualization and tissue manipulation. Embedded magnets in the body of the robot and in an exterior surgical console are used for attaching the robot to the interior abdominal wall. This enables the surgeon to arbitrarily position the robot throughout a procedure. The visualization and task assistance capabilities of the miniature robot were demonstrated in a nonsurvivable NOTES procedure in a porcine model. An endoscope was used to create a transgastric incision and advance an overtube into the peritoneal cavity. The robot was then inserted through the overtube and into the peritoneal cavity using an endoscope. The surgeon successfully used the robot to explore the peritoneum and perform small-bowel dissection. This study has demonstrated the feasibility of inserting an endolumenal robot per os. Once deployed, the robot provided visualization and dexterous capabilities from multiple orientations. Further miniaturization and increased dexterity will enhance future capabilities.

Natural orifice transluminal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgical techniques with flexible endoscopy technology. Surgical treatment has been in constant evolution in the search for minimizing incisions, regardless of the complexity of the operation. NOTES represents another step in this ongoing progression toward less invasive procedures. The advantages of such an approach include reduced incisional pain, decreased wound complications, such as infections and hernias, improved cosmetic results, and potentially faster recovery and return to work. Until substantial improvement in NOTES instrumentation are made to optimize this approach, these procedures are likely to require laparoscopic assistance. Critics challenge the safety and advantages of this technique in the face of effective minimally invasive surgical options such as laparoscopic surgery. Here, we discuss the current NOTES status and techniques.

Flexible endoscopy is increasingly developing into a therapeutic instead of a purely diagnostic discipline. Improved visualization makes early lesions easily detectable and allows us to decide ad hoc on the required treatment. Deep enteroscopy allows the exploration of even the small bowel – for long a “white spot” for gastrointestinal endoscopy – and to perform direct treatment. Endoscopic submucosal dissection is a considerable step forward in oncologically correct endoscopic treatment of (early) malignant lesions. Though still technically challenging, it is increasingly facilitated by new manipulation techniques and tools that are being steadily optimized. Closure of wall defects and hemostasis could be improved significantly. Even the anatomy beyond the gastrointestinal wall is being explored by the therapeutic use of endoluminal ultrasound. Endosonographic-guided surgery is not only a suitable fallback solution if conventional endoscopic retrograde cholangiopancreatography fails, but even makes necrosectomy procedures, abscess drainage, and neurolysis feasible for the endoscopist. Newly developed endoscopic approaches aim at formerly distinctive surgical domains like gastroesophageal reflux disease, appendicitis, and cholecystitis. Combined endoscopic/laparoscopic interventional techniques could become the harbingers of natural orifice transluminal endoscopic surgery, whereas pure natural orifice transluminal endoscopic surgery is currently still in its beginnings.

Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument. Therefore, "pure NOTES" transgastric cholecystectomy has not yet been described. The authors successfully performed "pure NOTES" transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure) that allows completion of the procedure by pure NOTES without an external instrument. With the subject under general anesthesia, a double-channel gastroscope (Storz®, Tuttlingen, Germany) passed by mouth entered the peritoneum through the distal anterior gastric wall. The most ideal site for a second gastric exit was then selected for another single-channel scope. With the gallbladder retracted by the assistant operating the double-channel scope, retrograde cholecystectomy was performed by the primary surgeon using the single-channel scope. Four animals were killed immediately to study the quality of the operative dissection, whereas the other four pigs were kept alive. The gastrotomy was closed using a 27- to 30-mm cardiac septal occluder (Occlutech®, GmbH, Jena, Germany) according to a previously described method. The postoperative follow-up assessment of these animals included laparoscopy and necropsy 2 weeks later. All the cholecystectomies were immediately successful without any intraoperative complication. Scope withdrawal caused no injuries to the esophagus or pharynx. Although no overt postoperative complication was evident, two surviving pigs had signs of minor peritoneal infection. This study investigated "pure NOTES" transgastric cholecystectomy using tentative experimentation to overcome the "retraction" and "triangulation" issues and to realize a "pure NOTES" operation. The use of two endoscopes with selected differentiation of their gastric placements compensated for the lack of triangulation and retraction.

Measuring the quality of colonoscopy at a district general hospital in south east England: adenoma detection rates and withdrawal times

Comparison of Major Clinical Outcomes Between Transvaginal NOTES and Traditional Laparoscopic Surgery: A Systematic Review and Meta-analysis

Addressing Access and Visualization Limitations in VNOTES: Evaluation of a Novel Laparoscopic Vaginal Speculum in a Porcine Model.