Towards a continuum variable-stiffness robotic arm for surgical applications

EUS and natural orifice transluminal endoscopic surgery

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 Much like laparoscopy has be feasible and an unpublished clinical case series demonstrated less physiologic impact than of transgastric appendectomies has been discussed laparotomy, NOTES may cause less physiologic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.

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.

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.

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.

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.

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

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.

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

Natural orifice transluminal endoscopic surgery (NOTES) has received considerable interest in recent years as a novel surgical technique. Here, we aim to review the current progress on NOTES, particularly focusing on the advantages and complications related to NOTES, the recent advances of surgical approaches, new instruments for closure of the natural orifice incision, and the newly developed platform for NOTES. Finally, we make a prediction of the conceivable applications of NOTES on human subjects.

Objective: Review of the application of natural orifice translumenal endoscopic surgery (NOTES) in human studies. Summary Background Data: NOTES presents the latest promising technology that allows new access into the abdominal cavity through a natural orifice for multiple clinical applications. It has generated excitement among physicians for a potentially scar-free surgery. Being in its infancy stage, the safety and efficacy of this technology must be studied with scrutiny. Methods: A PubMed search was conducted in April 2008 for “natural orifice translumenal endoscopic surgery” and for “natural orifice transluminal endoscopic surgery.” The search was limited to articles in English and those regarding human subjects. Results: The outcomes from the published case series show a level III evidence for the use of NOTES. However, human experience with NOTES is growing. Eleven articles involving human experience with NOTES have been published in 2007 and 2008. More studies are expected as the interest in this type of surgery has only just begun. Conclusions: NOTES is a promising new technology that needs fine-tuning before it is safely applied in the clinical setting. This highlights the need for further animal and human studies in well-controlled settings followed by industry trials and case series. The excitement about this new approach should be directed toward more training and more studies before larger clinical applications can begin.

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.

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.

Evaluation of a Hybrid Approach to NOTES and its performance relative to conventional procedures. Globally, numerous institutions have successfully implemented minimally invasive surgeries by applying natural orifice translumenal endoscopic surgery (NOTES) techniques and achieved decreased morbidity while performing incision-less surgery. However, these techniques are still not common in surgical practice in China and Pakistan. Documenting the experiences and challenges encountered in implementing NOTES in such environments can provide guidance for NOTES implementation elsewhere. From May 2010 to April 2012, 16 human transvaginal appendectomies were carried out applying a hybrid NOTES technique using a solo-umbilical trocar, which provided a safe access for laparoscopic assistance during surgical procedure. After removal of the appendix transvaginally, the colpotomy was sutured under direct vision with absorbable stitches. The outcomes of cases treated with hybrid NOTES techniques were compared to those of conventional laparoscopic appendectomy. All patients underwent a successful surgical procedure with no intra- or post-operative complications and provided no specific complaints during the tenth day and a monthly follow-up for 2 years. The patients convalesced promptly with healthy and satisfactory cosmetic results. Compared to conventional laparoscopic appendectomy, the hybrid NOTES operation had less post-operative pain, lower cost, and shorter hospitalization. Hybrid NOTES procedures can be performed safely using a solo-umbilical trocar. Our initial experience reveals that this hybrid technique is practically feasible and associated with minimal post-operative pain, reasonable convalescence time, and improved cosmetic outcomes.