David Silva

Transvesical thoracoscopy: A natural orifice translumenal endoscopic approach for thoracic surgery

BackgroundRecently there has been an increasing enthusiasm for using natural orifices translumenal endoscopic surgery (NOTES) to perform scarless abdominal procedures. We have previously reported the feasibility and safety of the transvesical endoscopic peritoneoscopy in a long-term survival porcine model as useful for those purposes. Herein, we report our successful experience performing transvesical and transdiaphragmatic endoscopic approach to the thoracic cavity in a long-term survival study in a porcine model.MethodsTransvesical and transdiaphragmatic endoscopic thoracoscopy was performed in six anesthetized female pigs. A 5 mm transvesical port was created on the bladder wall and an ureteroscope was advanced into the peritoneal cavity. After diaphragm inspection, we introduced through the left diaphragmatic dome a ureteroscope into the left thoracic cavity. In all animals, we performed thoracoscopy as well as peripheral lung biopsy. Animals were sacrificed by day 15 postoperatively.ResultsWe easily introduced a 9.8 Fr ureteroscope into the thoracic cavity that allowed us to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. Postmortem examination revealed complete healing of vesical and diaphragmatic holes, whereas no signs of infection or adhesions were observed in the peritoneal or thoracic cavities.ConclusionThis study demonstrates the feasibility of transvesical thoracoscopy in porcine model. However, although this study extends the potential applications of NOTES to the thoracic cavity, new instruments and further work are needed to provide evidence that this could be translated to humans and with advantages for patients.

Endoscopic Closure of Transmural Bladder Wall Perforations

BACKGROUND Traditionally, intraperitoneal bladder perforations caused by trauma or iatrogenic interventions have been treated by open or laparoscopic surgery. Additionally, transvesical access to the peritoneal cavity has been reported to be feasible and useful for natural orifice translumenal endoscopic surgery (NOTES) but would be enhanced by a reliable method of closing the vesicotomy. OBJECTIVE To assess the feasibility and safety of an endoscopic closure method for vesical perforations using a flexible, small-diameter endoscopic suturing kit in a survival porcine model. DESIGN, SETTING, AND PARTICIPANTS This pilot study was performed at the University of Minho, Braga, Portugal, using six anesthetized female pigs. INTERVENTIONS Closure of a full-thickness longitudinal incision in the bladder dome (up to 10 mm in four animals and up to 20 mm in two animals) with the endoscopic suturing kit using one to three absorbable stitches. MEASUREMENTS The acute quality of sealing was immediately tested by distending the bladder with methylene-blue dye under laparoscopic control (in two animals). Without a bladder catheter, the animals were monitored daily for 2 wk, and a necropsy examination was performed to check for the signs of peritonitis, wound dehiscence, and quality of healing. RESULTS AND LIMITATIONS Endoscopic closure of bladder perforation was carried out easily and quickly in all animals. The laparoscopic view revealed no acute leak of methylene-blue dye after distension of the bladder. After recovery from anaesthesia, the pigs began to void normally, and no adverse event occurred. Postmortem examination revealed complete healing of vesical incision with no signs of infection or adhesions in the peritoneal cavity. No limitations have yet been studied clinically. CONCLUSIONS This study demonstrates the feasibility and the safety of endoscopic closure of vesical perforations with an endoscopic suturing kit in a survival porcine model. This study provides support for further studies using endoscopic closure of the bladder which may lead to a new era in management of bladder rupture and adoption of the transvesical port in NOTES procedures.

In vivo assessment of gastrotomy closure with over-the-scope clips in an experimental model for varicocelectomy (with video)

BACKGROUND Gastrotomy closure remains the major limiting factor for human translation of transgastric surgery; the over-the-scope clip (OTSC) system was proposed as a possibility for this purpose. Transgastric access is good for a pelvic approach, making varicocelectomy a possible indication for natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE To evaluate the reliability of the OTSC system in vivo after transgastric testicular vessel ligation (varicocelectomy model). DESIGN There were 3 experimental groups (5 animals in each): groups 1 and 3, gastrotomy dilation up to 18 mm, surgery was performed with a double-channel endoscope; group 2, gastrotomy dilation up to 13 mm, surgery was performed with a single-channel endoscope. SETTING Surgical Sciences Research Domain, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal. INTERVENTIONS Bilateral testicular vessel ligation by transgastric access. Gastrotomy closed with the largest version of OTSC system (12 mm): a single clip in groups 1 and 2, and 2 clips in group 3. Animals were monitored for 2 weeks, killed, and submitted for necropsy. MAIN OUTCOME MEASUREMENTS Adequacy of closure and healing after the use of the OTSC system. Statistical analysis. RESULTS Vessel ligation was easily achieved in all groups. Although differences in the complication rate did not reach statistical significance (P = .099), there was a clear tendency for a better prognosis in groups 2 and 3 than group 1. In fact, only 2 animals from group 1 had complications related to incomplete gastrotomy closure. LIMITATIONS Small number of animals per group; nonrandomized study. CONCLUSIONS The OTSC system was shown to be easy and efficient for gastrotomy closure in a survival experimental model of varicocelectomy, when correctly matching the gastrotomy size with the clip size and/or number.

Peroral esophageal segmentectomy and anastomosis with single transthoracic trocar: a step forward in thoracic NOTES.

BACKGROUND AND STUDY AIMS A transesophageal natural orifice transluminal endoscopic surgery (NOTES) approach has been proposed for thoracic and mediastinal access. Similarly to transgastric surgery, serious limitations remain related to creating an esophagotomy and its safe closure. A hybrid approach in thoracic NOTES could work as an intermediate step before pure transesophageal NOTES. We assessed the benefit of hybrid thoracic NOTES for peroral segmental esophagectomy and subsequent complete esophageal anastomosis with a single transthoracic port. METHODS Two protocols were used to attempt esophago-esophageal anastomosis: ex vivo using a phantom model (n = 5), and in vivo after esophageal mobilization, and segmental esophagectomy achieved using either a gastroscope (flexible) (n = 5) or thoracoscope (rigid) instruments (n = 5). A forward-viewing double-channel endoscope and a transthoracic operative thoracoscope with a working channel were coordinated in order to create a complete single-layer, end-to-end esophageal anastomosis ex vivo as well as in vivo. Feasibility and anastomosis quality were evaluated by inside and outside assessment of: patency, the incorporation of mucosa in all stitches, and a leak test. RESULTS Anastomosis was achieved in all ex vivo experiments and thoracoscopically-led in vivo procedures. All anastomoses were patent, allowing distal passage of the endoscope, with mucosa incorporation. In in vivo experiments, a leak was detected in three animals and corrected with additional stitching. CONCLUSIONS Peroral esophageal anastomosis with a single transthoracic trocar is feasible, which may represent a step forward in thoracic NOTES.

Pure NOTES Transvesical Venous Ligation: Translational Animal Model of Varicocelectomy

OBJECTIVE To assess the feasibility of pure natural orifice transluminal endoscopic surgery (NOTES) transvesical venous ligation mimicking bilateral varicocelectomy in an animal model. MATERIALS AND METHODS Transvesical NOTES bilateral venous ligation was performed in 6 female pigs by considering lower epigastric vessels as a model for gonadal vessels. Under flexible cystoscopic guidance, a cystotomy was created on the anterior bladder. The flexible cystoscope was introduced through the over tube, and the lower epigastric vessels were visualized in retroflexion. Thulium laser was used to cut and coagulate the vessels. A bladder catheter was left in place for 4 days in all animals and they were sacrificed 15 days after the procedure. RESULTS The procedure was successfully carried out in all animals without intraoperative complications. Epigastric vessels were safely cut and coagulated using the thulium laser. Median time for the overall procedure, including establishment of the transvesical port, was 23 minutes (range 20-30). No complications were encountered during the postoperative follow-up period. Postmortem examination revealed complete coagulation and separation of vessels. CONCLUSION An animal model mimicking a NOTES transvesical bilateral varicocelectomy procedure is successfully shown in the present study. Despite being encouraging, these novel findings need to be interpreted with caution. Further research is warranted and development of purpose-built instrumentation is awaited to define potential urological applications of transvesical NOTES.

OPM3® Portugal Project – Information Systems and Technologies Organizations – Outcome Analysis

Increasing the maturity in Project Management (PM) has become a goal for many organizations, leading them to adopt maturity models to assess the current state of its PM practices and compare them with the best practices in the industry where the organization is inserted. One of the main PM maturity models is the Organizational Project Management Maturity Model (OPM3®), developed by the Project Management Institute. This paper presents the Information Systems and Technologies organizations outcome analysis, of the assesses made by the OPM3® Portugal Project, identifying the PM processes that are “best” implemented in this particular industry and those in which it is urgent to improve. Additionally, a comparison between the different organizations’ size analyzed is presented.