Oliver J. Wagner

Hybrid natural orifice transluminal endoscopic surgery (NOTES) for Roux-en-Y gastric bypass: an experimental surgical study in human cadavers.

BACKGROUND AND STUDY AIMS The advantages of a hybrid natural orifice transluminal endoscopic surgery approach to Roux-en-Y gastric bypass (hNOTES-RYGBP) might include: easier access to the peritoneal cavity, reduced number of ports and related complications, improved cosmesis, and others. However, currently available conventional endoscopic and laparoscopic instruments might be unsuitable for complex surgical procedures using transluminal access. The aim of this study was to investigate the feasibility and limitations of a NOTES RYGBP. METHODS hNOTES-RYGBP was performed in human cadavers. Pouch creation was achieved by needle-knife dissection using a transvaginal, flexible scope. Articulating linear staplers were placed transumbilically to transect the stomach. Measurements of the small bowel were accomplished intraluminally or with flexible and rigid graspers. New methods were tested to create the gastro-jejunal anastomosis. A linear laparoscopic stapler was used to form the jejuno-jejunal anastomosis. RESULTS Stapler manipulation and anvil docking, bowel manipulation and measurement, and tissue dissection presented the main obstacles for hNOTES-RYGBP. Conventional instruments were too short for some transvaginal manipulations. The time to complete the procedure was 6 - 9 hours. It was feasible to perform a complete hNOTES-RYGBP in four out of seven cadavers. Two cadavers were unsuitable due to anatomical abnormalities or advanced decay. One procedure was terminated before completion because of time constraints. Combinations of flexible and rigid visualization and manipulation were helpful, especially for dissection and gastric pouch creation. CONCLUSIONS Several factors made hNOTES-RYGBP very challenging and time-consuming. A lack of proper instrumentation resulting in insufficient tissue traction, countertraction, and instrument manipulation complicated several steps during the procedure. A combination of flexible with rigid endoscopic techniques offers specific advantages for components of this type of surgery. Changes in instrument design are required to improve more complex endosurgical procedures.

Robotic vs. laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease: systematic review and meta-analysis.

The aim of this meta‐analysis was to compare clinical outcome following laparoscopic and robotic Nissen fundoplication. A systematic literature search of Medline, Embase and Cochrane Library databases was performed. Primary outcome measures were the requirement for re‐operation, postoperative mortality and postoperative dysphagia. Secondary outcome measures were operative time, length of hospital stay, operative complications and cost. Six randomized trials, of 226 patients, were included in this meta‐analysis. There was no significant difference in requirement for re‐operation or in postoperative dysphagia. There was a significantly reduced total operative time in the laparoscopic group (weighted mean difference = 4.154; 95% CI = 1.932–6.375; p = 0.0002). There was no significant difference between robotic and laparoscopic groups for hospital stay or operative complications. Clinical results from robotic Nissen fundoplication were comparable to the standard laparoscopic approach, but there was associated increased operative time and procedure cost. Copyright

Set‐up and docking of the da Vinci® surgical system: prospective analysis of initial experience

Set‐up and docking of the da Vinci® surgical system are assumed to extend overall operating times. We hypothesized that these tasks could be achieved in adequate times. Therefore, a prospective analysis of set‐up and docking times of the da Vinci® Surgical System was conducted.

Transrectal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy in a porcine model.

OBJECTIVE To examine feasibility of transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy in the porcine model. NOTES uses ports of entry to the peritoneal cavity instead of abdominal wall incisions, thereby eliminating visible scar and also potentially reducing postoperative pain. METHODS After obtaining Institutional Animal Care and Use Committee approval, 3 female pigs (45 kg) underwent transrectal hybrid NOTES nephrectomy (2 right, 1 left). Pneumoperitoneum was created by a periumbilically-inserted 12-mm trocar, through which a laparoscope was advanced to obtain intraabdominal visualization. A horizontal incision was made 2 cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall/presacral space. A dual-channel gastroscope was advanced through the submucosal tunnel and retroperitoneum to the level of the kidney using air insufflation. A window in the peritoneum was created and renal mobilization was completed. A transumbilically applied laparoscopic 45-mm stapler was used to transect the ureter and renal hilum. A specimen extraction bag was deployed transrectally and the specimen was delivered intact, followed by transrectal incision closure. RESULTS Transrectal hybrid NOTES nephrectomy was successfully performed in all cases. Mean operative time was 180 minutes (30 minutes for rectal access). Estimated blood loss was 50 mL. On necropsy, no intraabdominal injuries were noted. CONCLUSIONS In this initial report on feasibility of transrectal hybrid NOTES nephrectomy, we were able to perform the procedures with minimal blood loss and extract intact specimen. Survival studies are prerequisite to assess sterility and short- and long-term complications. This approach may be useful as an alternative to transvaginal access.

Impact of IQ, computer-gaming skills, general dexterity, and laparoscopic experience on performance with the da Vinci surgical system.

Due to improved ergonomics and dexterity, robotic surgery is promoted as being easily performed by surgeons with no special skills necessary. We tested this hypothesis by measuring IQ elements, computer gaming skills, general dexterity with chopsticks, and evaluating laparoscopic experience in correlation to performance ability with the da Vinci® robot.

Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms

Single‐incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology.

Who should do NOTES? Initial endoscopic performance of laparoscopic surgeons compared to gastroenterologists and untrained individuals.

IntroductionNatural orifice transluminal endoscopic surgery (NOTES) is a multidisciplinary surgical technique. If conventional endoscopic instrumentation can be easily mastered, surgeons with laparoscopic experience could head NOTES interventions.Materials and MethodsThirty individuals were tested for endoscopic dexterity. Group 1 included seven gastroenterologists, group 2 included 12 laparoscopically experienced surgeons lacking endoscopic experience, and group 3 included 11 interns who had no hands-on endoscopic or surgical experience. Each individual repeated an easy (T1), medium (T2), and difficult (T3) task ten times with endoscopic equipment on a NOTES skills-box.ResultsGroup 3 had significantly poorer performances for all three tasks compared to the other groups. No significant differences were seen between groups 1 and 2 for T1 and T2. The initial T3 performance of group 1 was better than that of group 2, but their performance after repetition was not statistically different. Groups 2 and 3 improved significantly with repetition, and group 2 eventually performed as well as group 1.ConclusionsThe data indicate that laparoscopic surgeons quickly learned to handle the endoscopic equipment. This suggests that a lack of endoscopic experience does not handicap laparoscopic surgeons when performing endoscopic tasks. Based on their knowledge of anatomy and the complication management acquired during surgical education, surgeons are well equipped to take the lead in interdisciplinary NOTES collaborations.

Transrectal natural orifice transluminal endoscopic surgery for umbilical hernia repair in a human cadaver (with video)

The advantages of a natural orifice transluminal endoscopic surgery (NOTES) approach to umbilical repair might include easier access to the peritoneal cavity, superior views of the anterior abdominal wall, differently angled views of the field of surgery, and improved cosmesis. A single report of NOTES hernia repair in pigs can be found in the literature. However, when transferring NOTES from the laboratory to the patient, it is important to know that procedure is actually feasible in human anatomy. No reports concerning NOTES for hernia repair in humans or human cadavers were found. We hypothesized that it is feasible to perform a NOTES umbilical hernia repair in the human anatomy.

Sirolimus and intraoperative hyperthermic peritoneal chemoperfusion with mitomycin-C do not impair healing of bowel anastomoses

Surgeons will increasingly have to address the development of gastrointestinal disease in transplant patients or deal with extended bowel resection and bowel anastomosis in advanced cancer patients. Immunosuppressants as well as intraoperative hyperthermic peritoneal chemoperfusion (IHPC) may alter intestinal anastomotic healing. We evaluated the effects of the immunosuppressant sirolimus and of IHPC on healing and stability of bowel anastomoses in pigs. Twenty‐four pigs were divided into four groups (SIR: sirolimus was administered orally; IHPC: animals received IHPC with mitomycin‐C; COMP: combination of sirolimus and IHPC was administered; CON: sham‐treated control group). Animals underwent hand‐sutured small bowel and left colon anastomoses and were killed on postoperative day 4. Anastomoses were evaluated by morphometric analysis and immunohistochemistry (IHC) and by measuring the bursting pressure (BP). In all experimental groups (SIR, IHPC, COMP), anastomotic BPs remained unaltered and were not statistically different compared with control (CON). In addition, ileum villous height and colonic crypt depth analysis revealed no significant difference in mucosal thickness, and IHC showed no difference among groups in proliferation, as assessed by the number of KI‐67‐ and bromodeoxyuridine‐labeled cells. Immunosuppression with sirolimus as well as IHPC with mitomycin‐C do not alter healing of intestinal anastomosis in pigs.

643 Rigid and Flexible Trocars for NOTES Access in Human Anatomy

Background: Patients operated on for gallstone disease often receive prophylactic antibiotics especially in acute operations but frequently also in elective surgery even though evidence for the effectiveness of such treatment is lacking. In this study we present data on the use of prophylactic antibiotics and postoperative infections from a national, web based register of gallstone surgery. Methods: The Swedish Register for Gallstone Surgery and ERCP (GallRiks) started in May 2005 and soon reached a national coverage with 75% of all procedures being entered in 2007. It comprises open and laparoscopic surgery of the gallbladder as well as all endoscopic interventions of the bile ducts. GallRiks is an internet application with on line registration of procedures and follow up as well as electronic reports on demand. A program for validation of data has started and the results from the first 6 hospitals revised indicate a match between the medical records and the database in 98.6% of the cases. During 2006 and 2007 a total of 16400 operations were registered in GallRiks. Patients from hospitals who had registered less than 25 patients were excluded from this study as were patients who had either a major surgery along with the cholecystectomy or only had a choledochotomy (previous cholecystectomy). Incomplete records and cases with a missing 30-day follow up were also excluded. Altogether 747 patients (4.6%) were excluded for these reasons. In another 4726 patients (30%) the surgery was performed acute. Thus, this is a study of 10927 patients who had an elective cholecystectomy performed in 54 Swedish hospitals during the years 2006 and 2007. Results: The 54 hospitals used prophylactic antibiotics at very different rates, from 0% to 98% of the operations, which by far exceeds any random variation. A postoperative abscess was found in 93 (.9%) and in 377 patients (3.5%) some kind of septic complication occurred requiring antibiotic treatment. In a multiple logistic regression analysis, adjusting for age, sex, indications for surgery, surgical methods and operative difficulties peroperative antibiotics had no beneficial effect on the risk of postoperative septic complications. Conclusion: There is a huge variation in the use of prophylactic antibiotics in elective cholecystectomy between different hospitals in Sweden reflecting the lack of uniform guidelines. The rate of septic complications from this operation is low and is furthermore unaffected by prophylactic antibiotics.