Ricardo Zorron

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients.

Objectives: Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases. Methods: Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented. Results: Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients. Conclusions: Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

Perirectal NOTES access: "down-to-up" total mesorectal excision for rectal cancer.

Objectives. Clinical natural orifice surgery has been applied for abdominal surgery in recent years, mostly by vaginal and oral access. The study describes preliminary successful human applications of transcolonic natural orifice transluminal endoscopic surgery (NOTES), using a new transrectal total mesorectal excision procedure for rectal cancer. Methods. Institutional review board approval was obtained for the study. In 2 patients with rectal adenocarcinoma, total mesorectal resection and rectosigmoidectomy with lymphadenectomy was performed using a low NOTES transcolonic access. “Down-to-up” mesorectal dissection was achieved either using a flexible scope or a transrectal single port device. The specimens were extracted transanally, and transorificial low anastomosis was performed. Results. Operative time was 350 and 360 minutes, respectively; no complications occurred and patients were discharged after 6 days. Conclusion. Successful human reports on transcolonic NOTES suggest potential applications. The treatment of colorectal diseases through transorificial single port or flexible perirectal NOTES access are promising new approaches besides current methods to improve patient care.

NOTES: Transvaginal for Cancer Diagnostic Staging: Preliminary Clinical Application

Laparoscopy is now a reliable method for staging gastrointestinal cancer, orienting the therapy, and avoiding unnecessary laparotomy. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging concept with potential advantages for patient recovery. The first case of clinical diagnostic application of transvaginal NOTES for diagnostic cancer staging is presented. Informed consent and Institutional Commission approval were obtained for transvaginal clinical trials. On February 28, 2007, a patient with elective surgical indication for diagnostic cancer staging was submitted to transvaginal NOTES procedure, and intra- and postoperative parameters were documented. In a 50-year-old female patient presenting with ascitis, diffuse abdominal pain, and weight loss for 2 months, diagnosis of peritoneal carcinomatosis was suspected, which was also found when a CT scan was performed. Transvaginal NOTES was used for diagnostic staging of the patient, using a colonoscope introduced into the abdomen through a small incision in the vagina. Biopsies of liver, diaphragm, ovaries, and peritoneum were successfully performed. Operative time was 105 min, vaginal access and closure was obtained in 15 min. Abdominal inventory was reliable, and all 16 biopsies taken were positive for ovarian adenocarcinoma. The patient was dismissed 48 hours after the procedure without complications. Recent literature and experience of the study group suggest possibilities for preliminary clinical applications by transvaginal natural orifice surgery for diagnostic purposes.

New Hybrid Approach for NOTES Transvaginal Cholecystectomy: Preliminary Clinical Experience

Objectives. Natural orifice translumenal endoscopic surgery (NOTES) represents the first step toward scar-less surgery. The objective of this study is to evaluate early clinical results of transvaginal cholecystectomy using a new technique. Methods. Institutional review board approval was obtained and transvaginal NOTES cholecystectomy was performed in 12 women for cholelithiasis. A 2-channel videoendoscope was inserted in the abdominal cavity through a posterior colpotomy. Two 3-mm trocars were inserted deep in the umbilicus, and a 10-mm trocar was placed through the colpotomy parallel to the endoscope. Dissection was performed with endoscopic instruments combined with 3-mm laparoscopic instruments. Results. Mean operative time was 125.8 minutes. All procedures occurred without intraoperative complications or conversions, except for 1 vulvar laceration. There were no postoperative complications in the clinical follow-up. Conclusion. Transvaginal NOTES is a feasible and safe alternative for cholecystectomy in this preliminary clinical experience, allowing good cosmetic benefits and low analgesic requirement.

Down-to-Up transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients

BACKGROUND: Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde (“Down-to-Up”) total mesorectal excision for rectal cancer. MATERIALS AND METHODS: Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis. RESULTS: Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients. CONCLUSION: This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.

Transvaginal Hybrid Natural Orifice Transluminal Endoscopic Surgery Retroperitoneoscopy—The First Human Case Report

BACKGROUND Retroperitoneal and transabdominal laparoscopic access to retroperitoneal organs became the golden standard for treatment of most adrenal and renal diseases. Natural orifice surgery is a promising concept in the evolution of minimal access surgery. The possibility of a natural orifice transluminal endoscopic surgery (NOTES) transvaginal retroperitoneal access to diagnose and perform retroperitoneal surgery was developed in our institution, aiming an alternative natural orifice less-invasive approach. METHODS Institutional review board approval was obtained from the institution for clinical transvaginal NOTES. A 67-year-old woman (body mass index = 35.6 kg/m(2)) found to have a large renal cyst situated in the lower pole with compression symptoms was subjected to the technique. Transvaginal retroperitoneal access was obtained by direct vision open technique, the space was digitally dissected, and a flexible two-channel colonoscope progressed the dissection to the left kidney. The cyst was dissected using endoscopic instruments, and resection was completed with use of two laparoscopic instruments because of peritoneal tear with loss of retropneumoperitoneum. RESULTS NOTES transvaginal retroperitoneoscopy was performed, and anatomical landmarks, such as left ureter, inferior mesenteric artery (IMA), vena cava, and aorta, were identified. Insufflation and orientation were hazardous, because of constitutional fat, and operative time was 210 minutes. Postoperative course was complicated by postoperative face and neck enphysema, which disappeared after few days. Observation was maintained for 4 postoperative days, and the patient was discharged without other complications. Follow-up at 30 days was uneventful. CONCLUSION This first human procedure using flexible transvaginal retroperitoneoscopy showed feasibility of the access, but inadequate instruments led to technical difficulties for therapeutical purposes. However, the new concept of minimally invasive NOTES retroperitoneoscopy may open new therapeutic indications in clinical practice in the near future.

Single incision laparoscopic liver resection (SILL) – a systematic review

Background: Today, minimally invasive liver resections for both benign and malignant tumors are routinely performed. Recently, some authors have described single incision laparoscopic liver resection (SILL) procedures. Since SILL is a relatively young branch of laparoscopy, we performed a systematic review of the current literature to collect data on feasibility, perioperative results and oncological outcome. Methods: A literature research was performed on Medline for all studies that met the eligibility criteria. Titles and abstracts were screened by two authors independently. A study was included for review if consensus was obtained by discussion between the authors on the basis of predefined inclusion criteria. A thorough quality assessment of all included studies was performed. Data were analyzed and tabulated according to predefined outcome measures. Synthesis of the results was achieved by narrative review. Results: A total of 15 eligible studies were identified among which there was one prospective cohort study and one randomized controlled trial comparing SILL to multi incision laparoscopic liver resection (MILL). The rest were retrospective case series with a maximum of 24 patients. All studies demonstrated convincing results with regards to feasibility, morbidity and mortality. The rate of wound complications and incisional hernia was low. The cosmetic results were good. Conclusions: This is the first systematic review on SILL including prospective trials. The results of the existing studies reporting on SILL are favorable. However, a large body of scientific evidence on the field of SILL is missing, further randomized controlled studies are urgently needed.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (Notes): Surgical Technique and Results

In recent decades, surgical specialties have experienced numerous changes and developments, and minimally invasive surgical techniques have been adopted to reduce patient morbidity (Branco et al., 2008a). Laparoscopy has a well-established role in the modern era of surgery. Despite the difficulties in terms of learning curve early in the clinical implementation of this method, almost all surgical specialties have adopted the minimally invasive surgical approach as the gold standard. This results in less postoperative pain, shorter hospital stay, faster recovery and better aesthetic results (Jin et al., 2009; Keus et al., 2010; Kondo et al., 2006). Recently, a new minimally invasive surgical approach has been increasingly described in the literature as NOTES (Natural Orifice Transluminal Endoscopic Surgery). This is an access to the abdominal cavity without any incisions in the abdominal wall (scarless surgery), and the natural orifices serve as the gateway to the peritoneal cavity. Thus, an endoscope is inserted into the abdominal cavity through the stomach, vagina, bladder or colon (de la Fuente et al., 2007). The first report of this surgical technique was described by Gettman et al. (2002), at The University of Texas in 2002, which demonstrated that transvaginal nephrectomy in an experimental animal model was feasible. Two years later, Kalloo et al. (2004) performed transgastric liver biopsies at the Johns Hopkins University. After these initial reports, several researchers have demonstrated the safety of the transgastric access to perform tubal ligation (Jagannath et al., 2005), cholecystectomy (Park et al., 2005), gastrojejunostomy (Kantsevoy et al., 2005), subtotal hysterectomy with oophorectomy (Wagh et al, 2005; Wagh et al, 2006), splenectomy (Kantsevoy et al., 2006), gastric bypass (Kantsevoy et al., 2007), nephrectomy (Lima et al., 2007) and pancreatectomy (Matthes et al., 2007), all based on experimental studies in the porcine model. Since 2007, reports of cholecystectomy (Branco Filho et al., 2007; Marescaux et al., 2007; Zorron et al., 2007), nephrectomy (Branco et al., 2008b) and tubal ligation (Kondo et al., 2009)

Single-Access Gastrostomy (SAG) Dispenses Endoscopy or Laparoscopy: A Simple Method Under Local Anesthesia:

Objective. Gastrostomy for feeding or desobstructive purposes is often performed transendoscopically. However, as endoscopy specialists and instruments are not widely available in community hospitals in Brazil, an alternative method was developed at the authors’ institution. Surgical single-access gastrostomy (SAG), performed under local anesthesia and requiring no endoscopic guidance is described. Methods. The authors used the SAG technique on 19 patients eligible for gastrostomy, and the data were prospectively documented. After local anesthesia and a 1-cm incision, the gastric wall was localized under direct vision. Purse string sutures were placed to work as a fixed valve to rectus sheath. Results. SAG was feasible in all patients. Minor complications occurred in 3 patients. The mean operative time was 44.2 minutes, and the mean institution of gastrostomy feeding was 27.8 hours. Conclusion. SAG may dispense with the use of endoscopy and laparoscopy, providing a feasible, reproducible, and effective feeding gastrostomy in developing countries where alternative methods are not available.

Esplenectomia vídeo-laparoscópica para púrpura trombocitopênica imune: técnica e resultados

BACKGROUND: Immune thrombocytopenic purpura (ITP) is a common indication for splenectomy. In order to evaluate the results of Laparoscopic Splenectomy, 17 patients with ITP were submitted to this procedure in a prospective study. METHODS: Using three trocars through a posterior approach and simple inabsorbable ligatures, without using hemoclips and vascular stapplers, splenectomy was carried out in a prospective series of 17 patients. RESULTS: All patients were successfully managed laparoscopically, with no conversion to open surgery. Complications ocurred in three patients: one wound haematoma, one residual splenic tissue requiring reoperation, and one pancreatic pseudocyst that was treated by conservative measures. An additional fourth trocar was needed in four patients. Mean operative time was 132.9min, mean postoperative stay was 2.53 days. Intraoperative platelet transfusion was needed in two patients (11.8%) and accessory spleen was detected in four (23.5%). Favourable sustained response to splenectomy was obtained in 13 patients (76.5%), with partial or no response in four (23.5%). CONCLUSION: Careful anatomical dissection technique and search for accessory tissue is needed to avoid splenosis and therapy failure. Detection of accessory spleens by this method is precise and reliable. Patients with PTI have the same remission rates of open surgery, with less complications and shortened postoperative stay. The results suggest that Laparoscopic Splenectomy is effective and safe, and has become the golden standard for the treatment of ITP with surgical indication.