Wolfram Lamadé

Triluminal Hybrid NOS as a Novel Approach for Colonic Resection With Colorectal Anastomosis

Background: Minimal invasive surgery has led to a significant decrease in surgical trauma, pain, recovery time and improved cosmesis compared with open surgery. However, scar development and the risk of hot spots for infections and hernias are still present. Natural orifice surgery (NOS) promises to offer even further reduction in invasiveness and thus may lead to even faster recovery. The goal of this study was to establish a NOS colonic resection by using commercially available standard surgical instruments avoiding major abdominal incisions. Methods and Results: This article reports a new triluminal hybrid NOS approach for sigmoid and colonic resection (Tri-Port-NOS-SIG), established using rigid laparoscopic instruments through the umbilicus, the vagina, and the rectum, without any major abdominal incision. The specimen was retrieved through the anus avoiding dilatation of the vagina. In an early series of 5 patients the first patient was a 37-year-old woman with a 10-year history of recurrent diverticulitis. She recovered quickly and was discharged on postoperative day 2. She returned to sports activity on day 12 postoperatively and to her heavy-duty job on day 16. The following 4 patients also recovered well and were discharged on postoperative days 7 (2 patients), 8, and 11, respectively. One patient experienced a temporary, mild paresthesia of the left lower dorsal leg, most likely because of intraoperative positioning. No major complications occurred. Conclusion: Tri-Port-NOS-SIG offers a feasible scarless approach for abdominal resections using commercially available surgical instruments in experienced hands.

Impact of body image on patients’ attitude towards conventional, minimal invasive, and natural orifice surgery

PurposeA series of investigations proposed that patients’ preference on minimal invasive and scarless surgery may be influenced by age, sex, and surgical as well as endoscopic history of the individual patient. However, it is unknown which psychological criteria lead to the acceptance of increased personal surgical risk or increased personal expenses in patients demanding scarless operations. We investigated whether individual body image contributes to the patient’s readiness to assume higher risk in favor of potentially increased cosmesis.Materials and methodsWe conducted a nonrandomized survey among 63 consecutive surgical patients after receiving surgery. Individual body image perception was assessed postoperatively applying the FKB-20 questionnaire extended by four additional items. The FKB-20 questionnaire is a validated tool for measuring body image disturbances resulting in a two-dimensional score with negative body image (NBI) and vital body dynamics (VBD) being the two resulting scores. A subgroup analysis was performed according to the conducted operations: conventional open surgery = group 1, traditional laparoscopic surgery = group 2, and no scar surgery = group 3.ResultsThere was a significant correlation between a negative body image and the preference for scar sparing and scarless surgery indicated by a significantly increased acceptance of surgical risks and the willingness to spend additional money for receiving scarless surgery (ru2009=u20090.333; pu2009=u20090.0227). Allocated to operation subgroups, 17 of 63 patients belonged to group 1 (OS), 29 to group 2 (minimally invasive surgery), and 17 patients to group 3 (no scar). Although age and sex were unequally distributed, the groups were homogenous regarding body mass index and body image (NBI). Subgroup analysis revealed that postoperative desire for scar sparing approaches was most frequently expressed by patients who received no scar operations.ConclusionsPatients with an NBI tend towards scarless surgery and are willing to accept increased operative risk and to spend additional money for improved postoperative cosmesis.

Pure NOTES sigmoid resection in an animal survival model.

INTRODUCTIONnThe potential to use single-site transluminal access to perform major surgical procedures is limited. In the current study, a pure natural orifice transluminal endoscopic surgery (NOTES) technique was developed for sigmoid resection, with combined transgastric and transvaginal access to the abdominal cavity and assisted by colonoscopy.nnnMETHODSnThis experimental study was conducted on a porcine model. Transgastric access was achieved by needle-knife incision and balloon dilation. Colonoscopy was used to maneuver the colon and expose the colic mesentery. Mesocolic dissection close to the bowel was carried out gastroscopically using a coagulating forceps. To prepare the anastomosis, a circular stapler anvil was introduced endoluminally. Subsequently, sigmoid resection was performed using a roticulating linear stapler inserted transvaginally. Bowel extraction was performed by invagination transrectally. After extracorporeal distal linear stapling of the sigmoid, colorectal anastomosis was completed by application of a circular stapling device transrectally. Gastric access closure was achieved using the over-the-scope clipping system (OTSC).nnnRESULTSnThe procedure was successful in all animals, with the operation time ranging from 150 to 270 minutes. The first animal died at postoperative day 5 from peritonitis due to an infected hematoma following spleen injury by an observation trocar. All other animals gained weight postoperatively. Animals were sacrificed after postoperative day 35.u200aThe work-up showed complete anastomotic healing and healed gastric closure. The OTSC clip was still in situ in all animals.nnnCONCLUSIONnThe presented study shows that pure NOTES resection and anastomosis of the large bowel are feasible. Intraluminal organ manipulation provided excellent organ exposition and rendered one additional access site unnecessary. Transgastric preparation was shown to be safe and effective.

Signalstabilität als Grundvoraussetzung für kontinuierliches intraoperatives Neuromonitoring

ZusammenfassungHintergrundOperationsbedingte Paresen des Nervus laryngeus recurrens (NLR) sind nach wie vor eine gefürchtete Komplikation bei Schilddrüsenoperationen. Das kontinuierliche intraoperative Neuromonitoring (CIONM) wurde daher mit dem Ziel entwickelt, eine effektive Echtzeitüberwachung des NLR über seinen gesamten anatomischen Verlauf zu gewährleisten und auch geringgradige Leitfähigkeitsänderungen zu erfassen. Grundvoraussetzung für die zuverlässige Interpretation des CIONM ist die Signalstabilität.Patienten und MethodeIn einer prospektiv randomisierten Pilotstudie an 24 Patienten, entsprechend 30 „nerves at risk“ (NaR), wurde eine neu entwickelte, saxophonförmige Vagusstimulationselektrode (16xa0NaR) mit einer kommerziell erhältlichen Elektrode (14xa0NaR) verglichen. Als systemkritische Eigenschaften wurden Applizierbarkeit, Anwendungssicherheit und Signalstabilität untersucht. Dazu wurden Elektrodenimplantationszeiten, Stimulationsstromstärken, EMG-Amplituden und Elektrodendislokationsraten analysiert.ErgebnisseDie Saxophonelektrode erlaubte eine schnellere Platzierung sowie eine einfachere Extraktion als die zylindrische Elektrode. Akzidentelle Elektrodendislokationen traten bei Verwendung der zylindrischen Elektrode bis zu 8-mal pro Operation auf, während die Saxophonelektrode während der gesamten Studie nur 2-mal dislozierte. Die zur supramaximalen NLR-Stimulation notwendigen Stromstärken waren signifikant geringer unter Verwendung der Saxophonelektrode. Gleichzeitig wurden im Gegensatz zur zylindrischen Elektrode signifikant höhere, stabile EMG-Amplituden erreicht. Postoperative Rekurrensschädigungen traten im Rahmen der Studie nicht auf.SchlussfolgerungDie für ein CIONM notwendige Signalstabilität konnte in unseren Untersuchungen nur durch Einsatz der Saxophonelektrode erreicht werden. Ein geschlossenes Design, wie bei der getesteten Saxophonelektrode mit isolierten Stimulationskontakten und definierten Stromeintrittspunkten am Nerven ist nach den vorliegenden Ergebnissen Grundvoraussetzung für ein kontinuierliches intraoperatives Neuromonitoring.AbstractBackgroundPostoperative recurrent laryngeal nerve (RLN) palsy is a well-known and dreaded complication of thyroid surgery. Continuous intraoperative neuromonitoring (CIONM) has been developed in order to provide an effective real-time surveillance of the RLN to its full extent and to detect subtle changes in nerve conductivity. A key requirement for a reliable interpretation of CIONM is signal stability.Patients and methodsIn a prospective randomized controlled pilot study 24 patients corresponding to 30 nerves at risk (NaR) were included to compare a newly developed, flexible, saxophone-shaped backstrap electrode for vagal stimulation (16xa0NaR) to a commercially available CE-marked cylindrical and rigid electrode (14xa0NaR). Electrode applicability, safety and signal stability were analyzed by assessment of electrode implantation times, stimulation currents, EMG amplitudes and electrode displacement rates.ResultsImplantation and extraction was significantly faster and easier with the saxophone-shaped backstrap electrode. Accidental electrode displacement occurred up to eight times per operation when applying the cylindrical electrode, while a total of two displacements resulted using the backstrap electrode in this study. Stimulation currents necessary for supramaximal RLN stimulation were significantly lower using the newly developed electrode. At the same time, significantly greater stable EMG amplitudes resulted using the new saxophone-shaped electrode. No RLN palsy occurred during the study.ConclusionsAccording to the data, only the saxophone-shaped backstrap electrode provided the signal stability required for CIONM. The closed electrode geometry with isolated contacts for nerve stimulation and defined current entry provide the prerequisites required for reliable continuous intraoperative neuromonitoring.BACKGROUNDnPostoperative recurrent laryngeal nerve (RLN) palsy is a well-known and dreaded complication of thyroid surgery. Continuous intraoperative neuromonitoring (CIONM) has been developed in order to provide an effective real-time surveillance of the RLN to its full extent and to detect subtle changes in nerve conductivity. A key requirement for a reliable interpretation of CIONM is signal stability.nnnPATIENTS AND METHODSnIn a prospective randomized controlled pilot study 24 patients corresponding to 30 nerves at risk (NaR) were included to compare a newly developed, flexible, saxophone-shaped backstrap electrode for vagal stimulation (16 NaR) to a commercially available CE-marked cylindrical and rigid electrode (14 NaR). Electrode applicability, safety and signal stability were analyzed by assessment of electrode implantation times, stimulation currents, EMG amplitudes and electrode displacement rates.nnnRESULTSnImplantation and extraction was significantly faster and easier with the saxophone-shaped backstrap electrode. Accidental electrode displacement occurred up to eight times per operation when applying the cylindrical electrode, while a total of two displacements resulted using the backstrap electrode in this study. Stimulation currents necessary for supramaximal RLN stimulation were significantly lower using the newly developed electrode. At the same time, significantly greater stable EMG amplitudes resulted using the new saxophone-shaped electrode. No RLN palsy occurred during the study.nnnCONCLUSIONSnAccording to the data, only the saxophone-shaped backstrap electrode provided the signal stability required for CIONM. The closed electrode geometry with isolated contacts for nerve stimulation and defined current entry provide the prerequisites required for reliable continuous intraoperative neuromonitoring.

Trilumenal Hybrid-NOS Proctocolectomy

Background. The authors hypothesized that by combining transumbilical, transvaginal, and transrectal accesses, complex bowel operations, including proctocolectomy with restorative jejunal pouch reconstruction, might be possible. Methods and Results. Out of a series of 30 natural orifice surgery (NOS) operations performed at the authors’ institution in the past 12 months, proctocolectomy with ileoanal pouch reconstruction was planned for 3 female patients (31 years, BMI = 30; 50 years, BMI = 31; 30 years, BMI = 21) with extensive disease of ulcerative colitis, and they were operated via a 3-lumenal NOS approach. The first 2 patients received a proctocolectomy with a J-pouch formation. A 3-stage procedure was planned for the third patient, and she received a total colectomy. The colonic specimen was retrieved through the anus obviating dilation of the vagina. The J-pouch was prepared through a horizontal 2-cm incision, which later served as the protective loop ileostomy site. Conclusion . Trilumenal NOS proctocolectomy is feasible and safe providing a solution to overcome the lack of triangulation using a single-lumen approach.

Snake charmer NOTES - a two-luminal access for hybrid NOS operations

Abstract Despite recent advances in NOTES, NOS, SILS and related techniques, the feasibility of performing extensive surgery is still limited. Colon surgery usually requires additional access sites or complex technical means for triangulation and retraction. A method is presented that enables single-port colon surgery, supported by flexible colonoscopy. Single-port sigmoidectomy was performed in five cases on the porcine model. Flexible colonoscopy was used to manoeuvre the colon and expose its mesentery for dissection. The specimen was retrieved transrectally by invagination. Single-port sigmoidectomy supported by colonoscopy was feasible in all cases. The method provided a fixed framework, excellent organ guidance and exposition of the mesentery and enabled bowel-close mesocolic preparation. The access angle for preparation and visualisation could be altered during the procedure using the colonoscope. During autopsy on day 21, competent anastomotic healing with only rare interenteric adhesions was observed. One animal had a small preperitoneal abscess in the umbilical region while demonstrating completed skin healing. Flexible colonoscopy provided a fixed reference frame that enabled single-port preparation and dissection of the sigmoid colon. Under colonoscopic guidance, the access angle for dissection could be adapted according to the surgeons needs. The procedures could be performed safely and effectively.

Signal stability as key requirement for continuous intraoperative neuromonitoring

ZusammenfassungHintergrundOperationsbedingte Paresen des Nervus laryngeus recurrens (NLR) sind nach wie vor eine gefürchtete Komplikation bei Schilddrüsenoperationen. Das kontinuierliche intraoperative Neuromonitoring (CIONM) wurde daher mit dem Ziel entwickelt, eine effektive Echtzeitüberwachung des NLR über seinen gesamten anatomischen Verlauf zu gewährleisten und auch geringgradige Leitfähigkeitsänderungen zu erfassen. Grundvoraussetzung für die zuverlässige Interpretation des CIONM ist die Signalstabilität.Patienten und MethodeIn einer prospektiv randomisierten Pilotstudie an 24 Patienten, entsprechend 30 „nerves at risk“ (NaR), wurde eine neu entwickelte, saxophonförmige Vagusstimulationselektrode (16xa0NaR) mit einer kommerziell erhältlichen Elektrode (14xa0NaR) verglichen. Als systemkritische Eigenschaften wurden Applizierbarkeit, Anwendungssicherheit und Signalstabilität untersucht. Dazu wurden Elektrodenimplantationszeiten, Stimulationsstromstärken, EMG-Amplituden und Elektrodendislokationsraten analysiert.ErgebnisseDie Saxophonelektrode erlaubte eine schnellere Platzierung sowie eine einfachere Extraktion als die zylindrische Elektrode. Akzidentelle Elektrodendislokationen traten bei Verwendung der zylindrischen Elektrode bis zu 8-mal pro Operation auf, während die Saxophonelektrode während der gesamten Studie nur 2-mal dislozierte. Die zur supramaximalen NLR-Stimulation notwendigen Stromstärken waren signifikant geringer unter Verwendung der Saxophonelektrode. Gleichzeitig wurden im Gegensatz zur zylindrischen Elektrode signifikant höhere, stabile EMG-Amplituden erreicht. Postoperative Rekurrensschädigungen traten im Rahmen der Studie nicht auf.SchlussfolgerungDie für ein CIONM notwendige Signalstabilität konnte in unseren Untersuchungen nur durch Einsatz der Saxophonelektrode erreicht werden. Ein geschlossenes Design, wie bei der getesteten Saxophonelektrode mit isolierten Stimulationskontakten und definierten Stromeintrittspunkten am Nerven ist nach den vorliegenden Ergebnissen Grundvoraussetzung für ein kontinuierliches intraoperatives Neuromonitoring.AbstractBackgroundPostoperative recurrent laryngeal nerve (RLN) palsy is a well-known and dreaded complication of thyroid surgery. Continuous intraoperative neuromonitoring (CIONM) has been developed in order to provide an effective real-time surveillance of the RLN to its full extent and to detect subtle changes in nerve conductivity. A key requirement for a reliable interpretation of CIONM is signal stability.Patients and methodsIn a prospective randomized controlled pilot study 24 patients corresponding to 30 nerves at risk (NaR) were included to compare a newly developed, flexible, saxophone-shaped backstrap electrode for vagal stimulation (16xa0NaR) to a commercially available CE-marked cylindrical and rigid electrode (14xa0NaR). Electrode applicability, safety and signal stability were analyzed by assessment of electrode implantation times, stimulation currents, EMG amplitudes and electrode displacement rates.ResultsImplantation and extraction was significantly faster and easier with the saxophone-shaped backstrap electrode. Accidental electrode displacement occurred up to eight times per operation when applying the cylindrical electrode, while a total of two displacements resulted using the backstrap electrode in this study. Stimulation currents necessary for supramaximal RLN stimulation were significantly lower using the newly developed electrode. At the same time, significantly greater stable EMG amplitudes resulted using the new saxophone-shaped electrode. No RLN palsy occurred during the study.ConclusionsAccording to the data, only the saxophone-shaped backstrap electrode provided the signal stability required for CIONM. The closed electrode geometry with isolated contacts for nerve stimulation and defined current entry provide the prerequisites required for reliable continuous intraoperative neuromonitoring.BACKGROUNDnPostoperative recurrent laryngeal nerve (RLN) palsy is a well-known and dreaded complication of thyroid surgery. Continuous intraoperative neuromonitoring (CIONM) has been developed in order to provide an effective real-time surveillance of the RLN to its full extent and to detect subtle changes in nerve conductivity. A key requirement for a reliable interpretation of CIONM is signal stability.nnnPATIENTS AND METHODSnIn a prospective randomized controlled pilot study 24 patients corresponding to 30 nerves at risk (NaR) were included to compare a newly developed, flexible, saxophone-shaped backstrap electrode for vagal stimulation (16 NaR) to a commercially available CE-marked cylindrical and rigid electrode (14 NaR). Electrode applicability, safety and signal stability were analyzed by assessment of electrode implantation times, stimulation currents, EMG amplitudes and electrode displacement rates.nnnRESULTSnImplantation and extraction was significantly faster and easier with the saxophone-shaped backstrap electrode. Accidental electrode displacement occurred up to eight times per operation when applying the cylindrical electrode, while a total of two displacements resulted using the backstrap electrode in this study. Stimulation currents necessary for supramaximal RLN stimulation were significantly lower using the newly developed electrode. At the same time, significantly greater stable EMG amplitudes resulted using the new saxophone-shaped electrode. No RLN palsy occurred during the study.nnnCONCLUSIONSnAccording to the data, only the saxophone-shaped backstrap electrode provided the signal stability required for CIONM. The closed electrode geometry with isolated contacts for nerve stimulation and defined current entry provide the prerequisites required for reliable continuous intraoperative neuromonitoring.

[Snake charmer NOTES-proctocolectomy in a male patient].

Restricted ability of triangulation, a highly flexible intestine, as well as limited control and overview over the abdominal organs, complicated extensive abdominal interventions in the past. Thus, additional access sites were needed to allow sufficient interoperative control. The newly developed snake charmer NOTES-technique enables the reduction of accesses to the umbilicus and rectum. We report the first case of total proctocolectomy with ileoanal pouch formation in hybrid NOTES technique in a male patient.ZusammenfassungEingeschränkte Triangulation, begrenztes Sichtfeld sowie die Flexibilität des Darms machten große Darmeingriffe bei NOTES- („natural orifice translumenal endoscopic surgery“), Single-Port- und ähnlichen Verfahren lange Zeit unmöglich. Um die räumliche Kontrolle zu verbessern, bediente man sich daher zusätzlicher Zugänge. Diese können nun in der hier präsentierten neu entwickelten Snake-charmer-NOTES-Technik auf Nabel und Rektum beschränkt werden. Wir berichten vom ersten Fall einer Hybrid-NOTES-Proktokolektomie mit ileopouchanaler Anastomose bei einem männlichen Patienten.AbstractRestricted ability of triangulation, a highly flexible intestine, as well as limited control and overview over the abdominal organs, complicated extensive abdominal interventions in the past. Thus, additional access sites were needed to allow sufficient interoperative control. The newly developed snake charmer NOTES-technique enables the reduction of accesses to the umbilicus and rectum. We report the first case of total proctocolectomy with ileoanal pouch formation in hybrid NOTES technique in a male patient.

NOTES – internationaler Stand

Die klinische Einführung von NOTES begann nach kritischen Erfahrungen mit der unkontrollierten Einführung der laparoskopischen Chirurgie Anfang der 1990er Jahre zunächst zögerlich. Flexible endoskopische Eingriffe in der Bauchhöhle wurden bisher auch international nur in geringer Fallzahl durchgeführt, da das notwendige Instrumentarium und entsprechende Erfahrung fehlten. In den letzten Monaten ist jedoch ein klarer Fortschritt erkennbar. Parallel wurde die ‘Single Port Laparoscopic Surgery’ kombiniert transvaginal und transumbilikal oder geschlechtsunabhängig nur über den Nabel, insbesondere in Deutschland vorangetrieben, sodass in Kürze die Zahl von 1000 Eingriffen überschritten sein wird. In der vorliegenden Arbeit werden internationale Zahlen aus der Literatur und präliminär im Rahmen von Präsentationen bei internationalen Kongressen veröffentlichte Daten aufgeführt.

Sashimi NOTES - extraction of bulky specimens in no-scar operations

Abstract A major obstacle in no-scar surgery is the extraction of large, bulky or rigid specimen. Thus, a method is needed that allows for extraction of large specimens without situs contamination in women and men. It should enable safe treatment of infectious or malignant disease while preserving pathologic workup. Five patients suffering from diverticulitis with expected bulky and rigid specimen were enrolled into this early series. Preparation was performed transumbilically in single-port technique. To prevent new scar formation, the incision was limited to the base of the umbilicus without extension onto the sound abdominal skin. A functionally and topologically extracorporeal compartment was created within the abdomen by introduction and insufflation of a tear-proof impermeable retrieval bag. The specimen was sliced in a controlled fashion inside the compartment along a pre-marked geometry. Controlled specimen dissection in a dedicated intraabdominal resection compartment was feasible. The dissected specimen could be retrieved through the 1.5 cm umbilical incision without spillage of material. The geometry of the extracted organ was reconstructed in detail allowing for uncompromised pathological workup. Extraction of bulky and rigid specimen is possible through natural orifices by the proposed controlled dissection method enabling the pathologist to reconstruct anatomical affiliation.