Thinking Outside the Box

NOTES: Gathering momentum

To report the first case and detailed technique of laparoendoscopic single-site (LESS) surgery simple prostatectomy for benign hypertrophy.

A 67-year-old man presented with acute urinary retention requiring catheterization. Serum prostate-specific antigen level was 5 ng/mL, and a biopsy revealed benign hypertrophy with a transrectal ultrasound volume estimation of 110 mL. LESS simple prostatectomy was performed using a single multilumen port inserted through a solitary 2.5-cm intraumbilical incision. Standard laparoscopic ultrasonic shears and needle drivers, articulating scissors, and specifically designed bent grasping instruments facilitated dissection and suturing.

An R-port was placed intraperitoneally through a 2.5-cm intraumbilical incision. No extraumbilical skin incisions were made. Total operative time was 120 minutes and estimated blood loss was 200 mL. A closed suction drain was externalized through the umbilical incision. No intraoperative or postoperative complications occurred. Hospital stay was 2 days, the retropubic drain was removed at 3 days, and the catheter removed at 1 week. Specimen weight was 95 g and final pathology revealed benign prostatic hyperplasia. At 3 months follow-up, the patient was completely continent and voiding spontaneously with a Q_max. of 85 mL/s.

We demonstrate technical feasibility and describe the detailed surgical technique of LESS simple prostatectomy. Our initial experience suggests that this technique may be an alternative for large-volume benign prostatic hyperplasia in lieu of open surgery. Comparative studies with other surgical techniques will determine its place in the surgical armamentarium of benign prostatic hyperplasia.

The Direct Drive Endoscopic System (DDES) is a multitasking platform developed to overcome the limitations of the currently available rigid and flexible endoscopic systems in application to natural orifice transluminal endoscopic surgery (NOTES), single-port laparoscopy, and advanced endoluminal procedures. The system consists of a 3-channel, steerable guide sheath accepting a 6-mm endoscope and two 4-mm articulating instruments. The system's overall design enables the interventionalist to operate instruments bimanually from a stable platform, conveying a laparoscopic paradigm to the functional working space at the distal end of the flexible guide sheath.

To assess the basic functionality of the DDES device in a series of defined exercises by using ex vivo porcine stomachs and 1 in vivo animal model.

Ex vivo calibration and training exercises, including EMR, full-thickness suturing, and knot tying.

Animal laboratory.

EMR, full-thickness suturing, and knot tying.

Successful completion of specified tasks.

Independent instrument movement with a wide range of motion allowed the interventionalist to perform several complex tasks efficiently. The DDES was able to (1) grasp tissue and hold it under tension, (2) cut through layers of porcine stomach in a controlled fashion, (3) suture, and (4) tie knots.

Ex vivo study.

This novel multitasking platform demonstrated surgical functionality including triangulation, cutting, grasping, suturing, and knot tying. Preliminary results suggest that the DDES can perform complex endosurgical tasks that have traditionally been challenging or impossible with the standard endoscopic paradigm, and may enable NOTES, single-port laparoscopy, and complex endoluminal procedures.

Presentar nuestra experiencia inicial en LESS Surgery (Laparo-Endoscopic Single Site Surgery/Cirugía laparoendoscópica por acceso único), mediante uso de dispositivo multicanal, instrumentos estándar, articulables y otros adaptados para la consecución de los procedimientos.

Entre febrero y septiembre del 2008 se realizaron 28 procedimientos quirúrgicos LESS con puerto multicanal: prostatectomía simple transumbilical (PSTU) y transvesical (PSTV), nefrectomía simple (NS), enterocistoplastia de aumento (ECA) e histerectomía simple (HS). Los datos clínicos fueron recopilados de manera prospectiva y analizados retrospectivamente. Se utilizó dispositivo de acceso multicanal (R-Port). Los procedimientos fueron realizados en un centro por un solo cirujano (RS). La técnica quirúrgica empleada correspondió a la misma utilizada por vía laparoscópica convencional.

Se realizaron 28 intervenciones quirúrgicas: PSTU(01), PSTV(20), NS(01), ECA(01), HS(05). La incisión de acceso fue realizada a nivel umbilical o infraumbilical. Solo un caso (nefrectomía) ameritó uso de trocar adicional de 2 mm. La edad media en años por procedimiento fue: PSTU, 67; PSTV, 68 (57–89); NS, 12; ECA, 20; HS, 46.4 (41–54). El tiempo quirúrgico medio en minutos fue: PSTU, 120; PSTV, 91 (45–210); NS, 120; ECA, 300; HS, 112 (90–160). El sangrado operatorio fue: PSTU, 200cc; PSTV, 337 cc (50-1500); NS, 100cc; EAC, 100cc; HS, 118cc. (100–160). La complicación observada fue hematuria profusa en dos casos de PSTV, ambos pacientes requirieron exploración postoperatoria con evolución satisfactoria.

LESS es una alternativa factible y reproducible en patología uroginecológica de resolución quirúrgica. Mayores estudios, experiencias y seguimiento permitirán la evaluación objetiva de esta técnica.

We present our initial experience in laparo-endoscopic single site (LESS) surgery, through multichannel port, articulated instruments and standard instruments adapted others adapted for the procedures.

Between February and October 2008, 28 LESS surgical procedures with multi-port were performed (Transumbilical simple prostatectomy (PSTU) and transvesical (PSTV), simple nephrectomy (NS), Enterocystoplasty augmentation (ECA) and simple hysterectomy (HS)). The clinical data were collected prospectively and analyzed retrospectively. Was used access device Multichannel (R-Port). The procedures were performed for a single surgeon (RS). The surgical technique was the same route used by conventional laparoscopic.

Twenty-eight surgeries were performed: PSTU (01), PSTV (20), NS (01), ECA (01), HS (05). The incision was performed umbilical or infraumbilical. Only one case (nephrectomy) needed it placement of an additional trocar. The average age by procedure was PSTU and PSTV, 67 and 68 year-old (57-89 y) respectively; NS 12 year-old; RCT 20 year-old; HS 46.4 year-old (41 – 54 y). The operative time was: PSTU 120 minutes, PSTV 91 minutes (45-210 min); NS 120 minutes; RCT 300 minutes; HS 112 minutes(90-160 min). The operative bleeding was PSTU and PSTV 200 cc. and 337 cc (50-1500 cc) respectively; NS 100cc; EAC 100 cc; HS 118 cc (100-160 cc). The complication was haematury in two cases of PSTV, both patients required exploration postoperative endoscopic with satisfactory evolution.

LESS is a feasible and reproducible surgical option in uro-gynecologic surgical treatment. Further studies, experience and follow-up will provide an objective assessment of the technique.

Multiple studies have demonstrated the feasibility of natural orifice transluminal endoscopic surgery in animal models.

To determine the feasibility of transgastric peritoneoscopy and liver biopsy in human beings.

Our institutional review board approved the procedures in the operating room with the patients under general anesthesia.

During laparoscopic gastric bypass surgery a flexible endoscope was introduced into the peritoneal cavity through the gastric-wall incision. A peritoneoscopy with a liver biopsy was performed, then the flexible endoscope was withdrawn into the stomach, and gastric bypass surgery was completed laparoscopically.

Three patients who were morbidly obese (mean weight 115.22 ± 9.07 kg [254 ± 20 lb]).

The ability to navigate a flexible endoscope inside the peritoneal cavity, to visualize the intra-abdominal organs, and to perform a liver biopsy without laparoscopic assistance.

It was very easy to navigate the flexible endoscope inside the abdomen by using torque, advancement, and withdrawal of the endoscopic shaft, as well as by movement of the endoscope tip. The flexible endoscope provided an excellent view and adequate illumination of the peritoneal cavity. The orientation of the flexible endoscope inside the peritoneal cavity was technically easy, even in the retroflex position. Systematic visualization of the liver, the spleen, the omentum, and the small and large intestine was easily achieved through the flexible endoscope without laparoscopic assistance. A liver biopsy was successfully completed in all cases by obtaining adequate tissue samples for histologic examination.

This was a pilot feasibility study.

Transgastric flexible endoscopic peritoneoscopy in human beings is technically feasible, simple, and can become a valuable tool that complements and facilitates laparoscopic interventions inside the peritoneal cavity.

Human natural orifice translumenal endoscopic surgery (NOTES) is already being reported from numerous centers, and the results seem promising. There are key issues to be addressed and benefits over traditional safe procedures need to be demonstrated. Interestingly, however, human NOTES seem to be progressing at a fast pace compared with the evolution of surgical procedures or techniques described previously. This article examines the current status of NOTES in humans, the challenges, and the implications on the future of minimal access surgery.

Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about the field. Such is the case of natural orifice transluminal endoscopic surgery (NOTES). NOTES has yet to prove its value in patients. However, having challenged one of the most fundamental and deeply entrenched dogmas in surgery and endoscopy, many of us feel that “we will never be the same again.” In this article I will discuss the implications of this paradigm shift and suggest strategies for both gastroenterologists and surgeons that will allow us to test its full potential.