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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_605_Библиотеки_им_академика_М_И_Перельмана.pdf
364
Biomedical Engineering in Gastrointestinal Surgery
Ontheotherhand,thecomparativelylongdistancebetweenthe
mouth and the stomach enables indirect manipulations only. Even if
the endoscope is more or less sterile, it has to pass the mouth and the
hypopharynx and may be contaminated with these highly contamina ted
areas.
One major issue is to find an appropriate entrance point which is
both suitable for the surgery considered and safe. The stomach is covered
by the left liver lobes, flanked by the spleen, liver, and colon, and is positioned above the pancreas.
Kantsevoy modified the percutaneous endoscopic ga strostomy
(PEG) technique to gain safe access to the abdominal cavity
(
Fig. 9.10) for NOTES. The puncture site is enlarged using a
Figure 9.10 Technique of percutaneous endoscopic gastrostomy (PEG)-based creation of a transgastric approach into the abdomen. (A) Endoscopic view of the stomach: The anterior wall is illuminated. The light can be seen from the outside
(diaphanoscopy). (B) External puncture on the stomach. A needle is inserted through
the skin, the abdominal and anterior gastric wall into the lumen of the stomach.
(C) Guidewire insertion through the puncture site. (D) The guidewire is used to
deploy a traction papillotome to enlarge the puncture site. Courtesy: Prof. Dr. S. v.
Delius, Klinikum rechts der Isar.
Combined Laparoscopic-Endoscopic Procedures and NOTES
Figure 9.11 (A) Veress needle to create a pneumoperitoneum. (B) As soon as the
pneumoperitoneum is created, an incision can be made into the anterior gastric wall
using the needle knife without too much risk. (C) The incision is enlarged by balloon
dilatation.
365
papillotome (see Chapter 8: Inter ventional Flexible Endoscopy).
Alternatively, the puncture site can be enlarged by dilatation using a
balloon catheter.
This enlarged incision of the PEG technique serves as the access point
of the endoscope into the abdominal cavity
[13].
The Pneumoperitoneum Technique
An alternative technique is to establish a pneumoperitoneum first to
create a certain anterior gastric wall (
Fig. 9.11). Under normal circum-
stances, the middle part of the anterior gastric wall is not covered by adjacent tissue.
The pneumoperitoneum technique can be helpful if the instillation of
disinfectant fluids is additionally considered.
The Tunneling Technique
One major concern when using an interior entry point for NOTES is
a safe closure of the incision once the intervention has been finished. The
submucosal tunneling technique was developed to provide a valve-like
mechanism to close the stomach (
Fig. 9.12).
Various different techniques including endosonography have been
tried out experimentally but uptonow,nostandardprocedure
exists.
9.2.1.2 Transurethral Approach
Among the various natural openings of the human anatomy, the urethra/
urinary bladder is the only one which is (under regular circumstances)
free of bacterial contamination. Insofar, the transurethral would be the
366
Biomedical Engineering in Gastrointestinal Surgery
Figure 9.12 Submucosal tunneling method: After withdrawal of the instrument, the
submucosal tunnel collapses and seals the transmuscular hole. (A) Saline injected
into the submucosa. (B) Needle knife mucosal/submucosal puncture. (C) Creation of
submucosal space by blunt dissection and/or balloon dilation. (D) Off-site needle
knife penetration of the muscularis propria with subsequent entry into the peritoneum. (E) Offset closure of muscular defect with overlying mucosal flap. From Moyer
MT, Haluck RS, Gopal J, Pauli EM, Mathew A. Transgastric organ resection solely with
the prototype R-scope and the self-approximating transluminal access technique.
Gastrointest Endosc 2010;72(1):1706
[14].
Combined Laparoscopic-Endoscopic Procedures and NOTES
Figure 9.13 Male (left) and female (right) genitourinary anatomy: The long, S-shaped
male urethra permits the introduction of rigid instruments, but it is very difficult to
position it adequately to get a suitable puncture site. Flexible endoscopes are preferable. The female urethra is shorter, but the sphincter even more sensitive to overdistension. All from M. Scholle.
367
ideal approach (Fig. 9.13). Moreover, the incision of the bladder wall can
be easily and safely closed
[15].
The main drawback is that only small bore instruments (# 5mm in
diameter) can be used. If large bore instruments are applied, the risk is high
to overstretch the internal vesical sphincter resulting in urinary incontinence.
Schneider et al. developed a specially coated set of bougies which
allows for a successful bougienage of the urethra up to 36 French
(12 mm) without any harm to the sphincter (
Fig. 9.14A,B).
In male patients, flexible endoscopes are mandatory since it is impossible
to leav e the urinary bladder in an adequate angle for NOTES interventions
with a rigid telescope. Though currently of minor importance the transurethral approach could potentially gain importance as an auxiliary access
[16].
9.2.1.3 Transvaginal Approach
Transvaginal surgery is well-established in gynecology since many decades.
The vagina can easily be decontaminated. Even large bore instruments can be
inserted without any problems and wound closure is easy and safe (
Fig. 9.15).
Most NOTES cholecystectomies are perfor med via this route. Either
rig id or flexible scopes are in use. Though the complication rate is very
low
[17], many—in particular young—patients are not inclined to accept
this special type of approach. Vice versa, surgeons are often concerned
about long-term—real or pretended—side effects like dyspareunia due to
scar formation, etc.
However, this access is only available in 50% of the patients.
368
Biomedical Engineering in Gastrointestinal Surgery
Figure 9.14 (A) A set of specially designed bougies for the sphincter of the urinary
bladder: A guide wire is inserted into the abdominal cavity through the urinary bladder wall (A). The rigid (or even flexible) bougies are applied in an ascending line (B)
until finally the trocar (C) can be introduced over the bougies. (B) Sphincter manometry before, during, and 15 minutes after bougienage. Note the rapid recovery of the
resting pressure after the interval of 15 minutes. From Schneider A. Application tech-
nique for an innovative antireflux device using Natural Orifice Translulminal Endoscopic
Surgery (NOTES). Doctoral Thesis, Technical University of Munich; 2010.
9.2.1.4 Transcolonic Approach
In the early days of NOTES, the idea to use the rectosigmoid as an entry
point was not very popular. The rectum is densely contaminated with
(dangerous) bacteria and very difficult to clean. Any leakage of wound
closure leads inevitably to life-threatening peritonitis. On the other hand,
some particular advantages have to be kept in mind. If the anal sphincter
is cautiously dilated, instruments with a diameter of 3.54 cm can be
inserted safely without the risk of fecal incontinence (
Fig. 9.16).
Combined Laparoscopic-Endoscopic Procedures and NOTES
Figure 9.15 (A) Insertion of a trocar through the vagina (a view into the pelvis
through a laparoscope). (B) A view into the vagina after the procedure: The main trocar insertion site is closed with two stitches. An additional insertion site for a 5-mm
trocar is closed by another suture. All: Courtesy: Prof. C. Zornig, Israelitisches
Krankenhaus Hamburg.
369
Figure 9.16 Flexible endoscope introduced through the rectum for the removal of
the gallbladder: Most target regions can be reached straight forward. Retroflexion is
not required. From M. Scholle.
After intensive scientific studies, several dedicated overtube systems
have been developed
[18,19], resulting in a rising interest in transrectal
NOTES. Often also denounced as transanal minimally invasive surgery
(TaMIS), transrectal scarless colorectal surgeries are increasingly performed under clinical conditions.
370
Biomedical Engineering in Gastrointestinal Surgery
Figure 9.17 A new set of instruments (ISSA) designed to permit sterile sigmoid access
for transcolonic surgery: (1) part flexible obturator; (2) trocar head; (3) trocar tube; (4)
TEM obturator; (5) modified TEM cap; (6) modified rectoscope; (7) trocar port; (8)
instrument ports; and (9) optical port. From Fiolka A, Can S, Schneider A, Wilhelm D,
Feussner H. Instrumentation and surgical technique for an innovative safe sigmoid
approach for NOTES. Minim Invasive Ther Allied Technol 2008;17(6):33640.
Figure 9.18 (A) The intraabdominal fluid facilitates to identify the optimal entry site
without endangering adjacent anatomical structures. (B) The flexible endoscope is
advanced into the abdomen via the trocar. All from MITI.
Fiolka et al. developed an overtube for the transanal access with an
outer diameter of 18 mm (
Fig. 9.17). The front access is curved to avoid
collision with the promontory. To provide gas-tightness, a valve chamber
is integrated. The specially designed trocar is inserted using a modified
TEM system.
By instilling a decontaminating fluid into the abdominal cavity via a
Veress needle, an artificial ascites is created. Thus, an appropriate entry
site within the rectum can be selected using endorectal ultrasound
(
Fig. 9.18).
At the end of the procedure, the entry site can be reliably occluded
using a linear stapler under direct vision.
A similar system was recently reported
[19] which additionally
includes a balloon system to occlude the colon oralad the entry point.
Combined Laparoscopic-Endoscopic Procedures and NOTES
Figure 9.19 (A) Conventional endoscopic clips: Commonly, the mucosa is occluded
only. (B) Result after 7 days post application. All from MITI.
371
9.2.2 Intestinal Closure
Initially, endoscopic clips (see Chapter 8: Interventional Flexible
Endoscopy) were the only tools available. However, efficacy was not very
high. Both industrial companies and academic working groups strove for
better solutions. Though some progress could be achieved, the problem
of intestinal closure is not yet completely solved.
9.2.2.1 Clips
Endoscopists are familiar with the use of conventional endoscopic clips.
Application is comparatively easy (
Fig. 9.19).
However, closure of full wall defects is unreliable since only the
mucosal defect can be closed. Before the application, the edges of the
defect have to be approximated which is often impossible in the case of
larger lesions.
A big step forward is the development of the over-the-scope-clip as
described in detail in Chapter 8, Interventional Flexible Endoscopy. The
bilaterally acting forceps significantly facilitates tissue approximation.
Since NOTES incisions are comparatively short, they are well covered by
one single clip (
Fig. 9.20).
The clip will leave the gastrointestinal tract via naturales. If required,
it can easily be removed by means of a sort of endoscopic blowpipe.
Currently, the OTSC products are cleared for clinical use in the
European Union, the United States, Canada, Japan, Korea, China, and
selected other markets. Various alternative clips were designed, but none
of them have gained clinical acceptance up to now.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 9.20 The Ovesco clip occluding a NOTES entry site. Courtesy: PD Dr. D.
Wilhelm, Klinikum rechts der Isar.
9.2.2.2 Suturing Devices
Since robust and secure enterostomy closure is the “Achilles heel” of
NOTES, industry sensed that suturing might represent “a disruptive paradigm shift” in endoscopy. An explosion of innovative suturing devices
could be observed, whereas others tried to develop bimanual operating
platforms that could suture with standard surgical sutures (see
Section 9.9:
Multifunctional Endoscopes and Mechanical Platforms).
Unfortunately, none of the latter reached commercialization, but
today, at least two sut uring systems are available. They are b ased upon
two different principles. The first design is based upon the doubleanchor principle: If the two edges of a defect can be safely g ripped by
an anchor connected to a suture on each single side, they will inevitably
be approximated as soon as both sutures are knotted. The principle is
shown in
Fig. 9.21.
The second concept is more or less based upon the design of sewing
machines. A mechanically sophisticated device was presented in the short
history of NOTES (
Fig. 9.22).
The principle has been refined over the last couple of years and is
now available as the OverStitch endoscopic surgical system by Apollo
Endosurgery (
Fig. 9.23).
Combined Laparoscopic-Endoscopic Procedures and NOTES
Figure 9.21 (A) The first anchor is already positioned through the full-thickness of
the gastrointestinal wall (right side). The needle—already loaded with the second
threaded tag—targets the contralateral edge. (B) The second anchor is placed
through the whole wall. (C) The so-called thread locking device is pushed forward to
tie the threads together. (D) The two threads are firmly approximated and locked by
the stopper. (E) Both ends of the threads are cut by a cutter device integrated into
the system. Thus a safe interrupted suture line can be created.
373
Figure 9.22 First prototype of the endoscopic sewing machine: (A) Starting position;
(B) closed. All from MITI.
9.2.3 Flexible Staplers
Temporarily flexible linear staplers were available. They were used to perform experimentally to accomplish Roux-en-Y bypasses, sleeve resection
of the stomach, and colonic resection (
Fig. 9.24). For reasons unknown,
this type of stapler is no longer available. They certainly had the potential
to stimulate the development of NOTES. Hopefully, improved flexible
staplers will become available again.
9.2.4 Plicator-Like Devices
As already pointed out in Chapter 2.2: Esophagus, several innovative endoscopic approaches were started for the endoluminal treatment of gastroesophageal reflux disease about 15 years ago. Not many of the devices