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SECTION 2 Current Clinical Applications and Techniques
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SCM
Figure 18.14 View of the surgical procedure in a pig with all trocars in
position. (With kind permission from Springer Science + Business Media:
Surg Endosc , Wilhelm T, Benhidjeb T 2011; 25:1741–47.)
• Dissection and division of the upper pole arteries and
medial thyroid vein close to the gland.
• Division of branches of the inferior thyroid artery close to
the gland.
• If necessary, preparation of the retrothyroidal area including visualization of the recurrent laryngeal nerve.
• Thyroid resection from cranially to caudally and
transoral removal of the specimen through the 5 mm midline
incision.
Description of landmarks of surgical steps and dissection of
defi ned anatomic structures could be achieved. The subplatysmal space could be reached without any major problems within a short time. Anatomical dissection showed
intact muscles and vascular structures. One -side subtotal
thyroid resection could be successfully performed without
any additional skin incision in 60 minutes [10].
Application in living animals
Based on these preclinical experiments, questions arose as
to whether the target region could be reached in a living
patient and if a ‘‘bloodless’’ operation could be performed in
the space created. In addition, the postoperative course with
respect to infections, dysphagia, and oral food intake was of
interest. We therefore evaluated the technique in a short time-survival animal trial in fi ve male pigs.
The anatomy of the pig with respect to structure and
alignment of the suprahyoid muscles, as well as the superfi cial layers of the pretracheal muscles, is comparable to that
of humans. The thymus in pigs lies below these structures.
There is another layer of bilateral muscles dorsal to the pig ’s
thymus (pretracheal muscles), and below this is the pig ’s
rather small thyroid gland (up to 5.0 ml in 4 -month-old pigs)
[20]. We decided to resect the thyroid and parts of the
thymus in the operative procedure to the anterior neck
region. The thymus of the animals has a vascular supply,
PTM
TG
Figure 18.15 Endoscopic view of the transoral approach. SCM,
sternocleidomastoid; muscle; PTM, pretracheal muscle; IJV, internal
jugular vein; TG, thyroid gland under PTM. (With kind permission from
Springer Science + Business Media: Surg Endosc, Wilhelm T, Benhidjeb T
2011;25:1741–47.)
IJV
thus ensuring a realistic surgical setup during the operation.
Standard laparoscopic instruments (diameter 2.7 mm) as
well as specially built trocars (diameter 3.0 mm, Karl Storz
GmbH, Tuttlingen, Germany) were used.
After use of skin and mucosal disinfectant a midline incision was made sublingually between the papillae of Wharton’s ducts, revealing the muscles of the fl oor of the mouth.
These were divided into the median raphe and the trocar
was inserted into the subplatysmal layer in front of the
thyroid cartilage. After endoscopic control, CO
fl ated at 6 mmHg. The CO
formed a tent in the anterior neck
2
was insuf-
2
region through “gas dissection. ” After mucosal incision in
the vestibule on both sides, the next step was to loosen the
periost from the mandible. Following this, both working
trocars were inserted subplatysmal and moved toward the
layer of the thymus (Figure 18.14). After the midline
opening of the pretracheal muscles, thyroid and thymus
were displayed, loosened on both sides, and parts of them
were resected (Figure 18.15). Harvesting of the specimen
was attempted through the sublingual channel. Finally, the
incisions were closed with absorbable sutures.
The animals woke up breathing spontaneously and were
brought back into their sty after three hours. For the next
two days, all animals were observed to establish pain reactions and oral feeding. Possible pain reactions were estimated based on their social behavior in the sty; normally,
the animals fi ght with each other, especially during feeding.
If the pigs experience pain, they press their trunks against a
wall as this phantom pain detracts from other pain. On the
third postoperative day, all animals were anesthetized and
the incision sites in the oral cavity were checked. The
animals were subsequently euthanized. A complete dissec-
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CHAPTER 18 NOTES Thyroidectomy
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tion of the fl oor of mouth and the anterior cervical region,
including the surgical fi eld, was performed to reveal infections, hematomas, or other collateral damage.
In each case, the anterior neck could be reached endoscopically without a problem. There was no bleeding that
required surgical intervention. A midline incision of the
pretracheal muscle layer revealed the thyroid and thymus.
These were mobilized and the adjacent vessels were cauterized with monopolar scissors. All pigs breathed spontaneously after the surgical procedure and could be extubated
without complications. They recovered fast and no acute
postoperative bleeding occurred. After 4 –5 h, all animals
started oral food intake without signs of pain. For the following 2 days the animals were held in their sty and were
fed standard pig food and water. There were no irregularities, no notable signs of pain (i.e., they displayed normal
social behavior; none of the pigs pressed their trunks against
the wall). Signs of local infections in the neck tissues were
not noted. On the third postoperative day, all animals underwent a second anesthesia induction to examine the incision,
paying special attention to local infections or wound breakdown, comparing the fi ndings to the direct postoperative
fi nding: none of the pigs showed any such conditions. There
were no locoregional infections or other unusual fi ndings.
The animals were euthanized and the submandibular and
anterior cervical regions were dissected. After resection of
the skin and platysma, the subcutaneous tissue where the
trocars were placed could be examined. There were no fresh
bleeding, hematomas, or infection. Two local encapsulated
seromas were observed. Histologically, only a mild tissue
reaction was noted.
Application in human beings
Although the surgical feasibility of the TOVAT has been
demonstrated, there are still concerns about clinical feasibility [21,22]. One major concern is that the fl oor of mouth is
limited in size and might be damaged by an oversized instrument or removal of a large specimen. Another concern is
that it may not be possible to perform a totally endoscopic
thyroidectomy without using modern “energy” devices for
hemostasis. For this, it is necessary to replace the right 3 mm
trocar by a 5 mm one in order to be able to introduce a
harmonic or bipolar scalpel. This diameter might be risky,
because the lateral vestibulum trocar is localized close by the
mental nerve, which might be harmed during manipulation.
Other limiting factors concern triangulation and manipulation of instruments and diffi culties in visualization of the
recurrent laryngeal nerve. In addition, innovative surgical
procedures that have been tested in animal models cannot
simply be transferred to clinical trials without further refi nements and modifi cations [23]. This is particularly valid for
the TOVAT because of the anatomical differences concerning
the topographical anatomy of the thyroid gland between
humans and animals. The neck in pigs, for example, is much
larger than in humans, thus enabling better triangulation
and manipulation of instruments. Moreover, thyroidectomy
in pigs is much easy to perform due to the peculiar anatomical relationships of the gland, the absence of defi nite parathyroid glands, and its relatively simple blood supply [24].
TOVAT was performed in a 53 -year -old man with a solitary euthyroid nodule of the right hemithyroid with a
volume of 5.5 ml with concerns for patient safety [25,26]. A
subsequent series consisting of eight patients having TOVAT
has recently been published [27]. The authors encountered
signifi cant morbidity such as paresthesia of the mental nerve
in varying degrees in 6/8 cases (75%), conversion to open
surgery due to specimen size in 3/8 cases (37.5%), palsy of
the recurrent laryngeal nerve in 2/8 cases (25%), and one
permanent (12.5%) and local streptococci infection at the
vestibular incision site necessitating incision and irrigation
in one case (12.5%) [27,28]. It is worth mentioning that
morbidity in the highly standardized thyroid surgery is as
low as 4% and palsy of the recurrent laryngeal nerve occurs
in less than 3% of patients.
Conclusion
The minimally invasive aspect and the scarless character of
TOVAT form the rationale for the development of this transoral approach. Procedural technique and concerns have
been well defi ned. Access and feasibility of TOVAT could be
demonstrated in extensive preclinical investigations. The
current clinical experience has highlighted the need for
further refi nements of the access and instruments before its
general application can be recommended. TOVAT is a promising approach that will signifi cantly improve the cosmesis
of thyroidectomy.
Chapter video clip
Video 18.1 Totally transoral video -assisted thyroidectomy
(TOVAT).
References
1 Richmon JD, Pattani KM, Benhidjeb T, Tufano RP . Transoral
robotic-assisted thyroidectomy: a preclinical feasibility study in
2 cadavers . Head Neck 2011;33:330–33.
2 Gagner M. Endoscopic subtotal parathyroidectomy in patients
with primary hyperparathyroidism . Br J Surg 1996;83:875–80.
3 Miccoli P, Pinchera A, Cecchini G, et al. Minimally invasive,
video-assisted parathyreoid surgery for primary hyperparathyreoidism. J Endocrin Invest 1997;20:429–30.
4 Hüscher CS, Chiodini S, Napolitano G, Recher A. Endoscopic
right thyroid lobectomy . Surg Endosc 1997;11:877–8.
195
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
5 Miccoli P, Berti P, Coute M, et al. Minimally invasive surgery for
thyroid small nodules: preliminary report . J Endocrinol Invest
1999;22:849–51.
6 Bärlehner E, Benhidjeb T. Cervical scarless endoscopic thyroid-
ectomy: axillo -bilateral-breast approach (ABBA) . Surg Endosc
2008;22:154–7.
7 Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric
peritoneoscopy: a novel approach to diagnostic and therapeutic
interventions in the peritoneal cavity . Gastrointest Endosc
2004:60:114–17.
8 Benhidjeb T, Witzel K, Bärlehner E, Stark M. Natural-Orifi ce -
Surgery-(NOS-) Konzept. Vision und Rationale f ür einen Paradigmenwechsel. Chirurg 2007;78:537–42.
9 Witzel K, von Rahden BHA, Kaminski C, Stein HJ. Transoral
access for endoscopic thyroid resection . Surg Endosc 2008;22:
1871–5.
10 Benhidjeb T, Wilhelm T, Harlaar J, et al. Natural orifi ce surgery
on thyroid gland: totally transoral video -assisted thyroidectomy
(TOVAT): report of fi rst experimental results of a new surgical
method. Surg Endosc 2009;23:1119–20.
11 Downton D, Qvist G. Intra-oral excision of the submandibular
gland. Proc R Soc Med 1960;53:543–4.
12 Guerrissi JO, Taborda G. Endoscopic excision of the submandib-
ular gland by an intraoral approach . J Craniofacial Surg
2001;12:299–303.
13 Smith AD, Elahi MM, Kawamoto HK Jr , et al. Excision of the
submandibular gland by an intraoral approach . Plast Reconstr
Surg 2000;105:2092–5.
14 Yoel J. Submaxilectomía. Técnica por v ía bucal . Rev Asoc Odont
Argentina 1961;49:363–5.
15 Hong KW , Yang YS. Surgical results of the intraoral removal of
the submandibular gland . Otolaryngol Head Neck Surg 2008;139:
530–34.
16 Shellenberger T, Fornage B, Ginsberg L, Clayman GL. Transoral
resection of thyroid cancer metastasis to lateral retropharyngeal
nodes. Head Neck 2007;29:258–66.
17 Neugebauer EAM, On behalf of the EAES. EAES recommenda-
tions on methodology of innovation management in endoscopic
surgery . Surg Endosc 2010;24:1594–615.
18 Schardey HM, Schopf S, Kammal M, et al. Invisible scar endo-
scopic thyroidectomy by the dorsal approach: experimental
development of a new technique with human cadavers and
preliminary clinical results . Surg Endosc 2008;22:813–20.
19 Wilhelm T, Harlaar J, Kerver A, Kleinrensink GJ, Benhidjeb T.
Surgical anatomy of the fl oor of the oral cavity and the cervical
spaces as a rationale for trans -oral, minimal -invasive endoscopic
surgical procedures: results of anatomical studies . Eur Arch
Otorhinolaryngol 2010;267:1285–90.
20 Wilhelm T, Benhidjeb T. Transoral endoscopic neck surgery:
feasibility and safety in a porcine model based on the example
of thymectomy . Surg Endosc 2011;25:1741–47.
21 Miccoli P, Materazzi G, Berti P. Natural orifi ce surgery on the
thyroid gland using totally transoral video -assisted thyroidectomy: report of the fi rst experimental results for a new surgical
method: are we going in the right direction? Surg Endosc
2010;24:957–8.
22 Benhidjeb T, Wilhelm T, Harlaar J, et al. Reply to Miccoli P et
al. Surg Endosc 2010;24:959–60.
23 Margo CE. When is surgery research? Towards an operational
defi nition of human research . J Med Ethics 2001:27:40–43.
24 Caylor HD, Schlotthauer CF . The thyroid gland of swine . Anat
Rec 1927;34:331–9.
25 Wilhelm T, Metzig A. Endoscopic minimally invasive thyroidec-
tomy: fi rst clinical experience . Surg Endosc 2010;24:1757–8.
26 Benhidjeb T, Witzel K, Burghardt J, et al. Endoscopic minimally
invasive thyroidectomy: ethical and patients safety considerations on the fi rst clinical experience of an innovative approach .
Surgical Endoscopy 2010, Aug 24 [Epub ahead of print] DOI
10.1007/s00464-010-1290-9.
27 Wilhelm T, Metzig A. Endoscopic minimally invasive thyroidec-
tomy (eMIT): a prospective proof -of-concept study in humans .
World J Surg 2011;35(3):543–51.
28 Benhidjeb T, Stark M. Endoscopic minimally invasive thyroid-
ectomy (eMIT): safety fi rst! World J Surg 2011;35(8):1936–7.
196
3
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Perspectives on NOTES
19
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POEM and Emerging NOTES Applications
Haruhiro Inoue1& Ricardo Zorron
1
Showa University Northern Yokohama Hospital, Yokohama, Japan
2
Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany
Introduction
Since the development of the concept of natural orifi ce
surgery [1], a surgical paradigm shift occurred successfully
for transvaginal, transgastric, and more recently transcolonic
applications. Besides the slow acceptance rate of natural
orifi ce translumenal endoscopic surgery (NOTES) in clinical
practice due to a diffi cult learning curve and lack of
equipment, the demonstration of superiority of NOTES techniques over established laparoscopic ones, which is still not
evident, may occur as techniques develop and comparative
studies are performed. Nowadays, many clinical cases have
been described in the literature, and procedures such as
transvaginal cholecystectomy and nephrectomy are well
established, with hundreds of cases worldwide having been
reported with good results. Recently two large multicenter
studies showed good results of transvaginal and transgastric
approaches for many indications, and also the EURO -NOTES
Conference in 2010 covered current procedures and future
needs [2–4]. Other procedures and proposals are still in their
infancy, but with a high potential of being important alternatives to current therapy. This chapter on emerging NOTES
applications covers new procedures that might have a place
in surgical care in the near future.
Emerging NOTES applications
As surgeons ’ and industry -driven interest in research grew
in the fi eld, thinking “out of the box ” has resulted in many
new developments in all fi elds of surgical knowledge in
recent years, after a period of laparoscopic consolidation.
Researchers are on the way to discover how minimally invasive surgery (MIS) can evolve to a scarless, bloodless, and
2
painless procedure. In endocrine surgery, transoral, sublingual, and axillary techniques may provoke this next revolution. Retroperitoneal NOTES access for kidney, adrenals, and
other hidden organs, as well as transcolonic and transrectal
NOTES access for colorectal surgery, may easily follow in the
near future. Undoubtedly, the performance of transoral
endolumenal procedures that previously needed laparoscopy or formal open surgery, e.g., for refl ux disease, or
myotomy for achalasia, will possibly replace current standards by less -invasive procedures. Sometimes, as occurred for
endoscopic retrograde cholangiopancreatography (ERCP),
surgeons may also be replaced by endoscopists or other
professionals such as interventional radiologists or radiotherapists in future patient care.
NOTES thyroid and parathyroid surgery
Evolution of minimally invasive surgery
of the neck
The endoscopic surgical approach to the neck has reached
the attention of head and neck surgeons with a certain delay
compared to other fi elds of endoscopic procedures. This may
be attributed to the tight working space and abundance of
vital structures in the operating fi eld [5]. Since study groups
described fi rst attempts with endoscopic or video -assisted
removal of thyroid glands in the late 1990s, selective neck
dissections on animal models or cadaveric dissections were
performed in 2003.
In the late 1990s the fi rst descriptions of minimally invasive video -assisted thyroidectomy and parathyroidectomy
occurred in the literature [6,7]. This was ten years after the
time when other surgical specialties had discovered the
advantages of endoscopic techniques. The relative delay in
this approach has been attributed to the narrow operative
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
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SECTION 3 Perspectives on NOTES
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fi eld and the presence of many vital structures in the neck.
In general, endoscopic operations at the beginning were
limited to regions with natural cavities, such as the abdomen
and thorax. Endoscopic approaches, however, soon extended
their indications to regions without a natural cavity.
Cervical incision -free neck surgery is a promising alternative providing excellent cosmetic outcomes and improvement of patient satisfaction. Minimally invasive neck surgery
was initially centered on parathyroidectomy for adenoma,
performed by Gagner in 1996 [6], and the fi rst endoscopic
thyroid lobectomy was performed by Huscher et al. [7].
After these pioneering accomplishments, the technique of
minimally invasive video -assisted thyroidectomy (MIVAT)
developed by Miccoli became the most widespread method
to date [8]. These authors reduced the incision to a size of
20–25 mm and operated on the thyroid by the use of video endoscopic assistance. Unfortunately, the technique still
requires a visible neck incision, with variable cosmetic
results. Further in the evolution of cervical minimally invasive techniques, the axillo -bilateral-breast approach (ABBA)
described by Ikeda et al. and Shimazu et al. and later applied
by Barlehner and Benhidjeb is an alternative way to the
thyroid gland without any scars in the neck [9–11].
Single-incision transaxillary endoscopic
neck surgery
A different approach to the neck is described by Dutta et al.
[12]. This group published an endoscopic approach, the so called “stealth surgery, ” a single -incision transaxillary subcutaneous endoscopic excision of various benign neck
lesions, including parathyroid adenoma. After performing a
small axillar skin incision, the subcutaneous plane was dissected for 3 cm and a 5 mm port was introduced, insuffl ating
the subcutaneous space with CO
inserted and preparation carried on. As soon as enough
working space was created, two additional ports were placed
1 cm at each side of the camera port, and the dissection was
carried out by standard laparoscopic instruments. All procedures were successful, the mean operative time was 51
minutes, and there were no intra - or postoperative complications, with good cosmetic results.
The single -incision transaxillary approach for thyroidectomy was applied by Lee et al. in 2010 for four patients in
South Korea [13]. A 2 –2.5 cm skin incision was then made
along the skin crease of the axilla. Dissection was carried out
under direct vision to the upper portion of the pectoralis
major muscle. The working space for this operation was
created by gentle and blunt dissection with an acrylic bar.
After adequate dissection, the authors elaborated a single port system using a double -ring wound retractor (Alexis,
Applied Medical, Rancho Santa Margarita, CA, USA) and a
surgical glove. Three 5 mm trocars were inserted into the
glove fi ngers and dissection was carried out by ultrasonic
shears with CO
insuffl ation with pressures of 4 –6 mmHg.
2
. A 30 ° endoscope was
2
Operative times ranged from 145 to 185 minutes, and there
were no postoperative complications. Other authors using a
combined axillo -breast approach pointed to the risks of gas
insuffl ation and preferred neck dissection using mechanical
lifting [14].
Transoral video-assisted thyroidectomy
Benhidjeb and his study group in Berlin, Germany, described
a technique called totally transoral video -assisted thyroidectomy (TOVAT) [15] (see Chapter 18 for detailed description).
The fi rst experimental results show a feasible method
through the fl oor of the mouth using gas insuffl ation dissection. The surgical procedure was performed on fi ve cadavers
using one 5 mm trocar and two 3 mm trocars introduced
bilaterally through the fl oor of the mouth and the oral vestibule. A subplatysmal working space was created by blunt
dissection and CO
Division of the median raphe of the neck muscles was followed by exposure of the thyroid gland. The isthmus was
transected, the upper pole arteries dissected and divided, and
the medial thyroid vein cut close to the gland. Thyroid resection was performed from cranial to caudal and the specimen
was removed transorally through the 5 mm midline incision.
This method suggested for unilateral lesions has the potential of infection from the oral cavity to sterile tissues of the
neck, and this possibility has to be a fi eld of research in
further experimental studies.
Witzel et al. in 2008 described a technique of sublingual
thyroidectomy using a modifi ed axilloscope in a series of
human cadavers and an animal study showing feasibility
and short operative times (mean 50 min, 27 –103min), but
the survival study was limited to 2 hours postoperatively
[16]. Richmon et al. suggested the use of robotic transoral
thyroidectomy in a feasibility study in cadavers [17].
After these experimental fi ndings, Wilhelm and Metzig
from Borna, Germany, were able to perform in 2009 the fi rst
clinical application of sublingual thyroidectomy in a 53 -year old male patient with a benign nodule at the right thyroid
lobe [18]. Karakas et al. further performed transoral endoscopic parathyroidectomy in a female patient with primary
hyperparathyroidism [19]. The technique for thyroidectomy
is performed using CO
space. The team is ideally composed of a head -neck surgeon
and a general surgeon. The fi rst incision is made in the
midline sublingually. A 5 mm trocar is inserted through the
fl oor of the mouth into the subplatysmal layer and positioned at the level of the cricoid. Insuffl ation is established
at 6 mmHg of CO
Then, a second trocar for insertion of the surgical instruments is inserted over a vestibular incision into the same
subplatysmal layer. This allows the surgical fi eld to be visualized fully and dissected with mini - or standard laparoscopic
instruments. A third trocar for surgical instruments is then
placed through an incision on the left side of the vestibule
insuffl ation to a pressure of 4 –6 mmHg.
2
insuffl ation of the subplatysmal
2
to build a tent above the thyroid gland.
2
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of the mouth. Ultrasonic shears is the main instrument used
for dissection and bleeding control. The authors pointed out
the advantages of this technique as the reduction of surgical
trauma, its direct access to surgical planes and spaces, avoidance of swallowing disorders and postoperative dysphagia,
and excellent cosmesis with absence of skin scars.
State of research
Associated with good indication cases, video -assisted endoscopic techniques and subcutaneous approaches with gas fi lling procedures are feasible in neck surgery. Methods,
depending on surgeons ’ experience, showed no signifi cantly
extended operation times, faster wound healing, and an
optimized cosmetic outcome, compared to open approaches.
During neck procedures, surgeons should always be aware
of the limitations of the minimally invasive techniques
regarding complications or modifi cations during the dissection. Transoral fl exible or rigid techniques such as TOVAT
should still be investigated in survival studies to better
understand the risks of infection and hemorrhage, and
potential advantages, and will certainly be adopted for
future clinical studies.
Transrectal NOTES using single-port devices
Potential for transrectal NOTES access
Whereas most investigators have chosen to gain peritoneal
access via a transvaginal or transgastric route, few have
investigated the transcolonic route [20–25]. This approach
has several theoretic advantages over the transgastric route.
By eliminating the need for scope retrofl ection for upper
abdominal surgery, it allows a more direct route to the area
under scrutiny, and the anorectum allows passage of larger
diameter instrumentation and retrieval of larger specimens
[26]. NOTES transvaginal colectomy assisted by mini laparoscopy was fi rst described in a patient with sigmoid
cancer by Lacy et al., who named the technique MA -NOS
[27]. Hybrid transvaginal right hemicolectomy has also been
reported [28].
Access via the anal canal in the form of transrectal or
transcolonic NOTES appears to be an attractive option for
treating both colorectal and other abdominal diseases [29–
33]. Technical obstacles such as the risk of infection, safe
entrance into the abdominal cavity, and reliable closure of
the bowel wall have been inhibiting factors that have prevented the progress of transrectal and transcolonic applications in particular.
Transanal NOTES using rigid platforms has been the
subject of recent experimental cadaveric studies where
radical sigmoid colectomy, transanal specimen extraction,
and primary anastomosis have been possible [29]. The main
obstacles for the use of rigid systems in human transanal
NOTES are the acute angle created by the sacral promontory
and the limited reach of current instruments. Rigid transanal
resection of the colon has been achieved in a series of 14
non-survival and cadaveric animal experiments [34]. Leroy
et al. described a combined technique using fl exible and
rigid transrectal and fl exible transgastric accesses to perform
sigmoidectomy in a porcine model [35]. This totally NOTES
technique resulted in survival of all fi ve animals, and no
signs of peritonitis or intra -abdominal abscess were found
two weeks postoperatively.
Innovative techniques in transanal peri -rectal access in
animal studies and subsequently in human subjects have
been performed since 2009. Transrectal access via peri -rectal
NOTES access (PNA) allowed access to the mesorectal fascia
and therapy in the retroperitoneal space and ultimately
the abdominal cavity if needed. Velhote et al. peformed
transanal pull -through surgery using intracolonic laparoscopy [31], the group of Sylla and Lacy performed transrectal
laparoscopic-assisted rectal resection using a transanal endoscopic microsurgery (TEM) device [36], and Zorron et al.
described the technique of transrectal NOTES for rectosigmoidectomy using either fl exible or rigid instrumentation
by transanally inserted single -port device [26,37].
Surgical technique
Single-port devices suited for umbilical surgery have a
simple adaptation when inserted transanally, allowing for
intralumenal insuffl ation of CO
getting a good view and angle for dissection of the rectum,
especially above 4 cm from the anal verge (Figure 19.1).
Figure 19.1 Schematic view of down -to-up transanal PNA for total
mesorectal excision for rectal cancer. The single -port device (TriPort,
Olympus, Japan) is transanally inserted, the presacral space is reached,
and the rectum is sectioned 4 –5 cm below the distal margin of the tumor,
allowing TME progression in a retrograde manner.
, avoiding gas leaks, and
2
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Figure 19.2 Schematic view of PNA access for rectal cancer using
alternative fl exible transrectal dissection.
Figure 19.4 Instrument introduction through transanal single -port
surgery.
Figure 19.3 Transanal Insertion of single -port device and transrectal
insuffl ation with CO
.
2
Alternatively, a technique using a fl exible colonoscope
instead of rigid instruments was also described (Figure 19.2)
[26,37], using a TriPort (Olympus, Japan) with a 10 mm 45 °
laparoscope, a standard laparoscopic grasper, and either
ultrasonic shears or a semifl exible monopolar hook for performing rectal dissection (Figures 19.3 and 19.4). Other
standard laparoscopic instruments were used for the laparoscopic assistance.
The distal limit of the tumor can be easily identifi ed by
the single -port visualization. After the level of the circumferential resection line is identifi ed, a purse string suture is
placed below the tumor to avoid potential cell spillage and
202
Figure 19.5 Intralumenal view of anterior progression of TME dissection
to the posterior wall of the vagina.
subsequently to maintain pressure of CO 2 insuffl ation to the
retroperitoneal space during dissection. Once a full thickness
rectal wall incision is made, the anatomical plane between
the pelvic fl oor and the mesorectal fascia becomes apparent.
Developing this plane laterally and circumferentially allows
a retrograde total mesorectal excision (TME) to ascend
(Figure 19.5). Sharp dissection progresses until the peritoneal refl ection is breached anteriorly. Laparoscopic transabdominal assistance completes the vascular ligation and
liberation of splenic fl exure.
The specimen is then grasped transanally and fully delivered through the anus (Figure 19.6). The exposed colorectum is resected at an appropriate level in preparation for the
anastomosis. Hand -sewn coloanal or stapled anastomosis is
performed with or without a colonic pouch (Figure 19.7),
and using a defunctioning stoma. Our group described 11
performed cases, with one conversion to open surgery, and
CHAPTER 19 POEM and Emerging NOTES Applications
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Figure 19.6 Full transanal extraction of the specimen with intact
mesorectum.
one complication and re -operation due to anastomotic
necrosis [26].
Use of transanal endoscopic microsurgery
Developed and described by Buess et al. in the early 1980s,
TEM is a widely used minimally invasive alternative for a
range of benign and early malignant lesions of the rectum
[38]. The concept of installing a transanal platform to
perform colorectal surgery was initially reserved for resection of tumors located below the peritoneal refl ection in
order to avoid perforation into the peritoneal cavity. In fact,
this practice does not appear to increase infectious postoperative complications [39]. TEM is truly a precursor of
NOTES, as it may act also outside the bowel lumen, and in
many cases involves parietal resections and anastomosis.
Future expectations
Transanal down -to-up NOTES mesorectal excision using a
transanal single -port device represents an innovation in
current patient care, as it might represent easier access to
the distal part of the mesorectum that can be so diffi cult to
dissect under direct vision in both open and laparoscopic low
anterior resection, especially in men. The goal for transanal
access in colorectal surgery is the performance of totally
NOTES transanal resections of many of those procedures
performed today. Overcoming the technical limitations of
currently available instruments and making sure that any
advances are safe, both in the short and long terms, will
require patience and advanced training for those wishing to
pursue this exciting fi eld.
Figure 19.7 Resection of the exposed colorectum and preparation of
proximal colon by inserting the anvil of the circular stapler.
treatment of adrenal and renal disease. Despite successful
clinical applications of transvaginal and transgastric NOTES
for abdominal surgery, the use of direct NOTES retroperitoneal access for renal and adrenal surgery is still restricted to
animal experiments. Transvaginal retroperitoneoscopy was
successfully described with survival in a swine model in
2008 [40–42], suggesting future applications of this new
access for renal and adrenal surgery. These new techniques
tested in animal models suggest the benefi ts of reaching
retroperitoneal targets using transvaginal insertion of a fl exible endoscope directly in the retroperitoneal space, with
dissection performed by endoscopic instruments.
Recently, the fi rst clinical application was published [43]
for a 67 -year -old patient with a left renal cyst, with long
operative time (210 min). Diffi culties in spatial orientation
and maneuvering the fl exible instrumentation were the
causes of this prolonged time. The vaginal access and closure
itself can be done easily and quickly, with a short learning
curve, but retroperitoneal fl exible dissection and progression
is hazardous, due to diffi culties in insuffl ation and spatial
orientation, and with potential dangerous complications
related to retroperitoneal emphysema (Figures 19.8–19.10).
However, direct NOTES retroperitoneal access to the target
organs (transvaginal, transrectal, or transgastric) may quickly
promote ideal applications for changing current surgical
standards.
Per -oral endoscopic myotomy for
esophageal achalasia
Retroperitoneal NOTES
Retroperitoneal and transabdominal laparoscopic access to
retroperitoneal organs has become the gold standard for
Introduction
The concept of NOTES [1,44,45] has inspired endoscopists
and endoscopic surgeons to create and establish even less invasive treatment for various gastrointestinal diseases.
Esophageal achalasia is one of the considerable targets of
203
SECTION 3 Perspectives on NOTES
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Figure 19.8 Position of the patient, endoscope, and surgeon for NOTES
transvaginal retroperitoneoscopy using a fl exible two -channel
colonoscope.
Figure 19.9 Operative aspect of retroperitoneoscopy after direct
introduction of the colonoscope in the retroperitoneal space – left
internal iliac vessels.
Figure 19.10 Dissection of a left renal cyst by fl exible transvaginal
retroperitoneal NOTES.
NOTES. So far, treatments including Botox injection and
balloon dilation have been commonly performed as fi rst -line
endoscopic treatments for achalasia [46,47]. If those are
ineffective, laparoscopic myotomy is generally selected as
the next step of treatment [48].
Per -oral endoscopic myotomy (POEM) has been developed as a further less -invasive endoscopic treatment intending permanent cure for esophageal achalasia [49] (Figures
19.11–15). In the literature, the concept of endoscopic
myotomy was fi rstly reported around three decades ago
[50], but its direct incision method through the mucosal
layer was not considered to be a safe and reliable procedure.
204
Figure 19.11 Mucosal entry. Mucosal entry to submucosal space is
usually put at approximately 13 cm proximal to esophago -gastric junction
(EGJ). (From Inoue H [52], with permission from Georg Thieme Verlag
KG.)
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