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CHAPTER 24 Evolution and Future Developments of Instrument Technology for NOTES
https://t.me/med1917
Figure 24.16 Cobra from USGI. (Reprinted from [36] Vahe Karimyan,
Mikael Sodergren, James Clark, et al. Navigation systems and platforms in
natural orifi ce translumenal endoscopic surgery (NOTES). Int J Surg
2009;7:297–304 with permission from Elsevier.)
Cobra
The Cobra device has been developed by USGI to solve the
issue of triangulation by the addition of three independent
arms added to the ShapeLock -based shaft of the TransPort
[36] (Figure 24.16). The idea of endoscopic triangulation is
to reproduce the experience of complex two -handed laparoscopic dissection and suturing. The Cobra device uses a
standard 6 mm fl exible endoscope inserted through the
center channel of the scope. This makes the Cobra itself less
complex and therefore more cost effective. Although the
controls of this device are mechanical, currently the cable driven controls are imprecise, which makes the Cobra diffi cult to use for fi ne procedures. Another disadvantage of
this technology is that the instruments are fi xed and require
that the device be removed to exchange tools and then
reintroduced [35].
R-scope
A double -channel gastroscope made by Olympus, designed
to improve endoscopic submucosal dissection, called an
R-scope, has been employed in NOTES procedures [35]
(Figure 24.17). It has two bending sections: the proximal
section can be defl ected in a single plane (up -down); the
distal section can be defl ected in two planes (up -down,
right-left). There are also two actuated instrument channels:
one allows vertical elevation, the other allows a horizontal
“swing” movement. One channel moves a grasping forceps
vertically for tissue counter -traction, and the other swings a
cutting knife horizontally for dissection. This allows the
scope to be positioned at the operative fi eld and then frees
the surgeon ’s hands to perform fi ne retraction, dissection,
and manipulation [37]. The R -scope also has a larger, separate channel for suction and irrigation. The important disadvantages of this system are visiospatial disorientation and
its size and fl exibility [36].
EndoSAMURAI
Another endoscopic platform prototype developed is the
EndoSAMURAI (Olympus Corp., Tokyo, Japan) [33] (Figure
24.18). It consists of a specialized endoscope with a remote
working station and a locking overtube (Figure 24.19). It
provides an excellent visualization system with an image
equal to the laparoscopic image, two independent end effectors, a third conventional working channel, and an
ergonomic user interface. With fi ve degrees of freedom and
triangulation capabilities, the arms can tie sutures as well as
provide traction and counter -traction. Platform stability is
increased through a steerable and lockable overtube. The
EndoSAMURAI provides a stable horizon, which is preferable as the articulations of the working arms happen distal
to the lens and lights. This system employs a “drive, park
and move ” methodology, where the user navigates to the
target with the endoscope, locks the overtube system and
scope in position, and then proceeds to the user interface.
This effectively allows one operator to perform most of the
workload as the image is theoretically kept in place with the
locking system with subsequent maintenance of the image
by the assistant, which is somewhat similar to traditional
laparoscopy. It has been tested in animal models for cholecystectomy [38].
Direct Drive Endoscopic System
The Direct Drive Endoscopic System (DDES, Boston Scientifi c, Natick, MA, USA) consists of three main elements: (i)
a steerable fl exible guide tube with three channels, a 6 mm
visualization channel, and two independent 4 mm instrument channels; (ii) a set of articulating 4 mm instruments;
and (iii) an ergonomic table -mounted rail platform [36]
(Figures 24.20 and 24.21). When in place, the distal portion
of the DDES guide tube moves in a manner similar to that
of an endoscope with up, down, and left -right control.
When an endoscope is placed via the visualization channel,
it slides, rolls, and tilts without disturbing the instruments.
The proximal portion of the DDES guide tube is fi xed on a
stable rail platform. Control of the instruments is performed
through ergonomically driven handles, which slide on the
rail platform, passing hand motion to the tips of the instrument with fi ve degrees of freedom. With these designs, the
DDES allows independent instrument manipulation without
disturbing the visual perspective [39,40]. The platform is
designed for one operator aided by an assistant to maintain
the visual fi eld and help with instrument exchanges. Disadvantages of this system are the complexity, which requires
a long time for installation, navigation is still poor, and
instrument exchange is cumbersome.
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SECTION 3 Perspectives on NOTES
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(a) (b)
(c)
Figure 24.17 (a) The prototype R -scope with its separate wheel house (arrow) for a second articulated working channel. (b) The two separate,
articulated working channels of the R -scope. (c) The custom -made intestinal occlusion catheter, which is placed in the duodenum, preventing small bowel distention during the procedure. (Reprinted from [37] Matthew T. Moyer, Randy S. Haluck, Jegan Gopal, et al. Transgastric organ resection solely
with the prototype R -scope and the self -approximating transluminal access technique. Gastrointest Endosc 2010; 72:170–6 with permission from Elsevier.)
the NOTES setting, the professed possibilities are intriguing.
Robotics
Whether the electromechanical or magnetic system or some
other confi guration not yet conceived will predominate is
Flexible robotics
unknown.
Endoscopes with robotic technology in the future, with their
ability to create stable fi xation points while maintaining
precise tip maneuverability, might allow just the degree of
precision needed for NOTES [41]. Accessory instrumentation (graspers, scissors, biopsy forceps, and suction catheters) could be introduced and exchanged within working
channels at the push of a button. Multiple remotely controlled fl exible instruments can be potentially combined
inside a common channel. Each of these could splay outward
The da Vinci system
The da Vinci robotics platform in its current form has been
used by Box and associates to perform robot -assisted NOTES
nephrectomy [42]. The authors noted frequent collisions of
the robotic arms because of their proximity, but instrument
dexterity allowed effective tissue dissection. It seems clear
that a task -specifi c robotic system will ultimately be better
suited to the complexity of NOTES procedures in the future.
and create necessary triangulation from a common entry
point. This could give us the necessary triangulation and
degrees of freedom within a compact yet robust platform.
Though fl exible robotics technology is yet to be applied in
Micro robots
First prototypes of micro -robots have also been used in
experimental settings for facilitating minimal access surgery.
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CHAPTER 24 Evolution and Future Developments of Instrument Technology for NOTES
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Figure 24.18 Two arms are equipped at the tip portion of the
EndoSAMURAI. (Reprinted from Keiichi Ikeda, Kazuki Sumiyama, Hisao
Tajiri, et al. Evaluation of a new multitasking platform for endoscopic
full-thickness resection. Gastrointest Endosc 2011; 73:117–22 with
permission from Elsevier.)
Figure 24.19 Appearance in manipulating the EndoSAMURAI with both
hands. (Reprinted from Keiichi Ikeda, Kazuki Sumiyama, Hisao Tajiri, et al.
Evaluation of a new multitasking platform for endoscopic full -thickness
resection. Gastrointest Endosc 2011; 73:117–22 with permission from
Elsevier.)
Figure 24.20 Direct Drive Endoscopic System. (Reprinted from [40]
Christopher C. Thompson, Marvin Ryou, Nathaniel J. Soper, et al.
Evaluation of a manually driven, multitasking platform for complex
endoluminal and natural orifi ce transluminal endoscopic surgery
applications (with video). Gastrointest Endosc 2009; 70:121–5 with
permission from Elsevier.)
Studies have demonstrated that robotic systems help with
providing visual feedback through onboard cameras and
task assistance with the help of attached manipulators. A
mobile in vivo camera robot has successfully provided sole
vision feedback for a cholecystectomy in a porcine model,
Figure 24.21 Direct Drive Endoscopic System with operator. (Reprinted
from [40] Christopher C. Thompson, Marvin Ryou, Nathaniel J. Soper,
et al. Evaluation of a manually driven, multitasking platform for complex
endoluminal and natural orifi ce transluminal endoscopic surgery
applications (with video). Gastrointest Endosc 2009; 70:121–5 with
permission from Elsevier.)
indicating the possibility for reducing the number of incisions required for performing this procedure (Figure 24.22).
A similar robot with biopsy capabilities has successfully demonstrated the ability to independently complete a single -port
laparoscopic procedure in a porcine model. Rentschler and
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SECTION 3 Perspectives on NOTES
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Tail
Wheel
Camera lens
Figure 24.22 The mobile adjustable -focus camera robot has two
independently driven wheels that allow for forward, reverse, and turning
motion. A small tail prevents counter -rotation. (Reprinted from Sara L.
Best, Wareef Kabbani, Daniel J. Scott, et al. Magnetic anchoring and
guidance system instrumentation for laparo -endoscopic single -site
surgery/natural orifi ce transluminal endoscopic surgery: lack of histologic
damage after prolonged magnetic coupling across the abdominal wall.
Urology 2011; 77:243–7 with permission from Elsevier.)
colleagues developed a 12 mm diameter in vivo mobile robot
specially designed for a NOTES procedure [43]. The device
contains a helical wheel profi le, which provides suffi cient
traction for mobility without causing tissue damage. Two
helical wheels, independently driven by DC motors, are
designed to provide suffi cient traction without causing tissue
damage. The robot tail prevents counter -rotation of the
robot’s body when the wheels are turning. A gastrotomy was
created in a porcine model to allow for the insertion of the
in vivo robot into the abdominal cavity. Once in the abdominal cavity, the ability to effectively maneuver within the
cavity, including on the liver and small bowel, was successfully demonstrated. For this study, the in vivo robot was
observed with an endoscope. In an acute non -survival
porcine model, the feasibility of using multiple miniature
robots for improving spatial orientation and providing task
assistance was demonstrated. This preliminary cooperative
procedure used three miniature in vivo robots, including a
peritoneum-mounted imaging robot, a lighting robot, and a
retraction robot in cooperation with a standard upper endoscope to demonstrate various capabilities for NOTES procedures [44]. Although it is unlikely that the micro -robot
could be used alone to perform surgical procedures such as
an appendectomy, these features will provide the surgeon
with improved visualization, task assistance, and manipulation capabilities within the abdominal cavity. The miniaturization of micro -robots and the possibility to insert many
such robots into the peritoneal cavity through one hole
introduces a completely new concept in the development of
surgical tools as they allow the assignation of different tasks
to separate, independent tools. Furthermore, each device
may be super -specialized, potentially offering major advances
in that each instrument can serve at its best in the perform-
ance of any specifi c task. The fi eld of in vivo miniature
robotics is in its infancy. When wireless robots were used,
battery life was limited to less than 1 hour, and task -capable
in vivo robots now perform only simple maneuvers [45].
The pace of technologic advance is swift, however, and the
promise of a family of robots, each performing specifi c tasks,
is on the horizon.
Magnetic anchoring and guidance system
The evolution of NOTES procedures has created a need for
technical innovations whereby surgical instruments can be
deployed intracorporeally. Magnetic anchoring and guid-
ance system (MAGS) technology is one approach for deploy-
able instrumentation whereby intra -abdominal instruments
can be maneuvered by the use of an external handheld
magnet [46] (Figure 24.23). It involves an internal compo-
nent consisting of a surgical instrument attached to housing
fi tted with permanent magnets and an external, handheld
component carrying a complementary set of permanent
magnet stacks. The two components are held together via
magnetic coupling such that the internal component may be
directly manipulated by moving the external unit [47]. The
permanent magnet stacks are composed of neodymium iron
boron and are engineered to generate coupling forces well
in excess of those needed to suspend 25 to 45 g surgical
instruments. Such a strategy would permit a single access
port (either transabdominal or via a natural orifi ce) to serve
as an entry point for multiple instruments. MAGS technol-
ogy has thus far developed to incorporate instruments such
as retractors, an intra -abdominal camera, and cautery dis-
sectors. Magnets can potentially provide the vigorous trac-
tion and counter -traction required to advance NOTES
procedures, and several studies have shown the feasibility
of using magnets for tissue retraction in NOTES. Numerous
animal experiments have allowed for the successful pioneer-
ing of non -survival and survival surgery using MAGS instru-
mentation. Continuous instrument development and rapid
prototyping has resulted in successful performance of com-
pletely NOTES transvaginal cholecystectomy on both non -
survival and survival (14 day) porcine models with no
complications or infections [46]. The main limitation of this
technology is the decrease in the coupling strength of
magnets as a decaying exponential with respect to the dis-
tance between the source magnet and its target. Creation of
magnets capable of generating more robust magnetic fi elds
is required for use in patients with thick abdominal walls.
While early experience is promising, future work is neces-
sary to build more robust MAGS platforms to facilitate
simple deployment, positioning, and retrieval of intra -
abdominal robots and instruments.
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CHAPTER 24 Evolution and Future Developments of Instrument Technology for NOTES
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1
5
5
5
3
2
5
(a)
Figure 24.23 (a) Schematic representation of magnetic anchoring and
guidance system (MAGS) platform. One conventional trocar is depicted
with four deployed MAGS instruments: 1, deployment trocar; 2, MAGS
camera; 3, retractors; 4, robotic cauterizer; 5, hand -held external
magnets. (b) External view of pig with all four MAGS platforms in place,
in each of the four abdominal quadrants. Orange devices are
4
Spatial o rientation
One of the challenges identifi ed as a potential barrier to
clinical practice in the consensus document generated by the
NOSCAR group in NOTES is spatial orientation. However,
to date, despite its being identifi ed as a key issue of concern
by leaders in the fi eld, orientation has remained a challenge,
with few studies addressing it in the literature. Real - time
tracking of the endoscope tip with the ability to display the
location and orientation of the scope would be a signifi cant
advantage during NOTES [48] .
In the only study of an orientation device, recently the
NOTES research group from Queen ’s has described a novel
method using the Shape Tool (Northern Digital, Inc., Waterloo, Ontario, Canada), a customized catheter device embedded with multiple electromagnetic sensors in a single fl exible
tube, and an electromagnetic tracker (Aurora System,
Northern Digital, Inc.) [49] (Figure 24.24). The catheter is
2.2 mm in diameter and passes within an endoscope instrument channel allowing for three -dimensional imaging of the
shape and orientation of the endoscope.
Computer - assisted surgical (CAS) systems working with
3D information of the intervention site seem to be the future
area of research for better spatial orientation during NOTES
procedures [50]. Two such systems have been described. A
3D endoscope, called Multisensor - Time - of - Flight (MUSTOF)
endoscope, is actually being developed. Within these developments, an optical 3D time - of - fl ight (TOF) sensor is
attached to the proximal end of a common endoscope. The
3D depth information obtained by this enhanced endoscope
can furthermore be registered with pre -operatively acquired
(b)
extracorporeal, handheld magnets. (Reprinted from Sara L. Best, Wareef
Kabbani, Daniel J. Scott, et al. Magnetic anchoring and guidance system
instrumentation for laparo -endoscopic single -site surgery/natural orifi ce
transluminal endoscopic surgery: lack of histologic damage after
prolonged magnetic coupling across the abdominal wall. Urology
2011;77 :243 – 7 with permission from Elsevier.)
3D volumetric datasets such as CT or MRI. These enhanced
or augmented 3D data volumes could then be used to fi nd
the transgastric or transcolonic entry point to the abdomen.
Furthermore, such acquired endoscopic depth data can be
used to provide better orientation within the abdomen.
Moreover, it can also prevent intraoperative collisions and
provide an optimized fi eld of view with the possibility for
off - axis viewing.
In the Endosens approach, a tiny micro - electro - mechanical system (MEMS) tri -axial inertial sensor placed on the
distal tip of an endoscope can allow automated image orientation rectifi cation [50]. By measuring the impact of
gravity on each of the three orthogonal axes and correcting
for them, it provides a stable horizon on video - endoscopic
images. These devices are in development stages, undergoing evaluation in porcine models.
Lasers
Lasers can potentially be used for both diagnostic and therapeutic purposes in NOTES [51]. For diagnostics, lasers can
provide ultrahigh resolution, tissue discrimination, and
manifold types of fl uorescence detection. In addition, the
potential 3D capability promises enhanced recognition of
tissue type and pathological status. For translumenal procedures, the precise cutting and hemostatic capabilities of laser
energy, without transmission of mechanical forces, is of
special interest. The therapeutic potential ranges from induction of phototoxic effects over tissue welding, coagulation,
and tissue cutting to stone fragmentation. A 2 - micron
continuous - wave laser system has been evaluated in an
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Figure 24.24 The Shape Tool and display using an electromagnetic tracker. (Reprinted from [49] Sharyle Fowler, Mohamed S. Hefny, Elvis S. Chen,
et al. A prospective, randomized assessment of a spatial orientation device in natural orifi ce transluminal endoscopic surgery. Gastrointest Endosc
2011;73:123–7 with permission from Elsevier.)
acute animal experiment for NOTES procedures. It showed
promising capabilities for highly precise and safe dissection
[52]. Specialized NOTES endoscopes, in the future, will be
designed to incorporate suitable probes for laser fi bers with
advantageous light delivery possibility or innovative laser
beam manipulation systems. NOTES training centers may
support the propagation of the complex handling and the
safety aspects for clinical use to the benefi t of the patient.
lation over the years. There is a spectrum of simulator
devices available, from the high -end expensive models to
the more basic models that involve adaptation of the tools
already at hand in the skills laboratory [53]. Clark et al.
described their development of an inexpensive, realistic
robust simulator model, the natural orifi ce simulated surgical environment (NOSsE) for training in NOTES surgery
[54]. A laparoscopic box trainer was converted into an effective NOTES environment, in which many of the challenges
facing this new approach can be explored fi rst -hand in a
Training
laboratory setting. They found that training on this simula-
tor reduced the number of animals required for acquiring
Akin to the early development of laparoscopic surgery, interest in NOTES training is becoming widespread. Simulation
should be considered as the safest initial step for teaching
NOTES (see Chapter 27 for a detailed description). The use
of a simulator can reproduce some of the main challenges
facing the technique today and, as they improve, offer a
replacement to the animal model for training and education
for certain aspects of NOTES, particularly navigation, closure,
and new instrument development and validation. There has
been much advancement made in the fi eld of surgical simu-
basic skill sets and for validating new surgical protocols.
They concluded that the simulator acts as an aid to refi ning
experiments in a laboratory setting before moving onto trials
using animals.
Fiolka et al. recently reported their experience with a new
NOTES training simulator, the “ELITE” model [55]. The
ELITE is a full -size replica of a human female torso including
a gas -tight abdominal wall and offering various accesses to
the abdomen. A complete organ package including liver,
gallbladder, spleen, gastrointestinal tract, including the
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CHAPTER 24 Evolution and Future Developments of Instrument Technology for NOTES
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mesentery, and omentum is available for this system. Cholecystectomy and appendectomy can be simulated realistically
with this new training system. For more realistic conditions
during operations breathing -induced organ motion could be
integrated into this system. They have demonstrated the
construct validity of this simulation device in training NOTES
[56]. They found that a NOTES cholecystectomy could be
simulated successfully on the model and that signifi cant
progress by training could be demonstrated. They concluded
that the ELITE model can replace animal models at least in
acquiring the basic skills for the performance of a NOTES
procedure.
Conclusion
The advances in diagnostic and therapeutic endoscopy over
the past few years have yielded impressive results. At
present, there appears to be unprecedented invention, patenting of ideas, and development of devices to facilitate new
procedures. First barriers have been overcome, and all over
the world a lot of activities are under way. The long -term
effi cacy and utility of each platform, device, and technique
discussed has yet to be fully appreciated. The safe realization
and standardization of NOTES represents a real challenge
that necessitates close and effective interdisciplinary collaboration of surgeon, technicians, informatics, and endoscopic
and applied industries. At the moment interdisciplinary
research has to be performed carefully so that each profession can learn from each other to prevent drawbacks of the
kind that were present at the beginning of laparoscopic
surgery.
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25
https://t.me/med1917
Training the Gastroenterologist for NOTES
Nitin Kumar1& Christopher C. Thompson
1
Brigham and Women ’s Hospital, Boston, MA, USA
2
Harvard Medical School, Boston, MA, USA
Introduction
Since its introduction in the prior decade, natural orifi ce
translumenal endoscopic surgery (NOTES) has progressed
through multiple trials. Some translumenal procedures,
such as endoscopic necrosectomy, are fi nding increased clinical use. Despite these advances, NOTES has not achieved
widespread clinical application by gastroenterologists. Its
acceptance has been hampered not only by technical hurdles,
but also by the challenge of training gastroenterologists for
NOTES.
Technical challenges
The implementation of NOTES training for gastroenterologists has been analogized to the adoption of laparoscopic
procedures by surgeons. Indeed, laparoscopic cholecystectomy progressed from the initial human procedures to safe
and widespread application in just a few years. However,
basic laparoscopic methods took years to develop, and surgeons were familiar with open surgical techniques and anatomical variants. Thus, training largely focused on key
differences in specifi c technical aspects, including entry into
the abdominal cavity, exposure, and ligation. Gastroenterologists are familiar with fl exible endoscopy and endoscopic
instruments, but have variable knowledge of surgical principles, anatomy, techniques, and management of complications, which presents a signifi cant challenge.
Transmural access across the esophagus, stomach, colon,
bladder, or vagina presents its own set of cognitive and
technical challenges. Gastroenterologists may not be familiar
with puncture of any of these organs other than anterior
gastric puncture used in percutaneous gastrostomy, which
1,2
is largely devoid of adjacent vascular structures and viscera.
Understanding what structures are outside the lumen and
surgical anatomy is vital to performing many of these procedures safely. Additionally, as some procedures require triangulation of instruments, and one access point can result
in crossing of instruments or suboptimal visualization, the
gastroenterologist must also prepare for these technical
challenges.
Once outside the gastrointestinal lumen, the gastroenterologist must orient the camera and instruments in a three dimensional fi eld using landmarks projected onto a
two-dimensional screen. He/she must account for the orientation of the endoscope tip, which may be rotated or
retrofl exed. The constant three -dimensional cognitive
reconstruction required for spatial orientation and navigation increases mental workload beyond the procedure itself.
Once oriented, fl exible endoscopes can be diffi cult to maintain in position. While an assistant maintains the fi eld of
view during laparoscopic surgery, the endoscopist must use
a combination of navigation dials, rotational torque, and
coaxial scope movement to maintain view while performing
the procedure.
While gastroenterologists are comfortable with fl exible
endoscopes, the fl exible nature of these instruments presents
notable shortcomings when used in some NOTES procedures (detailed below). New devices and platforms for
NOTES present their own learning curve.
Instruments
One impediment to training of gastroenterologists for NOTES
has been the lack of effective, ergonomic, user -friendly
instruments that address the aforementioned technical
challenges.
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.
273
SECTION 3 Perspectives on NOTES
https://t.me/med1917
Dual-channel endoscope
Many NOTES procedures have been performed using a
double-channel endoscope (DCE). While gastroenterologists
are familiar with it, the DCE has shortcomings when used
in NOTES procedures. While a 10 mm laparoscope provides
380 lumens of illumination, typical endoscopes provide 25
lumens; this can make distant identifi cation of organs and
their colors diffi cult [1]. As the camera is located at the
endoscope tip, magnifi ed endoscopic views are useful in
close dissection; however, the entire instrument must be
retracted far from the operative site to provide a view of the
operative fi eld. As the instrument channels exit adjacent to
the camera and parallel to the camera (parallelism), triangulation and tissue manipulation are limited. The fl exibility
of the DCE means that forces may be attenuated and may
be transmitted at an articulated or retrofl exed angle. This
can make it diffi cult to obtain traction on organs and to drive
needles through tissue [2]. One study of force transfer via
endoscopic graspers and biopsy forceps found transfer rates
of 0.06 –0.08% maximum voluntary contraction/Newton
(MVC/N) versus 0.31 –3.56% MVC/N in laparoscopic graspers [3]. Furthermore, haptic feedback may be attenuated.
This makes assessment of tissue quality and tension more
diffi cult [4]. Finally, insuffl ation of the peritoneal cavity
often requires a supplemental source, and the irrigation and
suction channels of the DCE are insuffi cient to handle emergencies. Beyond high cognitive workload and extended procedure times, NOTES procedures performed with the DCE
can exact high physical demands. Although they use
purpose-designed instruments, 87% of laparoscopic surgeons report symptoms or injuries involving the neck, right
hand, or lower extremities; many endoscopists suffer mus-
culoskeletal symptoms in the left thumb, right wrist, neck,
and back [5,6]. The ergonomic characteristics of ring -transfer
and triangle -transfer tasks in a Stryker Endoscopy Park
Trainer Box (San Jose, CA) using a DCE (GIF -2T 160,
Olympus, Tokyo, Japan) have been examined using laparoscopic and endoscopic instruments [3]. Surgical attendings
and trainees performed the tasks while undergoing motion
capture and electromyography. Normalized procedure times
were signifi cantly higher using DCE than laparoscopy
(114.4 ± 11.9 s versus 20.0 ± 1.6 s, p < 0.05). Normalized
cumulative muscular workload was higher with DCE as well
(1315.8 ± 116.9% versus 153.9 ± 18.8%, p < 0.05), regardless of task. This was due to both longer activation time and
higher activation level; it was independent of the surgeon ’s
level of training.
NOTES platforms
A platform capable of effective triangulation, tissue traction
and counter -traction, dissection, and approximation could
decrease the cognitive and physical workload placed on the
NOTES endoscopist. A platform that separates camera and
instrument movement, can be moved fl exibly but stabilized
after positioning, allows camera anchoring, allows instrument rotation, effectively transmits force to its effectors, and
provides good haptic feedback is essential to ease adoption
of NOTES procedures by gastroenterologists. Powerful light
sources, air insuffl ation, and suction would be useful as well.
Currently available NOTES platforms, discussed here, already
possess some of these qualities.
The NOTES Scope (Olympus, Tokyo, Japan) is a DCE with
a lockable primary segment and a second bending segment
to allow for better positioning [1] (see Figure 25.1). The
(a)
274
(b)
Vertical
Horizontal
movement
Irrigation
channel
Figure 25.1 NOTES Scope (a) controls and
(b) distal tip. (From Shaikh SN [1], with
permission from Baishideng Publishing
Group Co.)
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