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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1127_Библиотеки_им_академика_М_И_Перельмана
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SECTION 1 Development of the NOTES Concept
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Left
(a)
12 o’ clock position
Upper
Right
Lower
(1) Image
orientation:
positioning to
the right
Right
(b)
Liver &
Upper
(3) Image orientation: inline (straight) positioning
gallbladder
1
(2) Image
orientation:
positioning to
the left
Right
Spleen
2
Pelvis
3
Upper
Right
Upper
Figure 5.3 Schematic of standard
endoscope imaging orientation. (a) Standard
fl exible endoscope at neutral position. Left,
the endoscope shaft preferably bends toward
the 12 o ’clock position; right, orientation of
imaging at neutral position. (b) Flexible
endoscope imaging orientation during a
transgastric procedure, showing different
endoscopic positioning inside the abdominal
cavity.
otherwise be necessary in the case of laparoscopy. Any
adverse outcome associated with the viscerotomy is unacceptable unless no other conventional access option is available. Major complications may arise from NOTES access,
including fi stula and intracavitary abscess [8]. In translumenal procedures for cancer resection, cancer cells can
theoretically spill across into the peritoneal cavity and
become a potential risk for abdominal cavity cancer cell
implantation.
One of the major goals for NOTES is minimization of
peritoneal soiling (Figure 5.5) and robust closure of the
42
viscerotomy. The most important measure for avoiding peritoneal contamination is to secure the point of access during
the entire endoscopic procedure. Proposed solutions for
these problems include the use of an overtube -style port
(Figures 5.6 and 5.7) [20,21]. These ports, extending through
the NO route to the entry point and inside the body cavity,
could theoretically act as sterile conduits maintaining a
stable and secure access and minimize peritoneal contamination. A sterile conduit will defi nitively be required for
implantation of prosthetic devices such as mesh for hernia
repair [22].
CHAPTER 5 NOTES Access Techniques
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Figure 5.4 Combined access approach. A
“pure ” NOTES sigmoid resection is
exemplifi ed. For mesosigmoid dissection, one
endoscope is inserted transgastrically. A
transanal manipulator is used for retraction.
Peritoneal cavity
Stomach
Sigmoid
Bladder
Uterus
Vagina
Mesosigmoid
Pancreas
Figure 5.5 Schematic of peritoneal contamination. A fl exible endoscope
is being inserted transgastrically inside the peritoneal cavity.
Access techniques: endoscopic ultrasound and
pre -insuffl ation of the abdominal cavity
Another major concern for NOTES procedures is viscerotomy technique safety. As in laparoscopic surgery, entering
the abdominal cavity may incur damage of surrounding
viscera and blood vessels (Table 5.4). Pneumoperitoneum
has become a standard initial procedural step prior to gastric
viscerotomy and transvaginal NOTES procedures [8,23].
(a)
(b)
Figure 5.6 Schematic of NOTES sterile port. (a) The port is inserted
using a viscerotomy at the upper rectum/lower sigmoid. A previously
placed purse string suture at the entry point is used to secure the port in
place. (b) A fl exible endoscope is advanced into the peritoneal cavity
through the sterile internal conduit port. (Reproduced from Wilhelm D,
Meining A, von Delius S, et al. An innovative, safe and sterile sigmoid
access (ISSA) for NOTES. Endoscopy 2007; 39(5):401–6 with permission
from Georg Thieme Verlag KG, Stuttgart.)
Laparoscopic guidance has also been used for increasing
NOTES access safety during this early period of adoption,
and its combination with abdominal insuffl ation provides
the most reliable method for choosing the transgastric access
spot [24]. This can be accomplished by inserting a 5 mm
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SECTION 1 Development of the NOTES Concept
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trocar and laparoscope through a pre -insuffl ated abdomen
(Figure 5.8).
Endoscopic ultrasound (EUS) has been proposed for
guiding entrance to the peritoneal and thoracic cavities
(Figure 5.9) [25], although it has not been used in clinical
NOTES. In animal studies, EUS guidance appears helpful in
targeting access into the peritoneal cavity and may increase
safety for NOTES access into the mediastinum, stomach, and
rectum [25,26]. However, EUS -guided access may not completely eliminate the risk of adjacent visceral damage [26].
EUS-guided access assisted with pre -injection of water
(hydroperitoneum) has been proposed to decrease these
complications [27]. In the setting of portal hypertension,
splenic vein thrombosis, and an atypical access location, e.g.,
close to the greater curve of the stomach, EUS could be
useful to identify potential vessels within the intended viscerotomy site. It is unlikely that more widespread use of EUS
will have a role in defi ning access over familiarity with surgical anatomic landmarks.
Specimen removal
Specimen removal may be a vexing problem for the surgeon
after successfully accomplishing a NOTES procedure through
a size -limited viscerotomy. A serious complication such as
esophageal laceration with mediastinitis after attempting to
remove a calculous gallbladder transorally during a transgastric cholecystectomy procedure has been described [8].
Pre-operative ultrasound assessment of gallbladder contents
Table 5.4 Human NOTES access -related complications.
Route Complication
Vaginal Intraoperative: vaginal bleeding, vulvar laceration, rectal
serosa laceration, rectal perforation, colon perforation, cul
de sac bleeding, urinary bladder perforation, small bowel
injury
Postoperative: vaginosis, vulvitis, dehiscence of colpotomy
closure, abscess in the Douglas space, dyspareunia, cul de
sac postoperative hemorrhage, ulceration in the vaginal
wall, colpitis, mild hematuria, vaginal bleeding, vaginal
granuloma
Oral Intraoperative: hematoma and bleeding of the greater
curvature, esophageal hematoma and esophageal
laceration due to large stone impaction (24 mm),
pneumothorax
Postoperative: peritonitis, esophageal perforation and
mediastinitis
Conversions and other technical issues not related to access technique
were excluded.
Figure 5.7 Gastric access port (Apollo Endosurgery, Austin, TX, USA) .
(b)
(a)
Figure 5.8 NOTES preinsuffl ation and laparoscopic surveillance (human cadaver). (a) The posterior vaginal wall being exposed using laparoscopic
graspers. (b) A trocar being inserted transvaginally into the Douglas pouch. (c) The access is secured using a multiport device.
(c)
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(a)
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CHAPTER 5 NOTES Access Techniques
devices exist only as rigid instruments [31]. Although transvaginal access may allow passage of large specimens, such
as the entire kidney [32], enlarging other visceral access sites
may increase the risk for access bleeding, devascularization,
and diffi culty in closure.
Oral route: transoral/transesophageal/trans
gastric/transduodenal access
Since the fi rst description of a per -oral appendectomy case
report more than 5 years ago [6], the oral route has been
the most appealing access route for NOTES. The oral route
has received attention for transoral esophageal submucosal
myotomy for achalasia (Table 5.5) [7]. Also, transgastric
endoscopic necrosectomy has an increasing role in the treatment of infected pancreatic necrosis in critically ill patients
without organized necrosis in an earlier infected fl uid phase
(ascites) [33], which is a NOTES procedure rapidly becoming
a standard of care. The oral route provides access to four
points of entry: sublingual, esophagus, stomach, and duodenum (Table 5.4). It enables procedures within the anterior
cervical compartment (thyroid and parathyroid) and mediastinum, as well as the thoracic, retroperitoneal, and peritoneal cavities.
(b)
Figure 5.9 Schematic of endoscopic ultrasound -guided NOTES access.
(a) A needle followed by a guidewire is advanced into the peritoneal
cavity under EUS guidance. (b) A dilating balloon is advanced over the
guidewire to the entry point for enlarging the access and allowing
passage of the endoscope.
has been proposed to predict success in transgastric NOTES
gallbladder extraction [28].
Depending on the size and nature of the specimen and
the viscerotomy size, extraction of the specimen may require
morcellation and fragmentation [29]; however, this procedure may induce dissemination of an unsuspected malignant tumor [30]. Current commercially available morcellation
Transoral access
The transoral access [1] has been described as an exclusively
endoscopic approach using three incisions in the vestibule
of the mouth to achieve a triangulated access using rigid
instruments (Figure 5.10) [1]. The aim of this approach is
to enter into anatomically defi ned fascial planes in the neck,
avoiding potential postoperative sequelae such as dysphagia
following sectioning and scarring of the muscle layers of the
neck. Indications and surgical technique are discussed in
Chapter 18. This procedure uses standard rigid endoscopic
instruments with a diameter of 3.7 mm and especially
designed trocars with working length of 190 mm and diameter of 5.5 mm.
Transesophageal access
The most popular transesophageal access in humans has
been through entering the submucosal space based on the
submucosal endoscopy with mucosal fl ap (SEMF) technique.
This transesophageal access has been explored for treatment
of achalasia and it may also provide a valuable access to the
mediastinal space, enabling NOTES cardiac intervention and
mediastinal lymph node sampling [13,34,35].
Submucosal Endoscopy with Mucosal Flap (Video
5.1)
The technique of SEMF was developed for using the submucosal space as a working environment for endoscopic interventions [36]. In this technique, the submucosal layer is
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SECTION 1 Development of the NOTES Concept
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Table 5.5 Human transoral procedures (excluding transgastric pancreatic necrosectomy procedures).
Route Reference Year Country
Transgastric Marks et al. 2007 USA 1 PEG rescue
Pearl et al. 2007 USA 4 Peritoneoscopy
Rao et al. 2008 India 3 Peritoneoscopy + liver biopsy
Hyder et al. 2008 Pakistan 1 Peritoneoscopy (gastric outlet obstruction)
Steele et al.
Swanstrom et al.
Tabusadze et al. 2009 Georgia 6 Cholecystectomy
Auyang et al. 2009 USA 4 Cholecystectomy
Horgan et al. 2009 USA 8 Cholecystectomy
Dallemagne et al. 2009 France 11 Cholecystectomy
Salinas et al. 2010 Peru 27 Cholecystectomy
Park et al. 2010 Sweden 3 Appendectomy
Campos et al. 2010 Brazil 1
Nau et al. 2011 USA 100 Peritoneoscopy (20 pancreatic masses)
Sweetser et al. 2011 USA 1 PEG rescue
Transoral Wilhelm et al. 2011 Germany 8 Thyroidectomy
Transesophageal Horgan et al.
Ionue et al.
Transduodenal Bingener et al.
Total 264
a
a
b
b
a
2008 USA 3 Peritoneoscopy + liver biopsy
2008 USA 4 Cholecystectomy
2011 USA 5 Esophageal myotomy
2011 Japan 56 Esophageal myotomy
2010 USA 2 Perforated ulcer omental patch repair
n
10 Appendectomy
1 Tubal ligation
1 Appendectomy
4 Sleeve gastrectomy (specimen removal)
Procedure
Abdominal abscess drainage
a
Results published solely as abstracts in congresses and meetings,
b
latest results published as abstracts in congresses and meetings.
Figure 5.10 Transoral access for thyroidectomy. Note the
transilluminated skin below the larynx.
mechanically tunneled and used as an offset entry into the
thoracic or peritoneal cavity. At fi rst, a small submucosal
bleb is created with a small volume of injected saline to
identify the submucosal tissue plane (Figure 5.11a). Then,
in the original method, high -pressure millisecond bursts of
CO
(CO 2 Duster, American Recorder Technology Inc., Simi
2
Valley, CA) are injected through a standard 23 -gauge needle
catheter into the bleb dissecting the submucosa and creating
a gas -fi lled bleb extending down the esophagus (Figure
5.11b). Hydroxypropyl methylcellulose (0.83% solution) is
then injected to prevent gas escape and to maintain the bleb.
A small mucosal incision is made at the upper margin of the
combination gas bleb and fl uid cushion with a needle knife.
The submucosal dissection is then carried out using a biliary
stone retrieval balloon through the mucosal incision. Balloon
dissection has been effective enough to obviate the need for
the initial gas dissection. Others dissect the submucosal
space using electrocautery [37]. The mucosal entry site and
dissected submucosal space should permit inserting an endo-
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(a)
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CHAPTER 5 NOTES Access Techniques
(c)
CO
burst
2
(b)
(d)
Figure 5.11 Submucosal endoscopy with mucosal fl ap technique. (a) Saline solution injection test to confi rm needle -tip entry into the submucosa.
(b) Gas submucosal dissection with high -pressure CO
closure of the muscular defect with overlying mucosal fl ap. (Reproduced from Sumiyama K, Gostout CJ, Rajan E, et al. Transesophageal mediastinoscopy
by submucosal endoscopy with mucosal fl ap safety valve technique. Gastrointest Endosc ;65(4):679–83, © 2007 Elsevier.)
scope with an (optionally) attached endoscopic mucosal
resection (EMR) cap. Opposite and at least 4 –5 cm from the
mucosal entry point and within the submucosal space, the
muscular layer can be incised or resected by the cap EMR
technique to create an open myotomy into the mediastinum
(or peritoneal cavity) (Figure 5.11c). Key to this method,
the isolated overlying mucosa is used as a biologic safety fl ap
valve to prevent contamination through the myotomy. At
the end of the procedure, the mucosal entry site can be
closed by simple mucosal apposition with clips or other
closure devices (Figure 5.11d).
. (c) Muscular -layer resection with cap -EMR technique inside the submucosal space. (d) Offset
2
also useful for transgastric procedures since it permits in -line
and secured positioning of the endoscope insertion tube
[13,40]. Prerequisites for choosing an ideal gastric access spot
to the peritoneal cavity are mid -distance from the greater
and lesser curvatures and, consequently, to the main gastric
vessels; a safe distance from other organs; and excellent
access to the gastric wall for a strain -free closure [24]. The
most ideal site for peritoneal access is along the anterior wall
of the stomach, in the distal body (pre -antral). This access
point allows the endoscope insertion tube to remain reasonably straight for navigation within the abdominal cavity.
Muscular layer sampling
Offset closure
Muscular defect
Gastrotomy with a pull -type sphincterotome, also called
Transgastric peritoneal access
Transgastric access allows entrance into the peritoneal and
retroperitoneal cavities. For the peritoneal cavity, peritoneoscopy is the most common reported procedure in humans.
It also allows inspection of the abdominal wall and adhesiolysis [38]. For accessing the peritoneal cavity, the gastrotomy should be initiated either with laparoscopic visualization
or an alternative technique such as the percutaneous endoscopic gastrostomy (PEG) approach to reduce the incidence
of visceral injury associated with transgastric peritoneal
entry [39]. The SEMF submucosal tunneling technique is
sphincterotome “cut” gastrotomy, was used to access the
peritoneal cavity in the fi rst NOTES report from Kalloo and
his colleagues [41]. In this method, initial entry to the peritoneal cavity is established by using an electrosurgical
endoscopic needle knife. The resultant fi stula is extended
with a sphincterotome to a size (approximately 15 –20 mm)
suffi cient for the endoscope insertion. A non -thermal or
Seldinger -type needle is not used because puncture is diffi cult and does not allow easy passage of dilating devices. The
use of this method has been declining in favor of balloon
gastrotomy.
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SECTION 1 Development of the NOTES Concept
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(a)
(c)
Figure 5.12 Schematic of a balloon gastrotomy. (a) Creation of the entry point using a needle knife. (b) Advancement of a guidewire through the
entry point. (c) Advancement of a dilating balloon through the guidewire. (d) Advancement of the endoscope into the peritoneal cavity. The balloon has
been snugged to the tip of the endoscope to facilitate endoscope insertion.
(b)
(d)
Balloon gastrotomy (Figure 5.12, Video 5.2)
Initial access to the peritoneal cavity is also performed with
a needle knife puncture. The gastrotomy is then created
with a >18 mm diameter balloon dilator. This procedure can
be facilitated by using a multilumen needle knife, which will
allow immediate placement of a guidewire catheter. Once
48
placed, the guidewire can be left in place to serve as a visual
marker. This can be helpful for localization during closure
of the gastrotomy and should the endoscope inadvertently
become withdrawn into the stomach.
Once the balloon has been fully infl ated, the endoscope
is snugged up to the balloon and both are immediately
CHAPTER 5 NOTES Access Techniques
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advanced into the peritoneal cavity. This step of the procedure can be technically challenging because of any offset
alignment of the endoscope relative to the balloon and its
catheter, along with the inherent fl exibility of the endoscope
insertion tube. This challenges a straight pushing force,
resulting in the tip of the endoscope tending to defl ect away
from a centered entry through the gastrotomy. This is most
problematic if the access point within the anterior wall is too
proximal, requiring the endoscope tip to be fl exed beyond
30–45 degrees. When the endoscope cannot pass through
the entry, repeat dilation with a larger -diameter balloon or
a supplemental electrosurgical incision may be required.
Specially designed overtubes have been engineered to minimize this problem. Balloon gastrotomy has technical advantages to an electrosurgically cut gastrotomy, enabling a
full-thickness opening in a more controlled fashion. Mechanical (expansile) disruption of the gastric wall may be less
traumatic to blood vessels and reduce the risk of bleeding.
In case of bleeding, the balloon may be used for tamponade.
Novel combination multichannel devices with a needle
knife, guidewire channel, and a balloon for the sequential
enlargement may expedite the procedure (Figure 5.13) [42].
A modifi cation of this technique uses gastric full -thickness
plication prior to balloon gastrotomy [43]. This creates a
ridge of tissue that acts as a valve, allowing visualization
while maintaining gastric distention when the endoscope is
withdrawn from the peritoneum into the lumen.
PEG-assisted transgastric access (Figure 5.14)
The foundation of the percutaneous -assisted transgastric
access technique is based on the percutaneous endoscopic
gastrostomy described approximately 30 years ago. The
anterior gastric wall is opposed against the abdominal wall
by gastric insuffl ation, pushing away adjacent viscera and
therefore minimizing injury to adjacent organs. Besides
safety, advantages of this technique may also include facilitation of the gastrotomy closure by placing stay sutures [44].
In one experimental study, the trocar used for puncturing
the stomach can be used for creation and enlargement
(balloon disruption) of the gastric point of entry. A hybrid
needle grasper is then inserted through the same percutaneous site to perform hybrid NOTES procedures [45].
Transgastric retroperitoneal access (Figure 5.15)
Current retroperitoneal access in humans is typically for
transmural drainage of organized infected pancreatic necrosis (Video 5.1). The ideal access site is opposite that for
peritoneal access: posterior gastric wall, mid -position relative to lesser and greater curve, and pre -antral (at 2 cm
proximal to the incisura). Needle knife puncture followed
by guidewire placement and balloon gastrotomy are used.
This technique may also access small pancreatic tumors and,
furthermore, assess the resectability of pancreatic tumors
through endoscopic retroperitoneoscopy [46].
Transduodenal access
In the clinical setting, the transduodenal approach has been
recently used by our group exclusively for endolumenally
assisted perforated ulcer omental patch repair (unpublished)
(Table 5.5). The procedure is started with the patient in the
supine position. A laparoscopically assisted endoscopic pre evaluation of the stomach, duodenum, and abdominal
cavity is undertaken. If the perforated ulcer allows insertion
of a standard fl exible endoscope, translumenal omental
patch repair is performed by navigating the per -orally
inserted endoscope into the peritoneal cavity, which can be
supplemented by balloon dilation. After multi -liter peritoneal saline irrigation, a free portion of omentum is grasped
and drawn into in through the perforation (Figure 5.16a).
The resulting omental plug is endolumenally fi xated using
endoscopic clips (Figure 5.16b). If the ulcer size is smaller
than 10 mm, a combined endolumenal -laparoscopically
assisted omental plug is performed. The omentum is laparoscopically directed to an open large hemostatic clip, used as
a forceps, and the omental fi xation is then performed endoscopically onto the duodenal mucosa (a similar technique is
also used for perforated gastric ulcers).
Figure 5.13 Multilumen balloon device with needle knife.
Vaginal route: transvaginal access
Historically, the vaginal route was the fi rst access used for
gynecologic endoscopy. Gynecologists pioneered the transvaginal access technique using a cul -de-sac approach called
culdoscopy in the early 1940s. This fi rst version of culdoscopy consisted of inserting a rigid endoscope with a light
source using a posterior cul -de-sac incision. This procedure
was initially done with the patient in knee –chest position,
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Peritoneal cavity
Stomach Stomach
Peritoneal cavity
Pancreas
(a)
Peritoneal cavity
Stomach
Pancreas
(c)
Figure 5.14 Schematic of a PEG -assisted transgastric access. (a) The stomach has been insuffl ated to oppose the anterior gastric wall against the
abdominal wall. A needle followed by a guidewire is inserted percutaneously into the stomach. (b) Two sutures are placed percutaneously to facilitate
closure. (c) Following creation of the point of entry, the endoscope is inserted into the gastric cavity for the NOTES procedure. (d) Entry point closure is
facilitated by fastening the two percutaneous sutures.
(b)
Stomach
(d)
Pancreas
Peritoneal cavity
Pancreas
which permitted better visualization with the assistance of
gravity and the negative pressure of the abdomen.
After a long hiatus and due to the increased preference
for videolaparoscopy, the culdoscopy technique has been
revisited for non -pelvic procedures [47,48]. In 2003 [48], a
laparoscopic cholecystectomy human case was performed
using a trocar placed in the cul -de-sac to allow insuffl ation,
and assist visualization and specimen removal. The cholecystectomy procedure was carried out using 2 –3 mm microlaparoscopy ports to minimize visible scars. Laparoscopic
surveillance was performed during the introduction of the
vaginal trocar to prevent complications.
50
With the advent of NOTES, the vaginal route became
appealing to minimize the use of surgical instruments
through the abdominal wall. In 2007 the vaginal route was
used for both instrumentation and visualization, which
enabled the fi rst transvaginal laparoscopically assisted cholecystectomies [49,50]. In this technique the laparoscope was
used for visualization of the point of entry and one trocar
was used for gallbladder retraction. Exposure of the gallbladder remained an issue for these procedures until 2009, when
totally transvaginal cholecystectomy was possible due to
insertion of extra vaginal ports or a second endoscope used
solely for gallbladder retraction [18]. The transvaginal route
Figure 5.15 Retroperitoneal transgastric access. A fl exible endoscope is
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being transgastrically advanced into the lesser sac for pancreatic
exploration. (From Moran EA, Bingener J, Murad F, et al. The challenges
with NOTES retroperitoneal access in humans. Surg Endosc
2011;25(4):1096–100. With kind permission from Springer Science +
Business Media.)
CHAPTER 5 NOTES Access Techniques
may allow access to the retroperitoneal cavity, enabling surgical procedures on the kidney (and collecting system),
adrenal, and distal pancreas [51]. As with any other access,
the vaginal route has several advantages and disadvantages
to be taken into account before its usage (Table 5.6).
Transvaginal access techniques
Most of the current transvaginal access techniques described
for NOTES are adapted from the previous experience in
culdoscopic procedures. Pre -operative gynecologic examination and imaging studies such as pelvic ultrasonography and
computed tomography (CT) scan are advised to exclude
operative contraindications, such as adhesions involving the
pouch of Douglas [52]. In a study encompassing 1589
patients undergoing culdoscopy, 5.7% had abnormalities
discovered during the pre -operative clinical examination
(chiefl y endometriosis of the rectovaginal space or a fi xed
retroverted uterus), precluding transvaginal access [53].
Inspection of the cervix therefore is important to identify
potential contraindications such as endometriosis. Lateral
displacement of the cervix to either side of midline signifi es
endometriosis in women with infertility or pelvic pain.
When the examiner attempts to push the cervix toward
midline, the shortened ligament is stretched, eliciting pain.
Some would consider this sign a contraindication to culdoscopy and an indication for laparoscopy [54].
Free portion of omentum
Gl tract
(a)
Free portion of omentum
Gl tract
(b)
Natural orifice omental patch repair
Figure 5.16 Schematics of a transduodenal access used for treating perforated ulcers. (a) Translumenal omental transfer. Note the endoscopic clipping
device being used for grasping the omentum. (b) Endolumenal omental fi xation.
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