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SECTION 1 Development of the NOTES Concept
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A diagnostic laparoscopy for the purpose of pre -therapeutic
staging should be performed when pre -operative imaging
procedures have demonstrated a T stage > T2 and curative
resection appears to be possible [33]. According to currently
available data, a staging laparoscopy may be recommended
for distal esophageal, gastric, pancreatic, or hepatocellular
carcinoma.
Diseases of the peritoneum
In addition to the diagnosis of peritoneal carcinosis, laparoscopy in conjunction with targeted biopsy also permits the
diagnosis of mesothelioma and peritoneal tuberculosis [36].
This is the reason why diagnostic laparoscopy is indicated in
patients with fever of ambiguous origin.
Ascites of unclear etiology
In cases of a negative outcome of cytologic and microbiologic
procedures for the diagnosis of ascites, laparoscopy is an
effi cient method to confi rm the diagnosis. Using laparoscopy
for the indication of ascites of unknown origin, Trujillo and
co-workers were able to confi rm the diagnosis in 43 of 48
patients (89%) [37].
Contraindications
The minimally invasive nature of laparoscopy has modifi ed
the known contraindications for this procedure. Bleeding
after laparoscopic organ biopsy can be controlled by hemostatic procedures such as compression or coagulation procedures (argon plasma coagulation, monopolar coagulation),
or the application of fi brin adhesive under visual control in
case of oozing hemorrhage.
Coagulation disorders are no more than a relative contraindication today. Because of this fact mini -laparoscopy
provides marked advantages especially in cases of coagulation disorders or signifi cant portal hypertension. In our own
series of more than 1000 mini -laparoscopic investigations in
conjunction with liver biopsy, performed in patients with
coagulation disorders (INR > 1.5; platelets < 50/μl or both)
and severe portal hypertension, we noted prolonged and
relevant bleeding (Figure 7.2) [38,39].
As massive ascites hinders the investigation, the clinician
should try to perform a puncture before considering the
investigation.
General contraindications for laparoscopy are bacterial
peritonitis and ileus, because of the risk of bowel perforation. Obstructive cholestasis should be excluded by ultrasonography before performing a liver biopsy (Table 7.1).
In cases of severe cardiac or pulmonary disease it is advisable to weigh the benefi ts and risks of laparoscopy. However,
even in intensive care patients, laparoscopy can be performed with a relatively low risk of complications [8].
Occurrence of bleeding requiring argon plasma
coagulation in regard to underlying disease
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Viral hepatitis
Figure 7.2 Overall occurrence of bleeding in patients with marked
coagulopathy after mini -laparoscopic liver biopsies. (Modifi ed from
Hoffman et al. Mini -laparoscopy in the endoscopy unit: safety and
outcomes in over one thousand patients. World J Gastrointest Endosc
2011;3:6–10.)
Table 7.1 Contraindications of mini -laparoscopy.
Infection of the peritoneum
Surgery with risk of adhesions
Ileus
Obstructive jaundice
Caput medusae (bleeding from abdominal cavity)
Even with a severe heart failure and a respiratory insuffi ciency a
mini-laparoscopy can be performed in the intensive care unit
p = <0.001
p = <0.001 p = <0.001
Autoimmune
hepatitis
Cirrhosis
Others
Thus, relative contraindications for conventional laparoscopy include severe coagulation disorders and marked portal
hypertension with caput medusae, in both cases mainly due
to the risk of hemorrhage from vessels of the abdominal
wall. Adhesions after surgery are also a relative contraindication for conventional laparoscopy.
Investigation technique
Laparoscopy can be performed in the endoscopic unit. The
investigation is greatly facilitated by an examination table
that can be adjusted and tilted because it offers a means of
fi xing the patient appropriately. Two physicians are needed
for the examination. A non -sterile nurse is needed to
perform the non -sterile steps of the procedure (adjusting the
examination table, operating gas, and video connections,
sedation during the investigation, etc.).
Instrumentation
Apart from the Veress needle the most important instrument is the laparoscope (conventional laparoscopy, mini -
72
Figure 7.3 Introducing the pneumoperitoneum using the Veress needle.
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CHAPTER 7 Mini-laparoscopy in the Endoscopy Unit
laparoscopy) (Figure 7.3). Additional instruments include an
N
O insuffl ator (CO 2 insuffl ation is not used because it
2
causes painful irritation of the peritoneum) and a tilting
table with a device for fi xing the patient.
Investigation
An ultrasound investigation should be performed before
commencing on the laparoscopy in order to visualize the size
of organs and shunting in case of portal hypertension, and
to rule out intrahepatic cholestasis prior to liver biopsy.
The core of the mini -laparoscopic technique is, in addition
to the Veress needle, the 0 ° mini -optics with a diameter of
1.9 mm.
The corresponding trocar with a diameter of 2.75 mm can
be used for the optics as well as the Veress needle (diameter
2.3 mm); it is provided with a connection for N
tion. Mini -laparoscopy is usually performed under intravenous sedation, as described previously. The abdominal
wall should be cleaned with Betadine solution and covered
with sterile drapes. Puncture of the abdominal wall is performed at the point of Kalk, which is located 2 cm left and
cephalad of the umbilicus (Figure 7.4). The puncture itself
is performed with a Veress needle of 2.3 mm diameter,
through a trocar of 2.75 mm diameter (Richard Wolf GmbH,
Tübingen, Germany), after local anesthesia of the puncture
site with 10 ml of mepivacaine 1%. The Veress needle is then
introduced through the skin, fascia, and peritoneum while
the patient performs a Valsalva maneuver (Figure. 7.4)
(Video 7.1).
After controlling the position of the Veress needle, the
pneumoperitoneum is introduced by injection of 10 –20 ml
NaCl via insuffl ation of about 1.5 –2 l of N
needle is then replaced by an optical instrument (Video 7.2).
A xenon light source should be used for illumination of the
O insuffl a-
2
O.The Veress
2
abdominal cavity. The abdomen is then inspected by the
usual procedure. The pro -grade 0 ° mini -optics is a slight
hindrance to complete inspection of the surface of the liver,
especially below the diaphragm. Nevertheless, at least 70%
of the surface can be inspected. The use of a rotating operation table is recommended for optimal inspection of the
liver. The patient may be slightly rotated to the left while
the upper body is kept elevated. Besides macroscopic assessment of the liver, the upper abdomen should be systematically examined for signs of portal hypertension, such as
splenomegaly, dilated intra -abdominal vessels, or peritoneal
carcinosis (Video 7.3). A liver biopsy can then be performed
under direct laparoscopic visualization with a 14, 16, or 18
gauge biopsy needle via a second 3 mm incision in the upper
right quadrant of the abdomen (Figure 7.5) (Videos 7.1 and
7.4). The puncture site may be selected in the right or left
lobe of the liver.
If vigorous bleeding is detected immediately after the liver
biopsy or the bleeding does not stop after about two minutes,
a small trocar with a diameter of 3 mm can be inserted at
the puncture site of the liver biopsy in the abdominal wall
and the bleeding can be treated with argon plasma coagulation (APC) under direct visual control. If necessary, in
patients with a high risk of bleeding the second trocar should
be inserted in the right upper quadrant of the abdomen
before performing the liver biopsy in order to rapidly apply
APC immediately after the biopsy (Video 7.5). Coagulation
is considered successful when no further signs of active
bleeding are observed after two minutes. Focal lesions can
be punctured by snap biopsy. This is also the method of
choice for puncture of suspicious lesions in the peritoneum,
especially peritoneal carcinosis (Figure 7.1).
After the investigation has been concluded and desuffl ation performed, no skin suture is required at the site of
puncture (Video 7.6).
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(a)
Figure 7.4 Technique of mini -laparoscopy. (a) After disinfection of the the abdominal wall, puncture is performed at the point of Kalk with a Veress
needle under the Valsalva maneuver. (b) Following the creation of a pneumoperitoneum, the Veress needle is replaced by an optical instrument. The
abdomen is then inspected by the usual procedure. A liver biopsy can then be performed under direct laparoscopic visualization.
Monitoring after the procedure
When the procedure has been uneventful the patient
by performing a coagulation procedure (APC) or by
application/injection of fi brin adhesive (Figure 7.6).
should remain in bed for a further four hours. During this
time, pulse and blood pressure should be controlled and
recorded at half -hour intervals. The patient should be asked
Complications
about his/her subjective well being and perception of pain.
If the investigation has been devoid of complications the
patient may ingest a small quantity of fl uid after two hours
and take a light meal after four hours. The patient is discharged on the morning after the investigation. It should be
noted that a mini -laparoscopy can be performed on an outpatient basis.
Nearly all of the severe lethal complications mentioned
in the published literature are due to bleeding, especially
of the abdominal wall, during placement of the pneumoperitoneum or the introduction of a guide sleeve with the
trocar [40]. Prolonged lethal bleeding or bile leaks with
subsequent lethal bilious peritonitis have also been reported
after organ biopsies (liver). Risk factors for post -biopsy
Hemostasis
After organ puncture (liver, spleen) the site of biopsy is
observed carefully. In case of marked bleeding or persistent
mild bleeding ( >5min), hemostasis should be accomplished
bleeding include limited coagulatory function, portal
hypertension with liver cirrhosis, and malignant organ invasion [39,41–43]. In the presence of these risks, after an
organ biopsy the examiner should perform prophylactic
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(b)
Figure 7.4 (Continued)
hemostasis (e.g., by means of coagulation) even in cases of
mild bleeding. In case of bile leaks, coagulation of the biopsy
site is indicated in every case in order to prevent bilious
peritonitis.
According to cumulated statistics the general complication
rate for diagnostic laparoscopy is 1.86% [40]. Serious complications requiring hospitalization or surgery occurred in
0.15% of patients. Lethal complications after laparoscopic
investigations occurred in 0.05% of cases or, in other words,
one death was registered per 2000 investigations.
In a recently published study we carried out a retrospective analysis of 1071 consecutive mini -laparoscopy-guided
liver biopsies, all performed at a single endoscopy unit [39].
The corresponding literature and our own retrospective
analysis confi rm the value of diagnostic laparoscopy as a
useful tool for the diagnosis of a variety of GI diseases. The
primary reasons for giving preference to mini -laparoscopy
rather than percutaneous biopsy were twofold: (i) the
former procedure permits control of potential bleeding com-
plications; and (ii) the procedure permits macroscopic evaluation of the liver (the severity of liver damage may be
underestimated if the assessment is based solely on histological investigation of biopsy material) (Figure 7.7). Any
bleeding that occurs immediately after liver biopsy during
mini-laparoscopy can be managed in an endoscopy unit.
Apart from yielding additional information on macroscopic
investigation, mini -laparoscopic liver biopsy permits histologic assessment of liver damage in patients with advanced
cirrhosis in whom percutaneous biopsy might be contraindicated because of the high risk of bleeding [22]. Mini laparoscopy is also useful for staging malignancies of the
upper GI tract, such as gastric and pancreatic cancer, and
sensitive for the diagnosis of peritoneal carcinosis [24–35].
When used to evaluate liver disease, mini -laparoscopy
permits macroscopic inspection of the liver and the ability
to perform targeted biopsies of focal lesions on the surface
of the liver. Besides, biopsies of the spleen can be performed
via diagnostic laparoscopy [44].
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Figure 7.5 Liver biopsy performed under direct laparoscopic visualization with a biopsy needle via a second 3 mm incision.
(a) (b) (c)
Figure 7.6 Laparoscopic management of bleeding after liver biposy. (a) Bleeding puncture site after liver biopsy. (b,c) Argon plasma coagulation.
The minimally invasive technique of mini -laparoscopy,
which requires smaller insertions in the abdominal wall
than conventional laparoscopy, has been shown to be useful
for these diagnostic non -surgical procedures.
In our recently published study we found that bleeding
from liver biopsy occurred signifi cantly more often in patients
with cirrhosis than non -cirrhotic patients, which resulted in
a more frequent need for APC at the biopsy site (Figure 7.6)
[39]. Presumably as a result of APC, we encountered no major
post-interventional bleeding in our patients. Liver biopsy can
be performed safely even in patients with decompensated
Child’s C cirrhosis accompanied by portal hypertension and
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(a)
Figure 7.7 Macroscopic evaluation of liver diseases. (a) Coagulation of a bleeding with argon plasma after liver punter, (b) successful coagulation with
any active bleeding. (Modifi ed from Hoffman et al. Mini -laparoscopy in the endoscopy unit: safety and outcomes in over one thousand patients. World J
Gastrointest Endosc 2011; 3:6–10.)
(b)
Figure 7.8 Liver cirrhosis with portal hypertension, mini -laparoscopic visualization.
in those with marked coagulopathy after administration of
fresh-frozen plasma and/or platelets (Figure 7.8).
In conclusion, mini -laparoscopy-guided liver biopsy is a
safe and effective technique for evaluation of patients with
liver disease [44]. It can be performed in an endoscopy unit
and permits macroscopic assessment of the liver as well as
the possibility to perform liver biopsy in patients with high
risk of bleeding. The procedure aids the clinician in the
management of complications and permits histologic diagnosis in patients with advanced liver disease or cirrhosis.
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Chapter video clips
Video 7.1 Puncture of the abdominal wall.
Video 7.2 Replacement of the Veress needle by an optical
instrument, and inspection of the abdomen.
Video 7.3 The use of a rotating operation table for optimal
inspection of the liver.
Video 7.4 Liver biopsy.
Video 7.5 Performance of a coagulation procedure (Argon
plasma coagulation).
Video 7.6 Liver biopsy specimen.
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8
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Single - port Surgery
Ricardo Zorron , 1 Katherine Gash , 2 & Anthony R. Dixon 3
1 Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany
2 Frenchay Hospital, Bristol, UK
3
North Bristol (Frenchay) & SPIRE Bristol Hospitals, Bristol, UK
Introduction
Since its conception, laparoscopic cholecystectomy has
remained virtually unchanged. During this timeframe, many
surgeons have suggested modifi cations to the technique but
have failed to prove further benefi ts. Single - port surgery
(laparo - endoscopic single - site surgery; single - incision laparoscopic surgery) is more capable of fulfi lling the surgeon ’ s
desire to be less invasive than formal laparoscopy. Laparo endoscopic single - site (LESS) surgery also involves minimal
shift of acquired knowledge and skills, and is now being
progressively incorporated into surgical practice. In 1996
Navarra et al. [1] reported on a single - incision laparoscopic
cholecystectomy using transabdominal sutures. His series
was performed using two trocars placed via a single umbilical incision, and transabdominal traction sutures helped to
perform the procedures. Piskun and Rajpal [2] used the
same concept of multiple trocars deployed via a single
umbilical incision in 1999 using two 5 mm ports and traction
sutures, also described by Bresadola et al. [3] , and this same
group presented 95 cases in 1996 [4] . Their report compared
this approach with standard laparoscopic cholecystectomy
and demonstrated lower pain scores in the single - port group.
One trocar appendectomy using a working trocar with
camera was described by Esposito in 1998 [5] .
Cuesta et al. suggested the “ invisible cholecystectomy, ”
defying surgeons again to achieve no - scar surgery [6] . Mini laparoscopy has also developed rapidly in recent years,
allowing reduction of incisions and surgical trauma [7] .
These techniques were subsequently applied and reported
by others as well, but although innovative, added benefi ts
were not evident. More recently, the idea of “ reduced - port
surgery, ” such as the three - port umbilical cholecystectomy
[8] , has been published and employed by many centers.
Although benefi ts may be minimal, if the same procedure is
done safely, there is no reason to insert a superfl uous port.
The next palpable evolution is there: from multiport laparoscopy to single - incision surgery.
Philosophy of s ingle - p ort a ccess
The subsequent paradigm shift in surgery was achieved by
successful clinical cases of natural orifi ce surgery in 2007,
and since then impressive publications of clinical series,
including multicenter studies, have shown acceptable results
for the new techniques [9,10] . Despite the objective of completely avoiding incision - related morbidity, natural orifi ce
translumenal endoscopic surgery (NOTES) is being adopted
at a slow pace, mainly due to technical diffi culties and the
barrier of vaginal access and fl exible surgery for the general
surgeon. This change of surgical philosophy has energized
both surgeons and industry to research important issues and
develop new technology to allow concepts such as single port laparoscopic surgery to become a reality.
A competing surgical technology to transvaginal cholecystectomy is transumbilical surgery. Possibly infl uenced by all
these ideas, since 2007 a new approach has emerged using
fewer incisions, with multiple instruments entering through
a single port device or incision, or using retraction sutures.
Many different techniques have been developed in this short
period, suggesting the strong desire for change and improvement, but a lack of complete satisfaction with the methods
designed so far.
The group of Curcillo in Philadelphia introduced the
concept of single - access surgery using different trocars
inserted in different fascial orifi ces, but through the same
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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umbilical skin incision, allowing better triangulation using
available laparoscopic instruments [8,11] (Video 8.1). During
the development of their technique, the group was concerned about possible “ sacrifi ce ” of the critical view of safety,
theoretically not being able to achieve the proper angle of
separation of the common and cystic ducts [11] . It was
decided early in its development that single - access cholecystectomy would revolve around the safe dissection and
maintenance of a familiar procedure rather than around
instrumentation or access devices. This maintenance of
safety was paramount, such that the technique could be
safely reproducible by large numbers of surgeons and therefore offered to more patients.
Further in the experience, they added a fourth instrument
through the same incision to allow lateral retraction, which
enabled safe visualization of Calot ’ s triangle. Using separate
trocars instead of an umbilical single - access device allowed
for each instrument to have independence of movement;
movement of one instrument does not affect movement of
others. The surrounding fascia allows this unique property
not found in multiport trocars. Independence of movement
at the level of the trocars then permits the other instruments
to safely dissect within the triangle of Calot and provides
uninhibited retraction. These ergonomic advantages will be
proven by further research.
Potential b enefi ts and h azards
Prashanth Rao et al., in their preliminary experience in
2008, noted that there were three main issues to be solved
by future technology for single - access surgery [12,13] . The
fi rst is that the instruments entering through a single port
led to clashing of instruments and the so - called “ chopsticks
effect ” with absolute loss of triangulation. This was minimized in their later cases by using modifi ed graspers and
dissectors angulated at the shaft. The second diffi culty was
related to collisions of the instruments with the tangential
light cable on the telescope, which was avoided by the use
of a camera with a coaxial light cable. The insertion of
10 mm clip appliers for large cystic ducts was the third technical problem, and was solved by the use of 5 mm clip appliers with 10 mm jaws.
Advantages of the laparoscopic transumbilical cholecystectomy include [14] : (i) the technique is similar to traditional laparoscopic surgery; (ii) the minimization of skin
incision morbidities (temporary incision pain and muscle
spasms, avoidance of epigastric vessel injury); (iii) one incision can be hidden within the umbilicus, rendering the
procedure virtually scarless (superior cosmesis); (iv) the
method allows the surgeon to “ convert ” the procedure to a
conventional laparoscopic approach at any point during the
operation, if needed; (v) compared with NOTES techniques,
laparoscopic transumbilical cholecystectomy is simpler and
Table 8.1 Advantages and disadvantages of the laparoscopic
transumbilical cholecystectomy.
Advantages Disadvantages
Technique is similar to laparoscopy Reduced triangulation
Minimization of skin incision
morbidities
Scarless procedure (occult incision) More diffi cult dissection
Conversion putting further trocars Instrument size limitation
One wound closure Hernia and wound infection
Ideal for specimen extraction (for
large organs)
Instrument collisions
Incision larger than specimen
(for small organs)
possibly safer; and (vi) the ability to use a rigid instrument
for retraction and conventional laparoscopic instruments
and clips.
Disadvantages of laparoscopic transumbilical cholecystectomy include: (i) the smaller degree of instrument triangulation compared with that in conventional laparoscopy and
the lack of lateral retraction during dissection of the triangle
of Calot; (ii) the parallel and close positioning of the right -
and left - hand instrument shafts tends to result in “ crowding ” of the laparoscope and instruments; (iii) the clashing
of instruments and the laparoscope is common and, as
such, signifi cant coordination between the surgeon and the
camera person is essential; and (iv) dissection through a
single port is more diffi cult than in conventional multiport
laparoscopy (Table 8.1 ).
Instrument size can also be limited by the port ’ s dimensions, as most manufactured ports require either the use of
a 5 mm camera or the sacrifi ce of a 10 mm channel to insert
the 10 mm laparoscope and therefore the requirement for a
5 mm clip applier inserted via a 5 mm channel. As this kind
of cystic duct closure is not always suitable for 5 mm clips,
alternative methods such as ligatures have to be employed,
increasing the learning curve and operative time.
Further concerns about hernia formation, wound
hematoma, and infection could be raised. As the incision
required for some ports is 2.5 – 4 cm, it could be considered
a mini - laparotomy, with increased risk of incisional hernia,
adhesions, and intestinal obstruction after time. As the technique is still very young, there is no data to support these
theoretic disadvantages yet, as such complications may
occur several years after the procedure. An increased risk of
early wound complications, such as infection, may occur as
the skin incision and subcutaneous dissection are wider than
in multiple trocar laparoscopy. Regarding the fascial incision,
industrial ports are ideal when a larger specimen extraction
is needed (spleen, kidney, colon), as the mini - laparotomy is
appropriate for these specimens. On the contrary, the incision needed for the port may seem exaggerated for smaller
organs such as the gallbladder, or when no extraction is
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