Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1550_Библиотеки_им_академика_М_И_Перельмана
.pdf
77
6 Exit Strategies
foreign body reaction. The use of a PEG tube for closure of gastrostomy access sites
has been reported [ 13 ] . This approach uses available materials but does result in a
visible scar, changing the scar-free idea of NOTES. Other mechanisms, such as the
application of glues, have been mentioned but have not come to widespread use for
reliable closure.
Evaluation of Adequate Transvisceral Closure
In the assessment of closure strategies, one must evaluate what is the best criterion
on which to judge transvisceral closure. Multiple published studies assessing trans-
visceral closure have not come to a consensus as to what is the ideal method for this
evaluation. Described methods include the use of air- and water-leak pressures,
appearance at necropsy, fl uoroscopic imaging, animal survival models, and abdomi-
nal microbiology as means of assessing quality.
When looking at the colorectal literature, intraoperative evaluation of the anasto-
mosis through leak testing has been shown to decrease both the rate of clinical and
radiographic anastomotic leak rate [ 2 ] . A similar trend has been shown in the bar-
iatric literature [ 14 ] . It is the hope that this assessment of intraoperative anastomotic
integrity will be able to decrease the rate of and/or prevent complications associated
with anastomotic breakdown.
One method for assessing closure following NOTES is through the use of pres-
sure testing. When critically evaluating the data available by authors from our insti-
tution and others [ 15 ] , the idea of bursting pressures as the ideal test for anastomotic
integrity falls short. In comparison of four independent transgastric closure devices
by pressure testing, most specimens failed at a nonsurgical site, implying that the
strength of the anastomosis created by all devices was superior to that of the native,
nonsurgical tissue [ 4 ] . Because of this fi nding, additional methods beyond pressure
measurement are required to assess adequate closure following NOTES.
Leak testing using fl uid or air, as is commonly performed in colorectal and bar-
iatric surgery, have been evaluated in the assessment of closure devices. Air-leak
tests have been performed using saline submersion under laparoscopic guidance
and using intraperitoneal pressure measurements as a marker for leak [ 12 ] . Fluid-
leak tests have been described using methylene blue injection under visual inspec-
tion and using contrast injection under fl uoroscopic assessment. As we have seen
with similar leak tests in humans following other procedures, the sensitivity and
speci fi city of these tests are not 100 %. The idea, however, behind anastomotic eval-
uation to decrease morbidity is an important one.
After performing a review of 46 studies describing 20 closure devices, Sodergren
et al. [ 8 ] concluded that there is no standardized method for testing anastomotic
integrity following NOTES in the published literature. The authors have proposed
an inclusive approach for evaluating transvisceral closure in an animal model for
future device development. Following the closure approach, radiographic imaging
with fl uoroscopy should be performed. Animals should be serially evaluated for
78
M.S. Phillips and J.L. Ponsky
sepsis or signs of peritonitis. Endoscopic examination of the closure area should be
performed on postprocedure day 7 to assess anastomotic integrity. Euthanasia
should be deferred until at least 7 days following the procedure, with a thorough
evaluation at necropsy of the abdomen and closure site. Explanted closure sites
should then be subjected to air- and water-leak testing, and histologic evaluation
should be performed on the closure area. This approach for evaluating closure meth-
ods remains to be tested but does offer a thorough approach into the investigation of
new closure devices.
In summary, NOTES offers many potential advantages, including less pain,
improved cosmesis, and shortened recovery. The widespread introduction of this
operative technique remains limited by reliable, safe transvisceral closure. Many
attempts have been made to develop closure methods that will consistently maintain
a high standard of repair with low patient morbidity. Devices continue to face chal-
lenges of providing full-thickness tissue incorporation, visualizing closure sites
adequately, and avoiding inadvertent injury to surrounding structures. Options for
closure have included open or laparoscopic suture closure, endoscopic suturing, clip
devices, endoscopic stapling, T-tag closures, tunnel-based approaches, and others.
Once designed, the platform on which to assess a NOTES closure continues to
allow room for improvement. Despite the multiple publications and ideas at this
time, no single approach has shown superiority in providing reliable results with
low morbidity. This challenge of appropriate transvisceral closure continues to be
an obstacle that must be conquered before NOTES can be introduced into wide-
spread use.
Con fl ict of Interest The authors have no relevant fi nancial disclosures or con fl icts of interest.
References
1. Davies AH, Bartolo DC, Richards AE, et al. Intra-operative air testing: an audit on rectal anas-
tomosis. Ann R Coll Surg Engl. 1988;70:345–7.
2. Beard JD, Nicholson ML, Sayers RD, Lloyd D, Everson NW. Intraoperative air testing of col-
orectal anastomoses: a prospective, randomized trial. Br J Surg. 1990;77:1095–7.
3. Sclabas GM, Swain P, Swanstrom LL. Endoluminal methods for gastrotomy closure in natural
ori fi ce transenteric surgery (NOTES). Surg Innov. 2006;13(1):23–30.
4. Schomisch S. Overcoming barriers to natural ori fi ce translumenal endoscopic surgery (NOTES).
OhioLINK Electronic Theses and Dissertations Center. 2009. Available at:
http://olc1.ohiolink.
edu:80/record=b27746215~S0
. Accessed on 20 June 2012.
5. Rattner D, Kalloo A. ASGE/SAGES Working Group on natural ori fi ce translumenal endoscopic
surgery, October 2005. Surg Endosc. 2006;20:329–33.
6. Hawes R. ASGE/SAGES Working Group on natural ori fi ce translumenal endoscopic surgery
white paper, October 2005. Gastrointest Endosc. 2006;63:199–203.
7. Arezzo A, Morino M. Endoscopic closure of gastric access in perspective NOTES: an update on
techniques and technologies. Surg Endosc. 2010;24(2):298–303.
8. Sodergren MH, Coomber R, Clark J, et al. What are the elements of safe gastrotomy closure in
NOTES? A systematic review. Surg Innov. 2010;17(4):318–31.
79
6 Exit Strategies
9. Natural Ori fi ce Surgery Consortium for Assessment and Research 2009 Working Group on
closure. 2009. Available at:
http://www.noscar.org . Accessed 14 Mar 2011.
10. Kang WD, Kim SM, Choi HS. Vaginal evisceration after radical hysterectomy and adjuvant
radiation. J Gynecol Oncol. 2009;20(1):63–4.
11. Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transa-
nal endoscopic microsurgery does not increase short-term complications. Am J Surg.
2004;187(5):630–4.
12. Dray X, Gabrielson KL, Buscaglia JM, et al. Air and fl uid leak tests after NOTES procedures:
a pilot study in a live porcine model. Gastrointest Endosc. 2008;68:513–9.
13. Marks J, Rosen M, McGee M, et al. A novel technique for management of endoscopic gastro-
tomy following natural ori fi ce transvisceral endoscopic surgery. Surg Endosc. 2006;20:S287.
14. Shin RB. Intraoperative endoscopic test resulting in no postoperative leaks from the gastric
pouch and gastrojejunal anastomosis in 366 laparoscopic Roux-en-Y gastric bypasses. Obes
Surg. 2004;14(8):1067–9.
15. Ryou M, Fong DG, Pai RD, et al. Transluminal closure for NOTES: an ex vivo study compar-
ing leak pressures of various gastrotomy and colotomy closure modalities. Endoscopy.
2008;40(5):432–6.
81
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_7, © Springer-Verlag London 2013
Keywords Laparoscopy • Minimally invasive • LESS • Mini-laparoscopy • NOTES
Introduction
The Impetus for Mini-Laparoscopic Systems
One of the driving forces behind the development of laparoscopy has always been
to decrease the morbidity of a laparotomy incision. The evolution from open sur-
gery to laparoscopy was the initial and most dramatic step in this progression. Mini-
laparoscopy, whereby the size of each laparoscopic instrument was decreased to the
limits of useful instrumentation, was thought to be the next natural evolution in
accomplishing this goal. By developing the smallest tools possible to safely and
effectively perform surgery, and if each access point creates pain and potential com-
plications, one might limit the trauma inherent to a given operation by miniaturizing
each access point.
Traditional laparoscopy utilizes laparoscopes between 5 and 10 mm in diameter,
affording excellent resolution and lighting. Mini-laparoscopy refers to the transition
to even smaller scopes and instruments. Mini-laparoscopic systems are those that
utilize these newer instruments and their technologies to provide an environment
for patients to have smaller incisions and, theoretically, less overall pain.
J. E. Humphrey , M.D. (*) • D. Canes , M.D.
Lahey Clinic Institute of Urology, Institute of Urology,
Lahey Clinic Medical Center, Tufts University School of Medicine ,
41 Mall Road , Burlington , MA 01805 , USA
e-mail: john.e.humphrey@lahey.org ; david.canes@lahey.org
Chapter 7
Mini-Laparoscopic Systems
John E. Humphrey and David Canes
82
J.E. Humphrey and D. Canes
A multitude of terms have been applied in this arena, including mini-laparoscopy,
micro-laparoscopy, small-diameter laparoscopy, and needlescopic surgery. The
published literature is broadly inclusive as regards the actual diameter of the instru-
ments, ranging from 1.9 to 5 mm. For the purposes of this chapter, we de fi ne mini-
laparoscopy to encompass the use of instruments 3.5 mm or smaller. We exclude
5 mm since they are widely regarded as conventional pure laparoscopy. Our goals
are to review the origins of mini-laparoscopy and describe its use as a standalone
technique, as an adjunct to standard laparoscopy, as well as its resurgence as an
adjunct to the latest scarless surgical techniques, including laparoendoscopic single-
site surgery (LESS) and natural ori fi ce translumenal endoscopic surgery (NOTES).
Early History
Gynecologic surgeons were the fi rst to incorporate mini-laparoscopy and publish
their experience. The fi rst reports describe its use for diagnostic laparoscopy in
1991, but the results were hampered by the prevailing technology, given the low
levels of light and poor resolution through the smaller laparoscopes [ 1 ] . As instru-
mentation and optics advanced, the technique showed more promise not only for
diagnostic purposes, but also for therapeutic interventions. Bauer et al. described
mini-laparoscopy use for diagnosis as well as for obtaining peritoneal access for
conventional laparoscopy in patients with extensive intraabdominal adhesions [ 2 ] .
A 1.9-mm laparoscope was used through a Veress needle port. Although one may
argue that the resolution did not have to be profound for the purpose, the visualiza-
tion through these diminutive scopes was felt to be comparable to conventional for
the diagnosis and staging of endometriosis and adnexal adhesions in patients with
pelvic pain [ 3 ] .
The progression of mini-laparoscopy eventually led other specialties to extend
its early indications. General surgeons have used mini-laparoscopy for traditionally
laparoscopic cases such as cholecystectomy [ 4 ] and appendectomy [ 5 ] , with com-
parable outcomes, including hospital stay and perioperative complications. In these
retrospective reviews, perioperative outcomes were equivalent between standard
and mini-laparoscopic techniques, and a trend was apparent that more mini-laparo-
scopic cases were converted to open surgery. Tu and Advincula [ 6 ] reviewed the rise
of mini-laparoscopic systems as they relate to gynecologic surgery. They point out
both the bene fi ts and limitations of using smaller instruments. The main deterrent to
smaller instruments as described above has been the limitations of the optics inher-
ent in smaller scopes. The 5- and 10-mm endoscopes use a rod-lens system that
allows the operator to see with great clarity, and include a variety of viewing angles,
from the 0° lens to 30°, 45°, and 70° lenses. Smaller 2-mm scopes use semirigid and
de fl ectable fi ber optic bundles, which, although they have improved, still provide
less resolution and a decreased depth of fi eld compared to the larger lenses.
Durability has also been a concern with smaller instruments, given the inherent
fragility with decreasing size.
83
7 Mini-Laparoscopic Systems
The initial experience with mini-laparoscopy (speci fi cally 2-mm instruments) in
the fi eld of urology was reviewed by Soble and Gill in 1998 [ 7 ] . They described the
use of “needlescopic” instruments in 42 procedures. At the time, certain tools were
unavailable with a diameter of 2 mm, such as a clip-applier and hook-blade elec-
trode. Not all procedures were pure mini-laparoscopy. The extirpative procedures
required one 10-mm port and one 5-mm port to supplement the remaining 2-mm
ports. The 5-mm port was necessary given the lack of certain 2-mm instruments at
the time. The authors report that 90.5 % of the cases were successful, with three
cases converted to conventional laparoscopy and one to an open procedure. The
authors highlighted inferior optics (resolution, clarity, and light-carrying capacity),
lack of instrument rigidity, and weaker grasping capability as inherent disadvan-
tages. The advantages were threefold: improved cosmesis, decreased analgesic
requirements, and possibly reduced hospital stay. The learning curve was steep,
however, and patient selection important (the procedure converted to open was in an
obese patient). Although the technology at the time was inferior to 5- and 10-mm
instruments, the authors hoped that future developments would make these proce-
dures more feasible.
Although these early results of needlescopic surgery in urology were promising,
the anticipated surge was not realized. The reasons are multifactorial but may be
due to the fact that standard laparoscopy was itself diffusing nationwide in its own
right, and surgeons may have been reluctant to simultaneously adopt instrumenta-
tion that was harder to control, de fl ectable, and more dif fi cult to obtain and main-
tain. More recently, even as laparoscopic techniques have become commonplace,
attention has turned to other rising technical advances such as robotics and, more
recently, single-site surgery. Now, with renewed interest in patient cosmesis and
perioperative pain management, mini-laparoscopy has reentered the conversation.
Nomenclature
In an effort to standardize the terms used to describe NOTES and LESS within the
literature, the Urologic NOTES Working Group published nomenclature for both
techniques [ 8 ] . NOTES is designated as a surgical procedure utilizing a natural
ori fi ce to puncture a hollow viscera to enter an otherwise inaccessible body cavity.
If there are additional ports/instruments passed transabdominally, this is designated
as a hybrid NOTES procedure (if >75 % is performed via the natural ori fi ce).
However, if the natural ori fi ce is not the main port of the procedure, it is considered
a NOTES-assisted surgery.
LESS, or laparoendoscopic single-site surgery, refers to a minimally invasive
operation performed through a single incision/location using conventional laparo-
scopic or newer instrumentation ( fi xed prebent or de fl ectable fl exible laparoscopic
instruments). This term was put forward to incorporate previous terms, such as
E-NOTES, SILS, OPUS, SPA, VSUS, SPL, and SIL, among others. LESS was
further de fi ned in 2010 at a consensus conference, where the ancillary use of
84
J.E. Humphrey and D. Canes
1.9-mm needle instruments was embraced, in the hopes that it would promote the
advancement of the bourgeoning fi eld [ 9 ] . In addition to a single-site port used for
the majority of the operation, the needle instruments can be placed through a 2-mm
Veress needle port requiring only a skin puncture and no true incision. There are
several potential advantages to using mini-laparoscopic adjuncts to LESS: enhanced
patient safety, increased intraoperative dexterity, and a greater repertoire of LESS
surgery to more complex procedures. In addition, and most importantly, needle-
scopic instruments help to restore surgical triangulation without substantially
detracting from the overall cosmesis with LESS (Fig. 7.1 ). Also noted are the limi-
tations, however, of reliability, strength, design, and lack of variety in needle instru-
ments. Even with these dif fi culties, it is clear that the use of ancillary needle
instruments will continue to provide invaluable aid to surgeons performing LESS
procedures, particularly during their learning curves.
What Bene fi ts Are Proven?
With every purported surgical advance, one must avoid the allure of technology for
technology’s sake alone. Our patients must always be the focus, such that a successful
operation fi ts the surgical indication for a given disease process. The ultimate goal of
an operation is de fi ned by the patient’s clinical disease and the indication for perform-
ing the operation. This must be kept in mind with new technology that is geared toward
smaller incisions. Micali et al. [
10 ] pointed out that LESS has only been shown to give
a bene fi t in cosmetic outcome. Functional and oncological outcomes are lacking.
Moreover, with extirpative procedures, an incision may need to be extended anyway at
the end of a case for specimen retrieval, therefore nullifying the cosmetic advantage.
One technique that has been evaluated in the urologic literature to conceal the sin-
gle-site scar is LESS performed through an umbilical incision, or U-LESS (previously
coined “embryonic natural ori fi ce transumbilical endoscopic surgery,” or E-NOTES).
Fig. 7.1 LESS donor
nephrectomy, whereby
( arrow ) mini-lap site does not
detract from the overall
cosmesis
85
7 Mini-Laparoscopic Systems
In a review article, Canes et al. [ 11 ] described the technique, instrumentation, and
perioperative outcomes of U-LESS in both nonurologic and urologic procedures. An
intraumbilical incision is used to place various types of ports (e.g., TriPort, Olympus,
Center Valley, PA) that can accommodate one 12-mm instrument and two 5-mm
instruments. The procedures completed range from extirpative (e.g., nephrectomy) to
reconstructive (pyeloplasty). Live-donor nephrectomy is one procedure in which mini-
laparoscopy has been used in conjunction with LESS: A needlescopic grasper was
used through a 2-mm port for tissue retraction. This is an example of the use of mini-
laparoscopy as an adjunct to LESS in early series. The technical challenges of LESS
include triangulation, retraction, instrument crowding, and patient-related limitations.
There is a real difference in technique compared with conventional laparoscopy, and
therefore a steep learning curve even for fully trained laparoscopists. However, with
ever-improving instrumentation, the future direction of LESS is promising. The addi-
tion of mini-laparoscopy as an adjunct to LESS has been important in easing the
transition from standard laparoscopy.
Technique and Instruments
The armament of mini-laparoscopic instruments has grown since its initial use. For
2-mm instruments, the MiniSite
TM
MiniPort
TM
(Covidien, Dublin, Ireland) combines
a Veress needle with an outer sheath (Fig. 7.2 ) that is left in place as a needlescopic
port [ 7, 12 ] . As such, it serves a dual purpose. These skin punctures only need a
single Steri-strip or dermal adhesive alone for closure, negating the need for suturing.
An apparent cosmetic advantage to their use is therefore apparent (Fig. 7.1 ). Table 7.1
shows the available trocars, instruments, and scopes for mini-laparoscopy.
Applications
Pure Mini-Laparoscopy
The use of mini-laparoscopy as a standalone technique is limited in urology.
However, diminutive instrumentation has had particular allure in the pediatric arena.
The treatment of pediatric hydroceles by mini-laparoscopic high-ligation of the
Fig. 7.2 MiniPort
TM
(Covidien, Dublin, Ireland)
for 2-mm access
86
J.E. Humphrey and D. Canes
processus vaginalis has been described [ 13 ] . Orchiopexy and orchiectomy for cryp-
torchidism has also been performed with success [ 14 ] .
Adult applications have included varicocelectomy [ 15 ] and adrenalectomy [ 16 ] .
For varicocelectomy, three 3.5-mm trocars were used with successful ligation of all
spermatic veins and preservation of spermatic arteries and lymphatics. The authors
report success with only a 0.6 % recurrence rate in 87 patients treated. An impres-
sively large series of mini-laparoscopic adrenalectomies was performed for 112
patients with adrenal tumors of less than 5 cm. The diameter used for the working
ports was 2 mm, while the tumor was extracted from an umbilical incision. The
operative time was longer compared to conventional laparoscopy, but the feasibility
of mini-laparoscopic adrenalectomy was demonstrated.
Nonurologic pure mini-laparoscopy has seen a broader application. As previously
mentioned, gynecologists have used mini-laparoscopy for diagnostic purposes as well
as pelvic pain mapping [ 6 ] , and general surgeons for cholecystectomy [ 4 ] and appen-
dectomy [ 5 ] . Pediatric laparoscopic inguinal hernia repair using three 3.5-mm trocars
with corresponding telescope and instruments has also been shown to be an effective
alternative to standard open herniotomy [ 17 ] . Overall, pure mini-laparoscopy has
solidi fi ed its presence in the surgical community as an effective standalone technique.
Conventional Laparoscopy with Mini-Laparoscopy
Recoiling somewhat from purists, surgeons began to incorporate the selective use of
mini-laparoscopic instrumentation during standard laparoscopy. Indeed, the patient
Table 7.1 Mini-laparoscopic instrumentation
Name Size (mm) Manufacturer
Trocars
ENDOPATH mini/micro trocars nonoptical 2–3 Ethicon
ENDOPATH access needle 3 Ethicon
Minisite
TM
MiniPort
TM
introducer system 2 Covidien
Instruments
KOH ultramicro needle holder 3 Karl Storz
Pediatric laparoscopic instrument set
a
3 Karl Storz
Reusable laparoscopic instruments 2 Covidien
Minisite
TM
ENDO GRASP
TM
2 Covidien
Minisite
TM
Minishears
TM
2 Covidien
Scopes
0° and 30° laparoscope
a
3 Karl Storz
0° laparoscope 3 Olympus
a
Designed for pediatric use, therefore shorter length
87
7 Mini-Laparoscopic Systems
can still gain cosmetic bene fi t from using needlescopic instruments during conven-
tional laparoscopic procedures where applicable. In this way, 2- or 3-mm instru-
ments replace the traditional 5-mm working ports, while still utilizing a larger
10–12-mm trocar for the endoscope and larger instruments. This combines excel-
lent optics with improved cosmesis, without sacri fi cing triangulation. An example
of such a technique has been described for laparoscopic adrenalectomy with selec-
tive use of needlescopic instruments [
18 ] . A 12-mm umbilical port is used with the
addition of two 2-mm working ports in the left subcostal region in order to complete
the operation. The same concept can be applied to any laparoscopic procedure, and
as such the combinations of standard and mini-laparoscopic instruments are limited
only by surgical creativity.
Nonurologic applications of this technique have been demonstrated as well.
Ventral hernia repair has been performed using both conventional and mini-
laparoscopic ports [ 19 ] . A main 12-mm port is introduced as well as a variable
number of working ports (2–5-mm) individualized based on the size, location, and
number of hernia defects present. Similarly, total laparoscopic hysterectomy has
bene fi ted from needlescopic instruments by using a 5-mm umbilical laparoscope
with 3-mm working ports [ 20 ] . The port size can safely be reduced with improve-
ment in cosmesis and no detriment to the surgeon’s technical performance.
NOTES and Mini-Laparoscopy
The use of NOTES in urology has mainly been described utilizing transvaginal
access for the portal of entry. Pure NOTES transvaginal nephrectomy without any
transabdominal incisions/ports is already a reality [ 21 ] . However, without assis-
tance from an umbilical port or needle instruments, the operation is time-consuming
and technically dif fi cult. Hybrid NOTES nephrectomy was previously described
[ 22 ] , using two abdominal 5-mm trocars to aid in visualization and triangulation.
Although this still requires abdominal incisions, it points toward the advantage in
having abdominal instruments to aid in the procedure.
Mini-laparoscopic abdominal instruments have successfully bridged the gap in
nonurologic NOTES procedures. The term used to describe them is “mini-laparo-
scopic-assisted natural ori fi ce surgery,” or MANOS [ 23 ] . Gynecological procedures
such as ovarian cystectomies, oophorectomies, and salpingo-oophorectomies have
been completed in this fashion. Appendectomy has also been described using the
MANOS technique. The use of mini-laparoscopy with NOTES combines the cos-
metic and triangulation advantage of additional mini-laparoscopic abdominal ports
with the optimal insuf fl ation, irrigation, extraction, and larger instruments utilized
by the transvaginal port.
Porpiglia et al. described a similar urologic technique (not actually coined as
MANOS), with transvaginal NOTES-assisted mini-laparoscopic nephrectomy [ 24 ] .
They describe their experience with fi ve patients undergoing nephrectomy with a
12-mm vaginal port and three 3.5-mm transabdominal ports. In contrast to a pure
Соседние файлы в папке Библиотека им академика М.И. Перельмана