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88
J.E. Humphrey and D. Canes
NOTES nephrectomy, this technique offers a simpler approach with less dif fi culty
without compromising the cosmetic bene fi t. Most importantly, the presence of
needlescopic instruments arguably made this pioneering work possible. There will
no doubt be more uses of mini-laparoscopy with NOTES in urology since these
techniques are in their infancy, and such hybrid approaches add a degree of safety
to these challenging procedures. Table 7.2 shows the use of mini-laparoscopy as an
adjunct to NOTES procedures, in both urologic and nonurologic literature.
LESS and Mini-Laparoscopy
Many of the fi rst reports of LESS incorporated needlescopic instrumentation as
adjuncts. The use of ancillary needle instruments during LESS restores triangula-
tion, improves dexterity, may enhance patient safety and cosmesis, and broadens the
scope of LESS within urology. The reader should certainly not get the impression
that mini-laparoscopic instrumentation is required for LESS, as surgeons have made
signi fi cant strides successfully with pure LESS [ 26– 28 ] . However, pure LESS with-
out the use of adjunctive needlescopic instruments can be frustrating, given the poor
Table 7.2 NOTES and mini-laparoscopy
Year Author
Procedure(s) (number
performed) Access Comments
Urologic
2011 Porpiglia
et al. [
24 ]
Nephrectomy [
5 ] One 12-mm
transvaginal
port
Simpler than pure
NOTES, with
less operative
time and
technical
dif fi culty
Three 3.5-mm
abdominal
ports
Nonurologic
2007 Tsin et al.
[
23 ]
Ovarian cystectomy,
oophorectomy,
salpingo-oophorecto-
mies, myomectomies,
appendectomies, and
cholecystectomies
(total = 100)
One 12-mm
transvaginal
port
Describes a variety
of NOTES
procedures
aided by mini-
laparoscopy
Three 3-mm
abdominal
ports
2009 Noguera
et al. [
25 ]
Cholecystectomy [
16 ] One 12-mm
transvaginal
port
Safe technique to
bridge NOTES
with laparos-
copy, without
abdominal wall
incisions
One 5-mm
umbilical port
One 3-mm right
upper
quadrant port
89
7 Mini-Laparoscopic Systems
Table 7.3 LESS and mini-laparoscopy in urology
Year Author
Procedure(s) (#
performed) Access Mini-laparoscopic function Comments
2010 Kawauchi et al. [
29 ] Pyeloplasty [ 1 ] Triport at umbilicus Used for dif fi cult dissection,
left hand grasper, and
placement of drain
postprocedure
Insertion of 2-mm port helps to
reduce operative time
2-mm miniport at left
subcostal area
2007 Raman et al. [
30 ] Right nephrectomy [ 1 ] Three adjacent umbilical
5-mm trocars
Used for liver retraction Not needed during two
left nephrectomies
One 3-mm subxyphoid
trocar
2008 Desai et al. [
12 ] Pyeloplasty [ 1 ] Umbilical triport Aid in retraction and triangula-
tion for pyeloplasty
suturing
Suggest use of needlescopic
port facilitates triangulation
during LESS
One 2-mm needlesopic
left subcostal port
2008 Gill et al. [
31 ] Donor nephrectomy [ 4 ] Umbilical triport Used for initial pneumoperito-
neum, adds triangulation
and retraction
Selective use of 2-mm
instruments expands scope
of single-site surgery
One 2-mm needlescopic
left subcostal port
2008 Aron et al. [
32 ] Partial nephrectomy [ 5 ] Umbilical triport Used for retraction and
dissection
2-mm site heals with excellent
cosmesis
One 2-mm needlescopic
right lower quadrant
port
2009 Ganpule et al. [
33 ] Donor nephrectomy [ 11 ] Umbilical triport Used for retraction in 11 of 13
patients
Majority of cases bene fi ted from
extra-small grasper
Extra 3- or 5-mm port
(continued)
90
J.E. Humphrey and D. Canes
Year Author
Procedure(s) (#
performed) Access Mini-laparoscopic function Comments
2009 Desai et al. [
34 ] Pyeloplasty [ 4 ] Umbilical triport Used with left hand during
suturing
Complex suturing for recon-
struction facilitated by
needlescopic instruments
Ileal ureter [
1 ] Variable-position
left-sided needle-
scopic port
Psoas hitch [
1 ]
2009 Desai et al. [
35 ] Simple nephrectomy [ 5 ] Umbilical triport Assist with retraction and
suturing
Demonstrates wide variety in
procedures
Radical nephrectomy [
3 ] One 2-mm needlescopic
port in various
positions
Donor nephrectomy [
18 ]
Partial nephrectomy [
6 ]
Kidney cyst excision [
1 ]
Pyeloplasty [
20 ]
Ureteral reimplant [
2 ]
Ileal ureter [
3 ]
Adrenalectomy [
1 ]
2009 Raman et al. [
36 ] Right nephrectomies
(not reported)
Three adjacent 5-mm
umbilical trocars
Used for liver retraction Only with right nephrectomy for
liver retraction
One 3-mm subxyphoid
trocar
2009 Tracy et al. [
37 ] Pyeloplasty [ 15 ] Three adjacent 5-mm
umbilical trocars
5-mm used for suturing and
drain site, 3-mm for liver
retraction in right
pyeloplasty
Note dif fi culty in performing
suturing without extra port
One 5-mm trocar
midaxillary line
One 3-mm subxyphoid
port (right side only)
Table 7.3
(continued)
91
7 Mini-Laparoscopic Systems
Year Author
Procedure(s) (#
performed) Access Mini-laparoscopic function Comments
2010 Raybourn et al. [
38 ] Nephrectomy [ 2 ] Umbilical triport Used for retraction Only used in 2 of 11 nephrecto-
mies due to dif fi cult
retraction
One 2-mm needlescopic
grasper in one case
One 5-mm grasper
through 3-mm
incision in second
case
2010 Canes et al. [
39 ] Donor nephrectomy [ 19 ] Umbilical triport Tissue retraction and dissection Solidi fi es technique previously
described
One 2-mm needlescopic
grasper in
hypochondrium
92
J.E. Humphrey and D. Canes
triangulation with instrument clashing and a steep learning curve. As a result, the
early LESS literature saw a resurgence in needlescopic instruments. Table 7.3 dem-
onstrates the impact of mini-laparoscopy on LESS. Although we de fi ne mini-lap-
aroscopy as using instruments equal to or less than 3.5 mm in diameter, we have
included those series using up to 5-mm ancillary ports for completeness.
As the table demonstrates, the number of different LESS procedures to which
mini-laparoscopic assistance has been applied is vast. The functions of the ancillary
instruments generally fall into three categories: (1) right-sided upper tract surgery,
where liver retraction is required and cannot be accomplished easily from the pri-
mary entry site (Fig. 7.3 ); (2) to facilitate suturing as a nondominant hand grasping
tool during complex reconstructive cases such as pyeloplasty (Fig. 7.4 ); and (3) as
a generic dissection or retraction tool. To put it simply, the needlescopic instruments
Fig. 7.3 Mini-laparoscopic
adjunct for liver retraction
during LESS (Courtesy of
Jay Raman, M.D.)
Fig. 7.4 Mini-laparoscopic
adjunct to LESS pyeloplasty
93
7 Mini-Laparoscopic Systems
restore triangulation, thereby overcoming the most frustrating aspects of pure LESS.
While not yet substantially patient-driven, a subset of patients does express a desire
for improved cosmesis. Mini-laparoscopic-assisted LESS provides an opportunity
for the surgeon to safely complete a given procedure while addressing this concern.
Needlescopic surgery lay relatively dormant until the steep LESS learning curve
revived its use. Depending on the trajectory of dedicated LESS instrumentation,
mini-laparoscopy may continue to fi nd a role in this regard.
Conclusion
Mini-laparoscopy began in the 1990s and was thought to be the next natural pro-
gression in the ever-increasing drive for surgery to become less invasive. In spite of
its promise, its diffusion was limited and its applications remained limited to single
centers based on surgical preference. Most agree that a cosmetic advantage exists
for these instruments compared to standard (5-mm and larger) laparoscopic port
sites. While scattered retrospective series demonstrated decreased pain and in some
cases shorter convalescence for patients undergoing mini-laparoscopic surgery,
such advantages have never been conclusively proven in adequately powered pro-
spective studies.
With the emergence of LESS and NOTES and the drive for scar-free or nearly
scar-free surgery, mini-laparoscopy has enjoyed a resurgence. Industry has provided
new and more robust instrumentation. The adjunctive use of mini-laparoscopic sys-
tems enables the urologist to have con fi dence in learning and completing NOTES,
and LESS procedures, and also serves as an adjunct during conventional laparos-
copy. Prospective studies examining the effect of mini-laparoscopy on perioperative
outcomes are needed.
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97
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_8, © Springer-Verlag London 2013
Keywords NOTES • Transgastric • Endoscopic closure • Transluminal access
Gastrotomy closure
Introduction
The original idea of natural ori fi ce translumenal endoscopic surgery was to create a
port of entry into the peritoneal cavity through the gastric wall [ 1 ] . Subsequently,
other routes of access were developed to surmount the challenges generated by the
original concept and extend the scope of existing natural ori fi ce accesses, such as
the transvaginal or transanal route. Until then, perforation of the stomach was con-
sidered a complication of interventional endoscopy. Gauderer and Ponsky were the
fi rst to break this dogma in 1980 by developing the technique of percutaneous place-
ment of a gastrostomy tube under endoscopic control [ 2 ] . Another currently widely
accepted procedure that involves a gastric perforation, endoscopic pseudocyst drain-
age, dates to 1985. Likewise, pancreatic necrosectomy and pancreatic pseudocyst
gastrotomy both breach the integrity of the visceral wall [ 3 ] . Finally, fi ne-needle
aspiration, which typically involves translumenal puncture, is a routine component
of endoscopic ultrasound examinations, with negligible rates of postprocedure com-
plications. Even if some purists consider pancreatic necrosectomy via a posterior
gastrotomy as the fi rst published NOTES procedure, it is in 2004 that Kalloo et al.
brought new fuel and new prospective to this approach [ 1 ] .
B. Dallemagne , M.D. (*) • S. Perretta , M.D. • M. Diana , M.D.
Department of Digestive and Endocrine Surgery
and IRCAD (Institut de Recherche contre les Cancers de l’Appareil Digestif),
University Hospital of Strasbourg ,
1, Place De L’Hopital , Strasbourg 67091 , France
e-mail: bernard.dallemagne@ircad.fr ; silvana.perretta@ircad.fr ; michelediana@virgilio.it
Chapter 8
Access: Transgastric
Bernard Dallemagne , Silvana Perretta , and Michele Diana
98
B. Dallemagne et al.
Contrary to transgastric drainage, the aim was to penetrate into the peritoneal
cavity and not in a closed cavity. This opening of the stomach into the peritoneal
cavity was common for surgeons, but quite new to the endoscopists. Surgeons and
endoscopists have formed collaboration to identify concerns and challenges in the
development of NOTES. Guidelines for the implementation of the technique were
outlined by the NOSCAR Working Group [
4 ] . The challenges were to develop and
validate techniques for creating the transgastric approach, taking into account the
blind nature of the maneuver, the risks of injury to adjacent organs, the potential
contamination of the peritoneal cavity, and to develop safe and reliable techniques
for closing the door after the completion of intraabdominal surgery. Many experi-
mental studies have been performed to address theses issues, but it should be recog-
nized that this route has not yet reached a signi fi cant clinical development.
Preparation of the Stomach for Transgastric Access
In the fi rst report issued by Kalloo et al. on transgastric natural ori fi ce surgery, the
authors prepared the stomach by lavage with 1,000 ml of antibiotic solution to reduce
the risk of intraoperative contamination [ 1 ] . This methodology had been established
empirically and had been repeated by other teams until the study by Narula et al. on
intraoperative contamination observed at the opening of the stomach during the
implementation of bypass procedures in obese patients [ 5 ] . The authors demonstrated
that transgastric instrumentation does contaminate the abdominal cavity, but the
pathogens are clinically insigni fi cant due to species or bacterial load. This observa-
tion was con fi rmed by additional studies of patients undergoing transgastric staging
of pancreatic cancer [ 6 ] or transgastric peritoneoscopy [ 7 ] . Patients on proton pump
inhibitors (PPIs) had an increased bacterial load in the gastric aspirate, with no clini-
cally signi fi cant infection. Ramamoorthy et al. con fi rmed the impact of PPIs on peri-
toneal contamination in a study demonstrating a signi fi cant increase in intraabdominal
infection and bacterial contamination in pigs on PPIs therapy before open gastroto-
tomy and intraperitoneal injection of the gastric content [ 8 ] . Several transgastric
experiments with survival study were subsequently performed that did not con fi rm
the primary hypothesis of the seminal transgastric report.
In the clinical setting, the authors did not experience any relevant infectious compli-
cations, although systematic sampling of the peritoneal cavity revealed peritoneal con-
tamination in 2 of 11 patients. Today, the only preventive measure that is used to prevent
peritoneal contamination is the cessation of PPIs 10 days before transgastric surgery.
Planning the Entry Site
The access to the peritoneal cavity starts with the planning of the entry site. Several
methods of transgastric entry into the peritoneum have been described, all of
which require blind puncture through the GI wall, with the inherent risk of injury
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