1
|
Patel AP, Khalaf MA, Riojas-Barrett M, Keihanian T, Othman MO. Expanding endoscopic boundaries: Endoscopic resection of large appendiceal orifice polyps with endoscopic mucosal resection and endoscopic submucosal dissection. World J Gastrointest Endosc 2023; 15:386-396. [PMID: 37274558 PMCID: PMC10236978 DOI: 10.4253/wjge.v15.i5.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Large appendiceal orifice polyps are traditionally treated surgically. Recently, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been utilized as alternative resection techniques. AIM To evaluate the efficacy and safety of endoscopic resection techniques for the management of large appendiceal orifice polyps. METHODS This was a retrospective observational study conducted to assess the feasibility and safety of EMR and ESD for large appendiceal orifice polyps. This project was approved by the Baylor College of Medicine Institutional Review Board. Patients who underwent endoscopic resection of appendiceal orifice polyps ≥ 1 cm from 2015 to 2022 at a tertiary referral endoscopy center in the United States were enrolled. The main outcomes of this study included en bloc resection, R0 resection, post resection adverse events, and polyp recurrence. RESULTS A total of 19 patients were identified. Most patients were female (53%) and Caucasian (95%). The mean age was 63.3 ± 10.8 years, and the average body mass index was 28.8 ± 6.4. The mean polyp size was 25.5 ± 14.2 mm. 74% of polyps were localized to the appendix (at or inside the appendiceal orifice) and the remaining extended into the cecum. 68% of polyps occupied ≥ 50% of the appendiceal orifice circumference. The mean procedure duration was 61.6 ± 37.9 minutes. Polyps were resected via endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid procedures in 5, 6, and 8 patients, respectively. Final pathology was remarkable for tubular adenoma (n = 10) [one with high grade dysplasia], sessile serrated adenoma (n = 7), and tubulovillous adenoma (n = 2) [two with high grade dysplasia]. En bloc resection was achieved in 84% with an 88% R0 resection rate. Despite the large polyp sizes and challenging procedures, 89% (n = 17) of patients were discharged on the same day as their procedure. Two patients were admitted for post-procedure observation for conservative pain management. Eight patients underwent repeat colonoscopy without evidence of residual or recurrent adenomatous polyps. CONCLUSION Our study highlights how endoscopic mucosal resection, endoscopic submucosal dissection, and hybrid procedures are all appropriate techniques with minimal adverse effects, further validating the utility of endoscopic procedures in the management of large appendiceal polyps.
Collapse
Affiliation(s)
- Ankur P Patel
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Mai A Khalaf
- Department of Tropical Medicine, Tanta University, Tanta 31527, Egypt
| | | | - Tara Keihanian
- Department of Gastroenterology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Mohamed O Othman
- Department of Gastroenterology, Baylor College of Medicine, Houston, TX 77030, United States
| |
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are novel techniques with potential to minimize the morbidity of surgery. Challenging ergonomics, instrument clashing, and the lack of true triangluation still remain great concerns. RECENT FINDINGS New technological developments in instrument design have been created to enhance clinical applicability of these techniques. Further technological advancements including the incorporation of novel robotic surgical platforms (R-LESS) exploit the ergonomic benefits in an attempt to further advance LESS surgery. Promising devices include magnetic anchoring and guidance systems that have the potential to allow external manoeuvring of intracorporeal instruments while facilitating triangulation and reducing clashing. As well, the benefit of miniature in-vivo robots that can be placed endoscopically intra-abdominally and controlled wirelessly will allow internal manipulation of tissue from internal repositionable platforms. SUMMARY It remains to be seen whether LESS or NOTES will prove their clinical benefit over standard laparoscopic or robotic procedures. In this chapter, we review the current LESS and NOTES technology, and focus on new innovations and research in the field.
Collapse
|
3
|
Yun JA, Yun SH, Park YA, Cho YB, Kim HC, Lee WY, Chun HK. Single-incision laparoscopic right colectomy compared with conventional laparoscopy for malignancy: assessment of perioperative and short-term oncologic outcomes. Surg Endosc 2013; 27:2122-30. [PMID: 23319285 DOI: 10.1007/s00464-012-2722-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/18/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic colectomy for malignancy currently is the standard operative technique together with open colectomy. Single-incision laparoscopic surgery (SIL) is a recent advance in minimally invasive surgical techniques. This study aimed to compare SIL right colectomy with conventional laparoscopy (CL) used to treat patients with colon cancer. METHODS This study was a retrospective analysis of data from the authors' prospectively collected colorectal surgery database. Between August 2009 and November 2010, 159 patients who underwent primary laparoscopic right colectomy at the Samsung Medical Center were recruited to participate in this study. Of these, 66 patients underwent SIL colectomy. RESULTS The SIL and CL right colectomy groups did not differ significantly in terms of general characteristics including age, sex, body mass index (BMI), American society of anesthesiology (ASA) score, previous abdominal operation, and diagnosis. The two groups also did not differ significantly in terms of perioperative complications (9.1 vs. 15.1 %, p = 0.335). Oncologic resection was similar in the two groups. The mean number of harvested lymph nodes was 24 for SIL and 27 for CL right colectomy (p = 0.068). Tumor size, disease stage, adjuvant chemotherapy, and proximal and distal resection margins did not differ significantly between the two groups. The mean follow-up period was 24.5 for the SIL group and 26.4 months for the CL group (p = 0.098), with six recurrences in the SIL group (9.1 %) and three recurrences in the CL group (3.2 %) (p = 0.120). One death occurred in the CL group. Disease-free survival at 24 months did not differ significantly between the two groups (89.7 vs. 96.3 %, p = 0.120). CONCLUSION The findings show that SIL right colectomy for colon cancer is safe and can provide resection and oncologic outcomes equal to those of conventional laparoscopic right colectomy.
Collapse
Affiliation(s)
- Jung-A Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Irwon-dong, Gangnam-gu, 135-710, Seoul, Korea.
| | | | | | | | | | | | | |
Collapse
|
4
|
Karim MA, Ahmed J, Mansour M, Ali A. Single incision vs. conventional multiport laparoscopic cholecystectomy: A comparison of two approaches. Int J Surg 2012; 10:368-72. [DOI: 10.1016/j.ijsu.2012.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 05/20/2012] [Accepted: 05/28/2012] [Indexed: 01/19/2023]
|
5
|
Swain CP, Bally K, Park PO, Mosse CA, Rothstein RI. New methods for innovation: the development of a toolbox for natural orifice translumenal endoscopic surgery (NOTES) procedures. Surg Endosc 2011; 26:1010-20. [PMID: 22052424 DOI: 10.1007/s00464-011-1987-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 10/04/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Devices used for flexible intralumenal procedures are inadequate when used for intraperitoneal surgical procedures such as cholecystectomy. OBJECTIVE To assess/address limitations of flexible endoscopic devices in intraperitoneal surgery. DESIGN To describe processes used to invent new devices to facilitate this new surgical genre. SETTING Engineering laboratory. PATIENTS None. INTERVENTIONS AND INVENTIONS: Reviews of the limitations of flexible endoscopic instruments and instrumentation/invention needs for a "NOTES cholecystectomy" were completed. MAIN OUTCOME MEASURES The appropriateness of existing methods of device innovation was evaluated against an inventory of new technologies necessary to perform NOTES. The deficiencies in traditional innovation methods led to the creation of a novel process for invention of new medical devices: the "Inventorama." METHODS Cooperation between clinicians and industry to develop device concepts to enable NOTES. RESULTS The devices included: (1) steerable flex trocar, (2) rotary access needle, (3) bipolar hemostasis forceps, (4) Maryland dissectors, (5) articulating hook knife, (6) rotating hook knife, (7) articulating graspers, (8) scissors, (9) ligating clip applier, and (10) tissue apposition system. Six of these ten were built and tested as initial crude prototypes in the Inventorama process; two underwent major modifications. Three were invented via alternate methods, including by independent clinicians. CONCLUSIONS A new method for efficient medical device invention and development was created to address key technology needs for NOTES. The result was a "toolbox" of devices designed to address the key surgical activities necessary for advanced intralumenal and translumenal flexible endoscopic procedures.
Collapse
Affiliation(s)
- C Paul Swain
- Department of Bio Surgery & Surgical Technology, Imperial College London, St. Mary's Hospital, London, UK.
| | | | | | | | | |
Collapse
|
6
|
Rivet EB, Mutch MG, Ritter JH, Khan AA, Lewis JS, Winslow E, Fleshman JW. Ex vivo sentinel lymph node mapping in laparoscopic resection of colon cancer. Colorectal Dis 2011; 13:1249-55. [PMID: 21083799 DOI: 10.1111/j.1463-1318.2010.02450.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The study examined the feasibility and potential benefit of ex vivo sentinel lymph node (SLN) mapping, including multilevel sectioning (MLS) and immunohistochemistry (IHC) in colon cancer patients undergoing laparoscopic colectomy. The secondary goals were (i) to identify patient and tumour characteristics that might influence the success of the SLN technique, (ii) to investigate the extent of lymphadenectomy required to encompass tumour-positive nonsentinel lymph nodes (NSLN) and (iii) to ascertain the association of SLN status with oncological outcomes. METHOD SLN mapping was performed after specimen extraction using 1% Isosulfan blue. The SLNs were analysed with H&E staining after MLS, and if negative, IHC was performed. NSLNs were grouped by distance either greater than or less than 4 cm from the tumour. RESULTS Seventy-one patients completed the study between 2003 and 2007. Using H&E with MLS, the accuracy of SLN mapping was 76%, sensitivity was 52% and the false-negative rate was 48%. Excluding patients with clinically positive lymph nodes resulted in a significant improvement in accuracy to 81% and decreased the false-negative rate to 30%. Furthermore, as the only positive NSLN > 4 cm from the tumour was grossly positive, SLN mapping with a 4-cm mesenteric cuff would have given 100% sensitivity in patients without macroscopically involved nodes. CONCLUSIONS SLN mapping may be of value in selected patients. It may be possible to accurately stage patients with a 4-cm cuff of mesentery, although further validation of this proposal is required.
Collapse
Affiliation(s)
- E B Rivet
- Bon Secours Hampton Roads Health System, Suffolk, Virginia, USA
| | | | | | | | | | | | | |
Collapse
|
7
|
Ross H, Steele S, Whiteford M, Lee S, Albert M, Mutch M, Rivadeneira D, Marcello P. Early multi-institution experience with single-incision laparoscopic colectomy. Dis Colon Rectum 2011; 54:187-92. [PMID: 21228667 DOI: 10.1007/dcr.0b013e3181f8d972] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Single-incision laparoscopic colectomy represents a potential advance in minimally invasive surgical approaches to colorectal disease. Although widely promoted, outcome data are virtually absent. A group of highly experienced laparoscopic attending colorectal surgeons convened to standardize technique and prospectively record operative details and outcomes. METHODS Single-incision laparoscopic colectomy was performed by 10 experienced attending colorectal surgeons with minimal or no prior single-incision laparoscopic colectomy experience. Surgeon rating of ergonomics and 15 components of operation conduct was compared with conventional multiple-port laparoscopic colectomy. Patient demographics, operative details, and outcome data were prospectively collected. RESULTS Thirty-nine single-incision laparoscopic colectomies were performed (25 right colectomies, 5 ileocolic resections, 8 sigmoidectomies, and 1 low anterior resection). Underlying pathology included polyps (12), cancer (15), Crohn's disease (5), and diverticulitis (7). Patients were highly selected with a mean body mass index of 25.6 (range, 16-40). Two conversions to open resection occurred, 1 because of fistula and 1 because of adhesions, in patients with a mean body mass index of 34. An additional port was required in 3 patients. Mean incision length was 4.2 cm (range, 2.5-8) and operative time was 120 minutes (range, 68-210). Complications included 1 wound infection and 2 anastomotic bleeds requiring transfusion. Average length of stay was 4.4 days (range, 2-8). Mean lymph node harvest was 19 (range, 12-39). Exposure, instrument conflict, ergonomics, ease of instrumentation, and camera operation were rated significantly more difficult with single-incision laparoscopic colectomy than with multiple-port laparoscopic colectomy. CONCLUSIONS Preliminary data demonstrate that single-incision laparoscopic colectomy can be performed safely in selected patients by experienced surgeons. The benefits of single-incision compared with multiple-port laparoscopic colectomy are not immediately evident. Despite the advanced skills of the faculty, a learning curve of undetermined length still exists in which specific components of single-incision laparoscopic colectomy are more difficult than multiple-port laparoscopic colectomy, and areas of focus remain that require advances to make single-incision laparoscopic colectomy equivalent to multiple-port laparoscopic colectomy. The multi-institutional registry will enable further analysis of single-incision laparoscopic colectomy.
Collapse
Affiliation(s)
- H Ross
- Riverview Medical Center, Red Bank, New Jersey 07701, USA.
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Abstract
For more than 150 years, doctors have had the ability to transmit medical information to advise and assist their colleagues in remote locations via teleconsultation using a variety of communication modalities. In surgery this has evolved into the telementoring of minimally invasive procedures, particularly, robotic surgery, which have become relatively commonplace in urology. The ultimate progression to true telerobotic surgery, in which remote surgeons independently perform complex and fundamental parts of procedures at long range, is starting to occur. This article discusses the current state of telementoring and telerobotics in urology and examines the pros and cons of this technology at the present time.
Collapse
Affiliation(s)
- Ben Challacombe
- Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, 3050, Australia.
| | | |
Collapse
|
9
|
Tissue apposition system: new technology to minimize surgery for endoscopically unresectable colonic polyps. Surg Endosc 2010; 24:3113-8. [PMID: 20490565 DOI: 10.1007/s00464-010-1098-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 01/03/2010] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This is the first clinical series using the Tissue Apposition System (TAS) device in a feasibility study of polypectomy as an alternative to laparoscopic colectomy (LC) for endoscopically unresectable polyps. TAS is a novel T-tag system for endoscopic placement of sutures, facilitating closure of larger defects from advanced endoluminal or transluminal endoscopic procedures. Such novel instrumentation may reduce risk and accelerate recovery. METHODS After institutional review board approval, patients with endoscopically unresectable polyps who would otherwise require LC were enrolled. The polyp site was visualized by colonoscopy and resected with laparoscopic assistance, using endoscopic mucosal resection (EMR) or submucosal dissection. After confirming benign disease by frozen section, the polypectomy site was closed by TAS under laparoscopic observation to avoid injury to surrounding structures. Follow-up colonoscopy was performed at 3 months. RESULTS Seven patients were recruited (5 men; mean age, 66 years). Polyps were from 20 to 50 (mean, 30) mm in diameter; six were in the right colon, and three were on the mesenteric border of the bowel. All final pathology was benign. Mean EMR time was 29 min, mean time taken for TAS was 37 min, and mean total operative time was 199 min. Two TAS procedures required conversion to LC (one unresectable polyp and one device failure). Five TAS procedures were completed, with a mean hospital stay of 1.2 days, and no complications. Follow-up colonoscopy revealed healing without polyp recurrence in any case. One patient (initial 5-cm sigmoid polyp) developed a very mild clinically asymptomatic stricture in the sigmoid colon. CONCLUSIONS This initial human experience demonstrates that TAS can be used safely in the colon under laparoscopic control. TAS permits safe closure of defects after endoscopic polypectomy of selected and otherwise unresectable polyps. Such technology may potentially avoid the need for LC and permit rapid recovery with short hospital stay.
Collapse
|
10
|
Varma MG. Robotics for Pelvic Floor Disorders: Rectopexy and Pelvic Organ Prolapse. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
11
|
Cahill R, Lindsey I, Cunningham C. Address of early stage primary colonic neoplasia by N.O.T.E.S. Surg Oncol 2009; 18:163-8. [DOI: 10.1016/j.suronc.2008.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
12
|
Abstract
Over the last number of years, the emphasis in abdominal surgery has been to reduce invasiveness and to minimise trauma to the patient. This has led to the rapid development of laparoscopic techniques initially for the surgical management of benign disease and later for the successful management of malignant disease. Laparoscopy has now been shown to provide significant benefits to the cancer patient, in particular the reduction of wound infection, herniation and pain. More recently, benefits have been demonstrated in earlier discharge from hospital and return to normal activity. Laparoscopy has therefore been accepted as at least a valid alternative to open surgery for most types of abdominal cancer. With the objective of reducing invasiveness even more, the last few years has seen a rapid expansion in the development of Natural Orifice Translumenal Endoscopic Surgery (NOTES). Currently, NOTES is still in the early stages of evolution but its potential uses in the field of cancer surgery are already being proposed. To develop NOTES to the stage that it will be safe, effective and widely available for the management of cancer patients represents a huge challenge ranging from the development of equipment and techniques to the demonstration of safety and efficacy in clinical trials as well as training and competence issues. It is still not clear whether these challenges will be surmounted so that NOTES becomes mainstream therapy. A period of 'watchful waiting' seems appropriate therefore for the uncommitted general surgeon in order that NOTES may be given time to prove compelling and convincing before its general uptake into routine practice.
Collapse
|
13
|
Boni L, Dionigi G, Rovera F. Natural orifices transluminal endoscopic surgery (NOTES) and other allied "ultra" minimally invasive procedures: are we loosing the plot? Surg Endosc 2009; 23:927-9. [PMID: 19259733 DOI: 10.1007/s00464-009-0353-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Accepted: 01/09/2009] [Indexed: 11/30/2022]
|
14
|
Lacy AM, Delgado S, Rojas OA, Ibarzabal A, Fernandez-Esparrach G, Taura P. Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient. Surg Endosc 2009; 23:1130-7. [PMID: 19242758 DOI: 10.1007/s00464-008-0292-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 12/03/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND Standard sleeve gastrectomy for the morbidly obese is feasible and safe using the hybrid transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS) with available laparoscopic/endoscopic instruments and technology as illustrated by this technical report on a female patient. METHODS The intervention was a transvaginal sleeve gastrectomy in a 67-year-old woman who was hypertensive, noninsulin-dependent with diabetes with morbid obesity (BMI, 37). Operative field view was maintained at all times with a gastroscope introduced through a transvaginal trocar. The surgeon positioned himself at the right side of the patient using a 2-mm needle port/mini-grasper placed in the left upper quadrant for traction of the greater curvature of the stomach. A 12-mm umbilical trocar was used as the port for insertion of the LigaSure device used for division of the short gastric vessels and the Endo-GIA stapler for creation of the gastric tube. The first assistant used a second mini-grasper for liver retraction and stomach positioning. The resected stomach was retrieved through the vagina. There were no intraoperative complications. The operative time was 150 minutes. RESULTS The advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All component steps of a laparoscopic sleeve gastrectomy (LSG) were reproduced. The patient was discharged on the third postoperative day. CONCLUSIONS Transvaginal hybrid MA-NOS sleeve gastrectomy is both feasible and safe. The hybrid technique ensured safety during the performance of the procedure. MA-NOS is a potential option to avoid abdominal incisions and related complications for the laparoscopic resection of large intra-abdominal organs. Combined hybrid laparoscopic NOS for humans is currently a safe and reliable approach for major surgery through the NOS approach in female patients. Hybrid surgery allows controlled implementation of NOS techniques in clinical practice, providing a stepwise progression to the pure NOS approach once the appropriate technology has been developed. Additionally, it is the best way to stimulate the active development and evaluation of the underpinning technologies and instruments for these novel endoscopic surgical approaches. Appropriate clinical indications for these new procedures are yet to be defined. LSG is associated with short-term excess weight loss and resolution of comorbidities comparable to those obtained with other restrictive procedures. The performance of sleeve gastrectomy is an option in selected patients undergoing bariatric surgical treatment, particularly in the super obese and those who are considered high risk because of comorbid disease.
Collapse
Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery, Centro de Investigaciones Biomédicas Esther Koplowitz, IMDiM, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | | | | | | | | | | |
Collapse
|
15
|
Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J. MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 2008; 22:1717-23. [PMID: 18461385 DOI: 10.1007/s00464-008-9956-2] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 04/17/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND With available laparoscopic and endoscopic instruments/technology a standard radical sigmoid resection is feasible and safe using transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS). METHODS The intervention was a transvaginal MA-NOS sigmoidectomy in a 78-year-old woman with a sigmoid adenocarcinoma. Maintaining triangulation the surgeon positioned himself at the right side of the patient and used the transvaginal trocar for dissection and stapling of both the inferior mesenteric vessels and the upper rectum. The colonic resection was performed extracorporeally in the conventional fashion and was followed by an intra-abdominal endoscopically assisted stapled anastomosis. RESULTS Advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All oncological principles governing resection and management were accomplished and the pathology examination confirmed a T3N1 lesion. The patient was discharged on the fourth postoperative day. CONCLUSION Transvaginal MA-NOS radical sigmoidectomy is a feasible and oncologically safe procedure. MA-NOS is a realistic option for avoiding the need of assisting incisions and related morbidity in the laparoscopic resection of large intra-abdominal lesions. Combined hybrid laparoscopic NOS in humans (MA-NOS) currently provides a safe and reliable way of defining future clinical applications and advantages of NOS and NOTES. Additionally, it stimulates the active development and evaluation of the underpinning technologies and instrumentation.
Collapse
Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery and Centro de Investigaciones Biomédicas Esther Koplowitz, Institut de Malalties Digestives I Metaboliques, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | | | | | | | | | | |
Collapse
|