Devuelta al Lumen · The NOTES Concept . Abdominal Surgery in Perspective Open Surgery . ... Cios,...
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Transcript of Devuelta al Lumen · The NOTES Concept . Abdominal Surgery in Perspective Open Surgery . ... Cios,...
Devuelta al Lumen: Cirugía endoscópica transluminal a través
de orificios naturales 2012 Curso Internacional Retos Clinicos en la Gastroenterologia de
Urgencias Asociacion Colombiana de Gastroenterologia
1 de Septiembre, 2012 Pereira, Risaralda • Hotel Movich
John A. Martin, MD
Associate Professor of Medicine and Surgery Director of Endoscopy
Northwestern University Feinberg School of Medicine • Chicago, Illinois
In the beginning…
In the beginning…
Rao GV, Reddy N., 2005 Transgastric Appendectomy in Humans. Unpublished; presentation at World Congress of Gastroenterology, Montreal, Quebec, Canada, September 2005.
• Enter body through natural orifice with standard flexible endoscope
• Open wall of viscus • Replicate traditionally surgical intra-
abdominal procedure • Withdraw into viscus and close visceral
wall securely • Remove endoscope from orifice
The NOTES Concept
Abdominal Surgery in Perspective Open Surgery
Laparoscopic Surgery (same operations, smaller incisions)
Percutaneous + Endoscopic Excision, Ablation, Debridement, Drainage
(Interventional radiology & endoscopy)
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
Why NOTES? • Less invasive (?)
– Less pain
– Less tissue trauma
• Lower anesthesia requirement (?)
• Better postop pulmonary function (?)
• Decreased hernia formation
• Decreased wound infection
• Decreased immunomodulation (?)
Why NOTES? • Faster recovery times
• Shorter hospital stays
• Outpatient procedures (?)
• Improved cosmesis
• Anticipated public demand for
“incisionless” surgery
• Potential positive impact on endoluminal
procedures
NOTES would • Change laparoscopic surgery • Expand the horizon of the
gastroenterologist • Lead to rapid development of
instrumentation specific to NOTES • Evolve new breed of GI
interventionalist—neither surgeon nor gastroenterologist
The NOTES Concept: Chapter 1
NOTES would • Change laparoscopic surgery • Expand the horizon of the
gastroenterologist • Lead to rapid development of
instrumentation specific to NOTES • Evolve new breed of GI
interventionalist—neither surgeon nor gastroenterologist— really?
The NOTES Concept: Chapter 1
What actually happened? • Gastroenterologists and surgeons
teamed up and started to work together
• Industry teamed up with clinical teams of clinical investigators
• Conceptualization and development of new technology accelerated rapidly
• NOSCAR formed
The NOTES Concept: Chapter 1
NOSCAR
• Natural Orifice Surgery Consortium for Assessment and Research
• Joint initiative supported by both ASGE & SAGES
• White papers published 2006
• Industry grants $2 million
• 3rd annual conference held in San Francisco, July 10-12, 2008 (www.noscar.org)
The NOTES Concept: Chapter 1
Early animal work • Liver biopsy
• Oophrectomy
• Tubal ligation
• Cholecystectomy
• Splenectomy
• Gastrojejunostomy
Closure devices: clips + clamps
Closure devices: T-tags
Closure devices: suturing
Closure devices: suturing
Closure devices: plugs
Cios, et al., Surg Endosc 2007
100% successful closure of standardized 1cm gastrotomy in large animal survival model
Closure devices: atrial septal occluder
Perretta, et al., Gastrointest Endosc 2007;66: 809-813.
Closure devices: flexible stapler
Kaehler, et al., Surg Endosc 2007;20:519-521.
New Generation Endoscopes
“Endoscopic paradigm”
Multitasking platforms
“Surgical paradigm”
Multitasking platforms
“Combining endoscopic & surgical paradigms”
Proprietary platform
Dedicated instrumentation
Human NOTES Procedures Appendectomy Cholecystectomy PEG “rescue” Proposed Staging for cancer Diagnosis / treatment of pain
syndromes Tubal ligation / Oophrectomy Adhesiolysis Diaphragm pacing Gastric pacing
Technical limitations to current platform • Flexible endoscopes
• Too flexible for counter-forces • Small instrument channels • Weak suction / insufflation • Parallel (instrument and visual) access
• Endoscopic Instrumentation • Weak graspers • Small end-effectors • No (or limited) independent steering • Inadequate tissue approximators & hemostasis
The NOTES Concept: Chapter 1 What did we learn?
NOTES Hybrid Human Chole (not the full Monty)
Auyang E, Vaziri K, Martin J, Hungness E, Soper N. Human NOTES Hybrid Transgastric Cholecystectomy. DDW 2008, San Diego, CA
Issues: Technological & Technical
Issues: Efficiency & Ergonomics
• Technical limitations to current platform
• Conceptualization and development of new technology takes time
• Laparoscopy is a very good technology
• Fundamental differences between gastroenterologist and surgeon
The NOTES Concept: Chapter 1 What did we learn?
• “Hybrid NOTES” instead of “pure NOTES” • Single laparoscopic port • Other abdominally-inserted end-
effectors • The understanding that there must be
more to NOTES than simply replicating what laparoscopy already does well
The NOTES Concept: Chapter 1 What did this lead to?
• Gastroenterologists are not surgeons, and surgeons are not gastroenterologists • Different knowledge base • Distinct skill-sets • Working together in NOTES yields
different rewards to each • What are NOTES’s rewards for the
gastroenterologist?
The NOTES Concept: Chapter 1 What was realized?
(post NOSCAR 2008)
Pasricha P, Hawari R, Ahmed I , Chen J, Cotton P, Hawes R, Kalloo A, Kantsevoy S, Gostout CJ. Endoscopic Submucosal Esophageal Myotomy. Endoscopy
2007;39:761-764, and DDW 2007, Washington, DC
Auyang E, Vaziri K, Volckmann E, Martin J, Soper N, Hungness E. Cadaveric Rendezvous Hybrid Small Bowel Resection. Surg Endosc 2008 & SAGES 2008.
Desilets D, Romanelli J, Earle D. Endoscopic Stapled Cystgastrostomy. DDW 2008, San Diego, CA, May, 2008
From Kim HB, Fauza D, Garza J, Oh JT, Nurko N, Jaksic T. Serial Transverse Enteroplasty (STEP): A Novel Bowel Lengthening Procedure. J Ped Surg 2003.
What else is possible?
*
Cy5.5 monofunctional dye
Fluorescence Probe Endoscopy The cathepsin probe: are molecular probes the future of diagnostic endoscopy? Gounaris and Khazaie, PLoS ONE 2008; 3: e2916.
Molecular imaging in endoscopy: Cathepsin probe endoscopy in a mouse model Gounaris and Khazaie
The Wish List Endoscopic stapler
Better knives
Improved mucosal undermining
Robust retractors, approximators, & hemostatic apparatus
More secure closure
Agile, versatile multitasking platforms
•endoscopic directional control •flexible •robust
Fly-by-Wire?
From Ho, KY, et al. Endoscopic Submucosal Dissection Using a Computer-controlled Master-Slave Robot. DDW 2009
