A SAGES technology and value assessment and pediatric committee evaluation of mini-laparoscopic instrumentation.

BACKGROUND: The TAVAC and Pediatric Committees of SAGES evaluated the current use of mini-laparoscopic instrumentation to better understand the role this category of devices plays in the delivery of minimally invasive surgery today. METHODS: The role of mini-laparoscopic instrumentation, defined as minimally invasive instruments of between 1 and 4 mm in diameter, was assessed by an exhaustive review of the peer reviewed literature on the subject between 1990 and 2021. The instruments, their use, and their perceived value were tabulated and described. RESULTS: Several reported studies propose a value to using mini-laparoscopic instrumentation over the use of larger instruments or as minimally invasive additions to commonly performed procedures. Additionally, specifically developed smaller-diameter instruments appear to be beneficial additions to our minimally invasive toolbox. CONCLUSIONS: The development of small instrumentation for the effective performance of minimally invasive surgery, while perhaps best suited to pediatric populations, proves useful as adjuncts to a wide variety of adult surgical procedures. Mini-laparoscopic instrumentation thus proves valuable in selected cases.

Incisionless revision of post-Roux-en-Y bypass stomal and pouch dilation: multicenter registry results.

BACKGROUND: Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endoluminal revision of stoma and pouch dilation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multicenter intraoperative experience and postoperative follow-up to date using the Incisionless Operating Platform for this patient subset. METHODS: The patients who had regained significant weight >or=2 years after RYGB after losing >or=50% of excess body weight after RYGB were endoscopically screened for stomal and/or pouch dilation. Qualified patients underwent incisionless revision using the Incisionless Operating Platform to reduce the stoma and pouch size by placing anchors to create tissue plications. Data on the safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date as a part of 2 years of postoperative follow-up. RESULTS: A total of 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112 (97%) of 116 patients, with an average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. The operating room time averaged 87 minutes. No significant complications occurred. At 6 months after the procedure (n = 96), an average of 32% of weight regain that had occurred after RYGB had been lost. The percentage of excess weight loss averaged 18%. The 12-month esophagogastroduodenoscopy results confirmed the presence of the anchors and durable tissue folds. CONCLUSIONS: Incisionless revision of stoma and pouch dilation using the Incisionless Operating Platform can be performed safely. The data to date have demonstrated mild-to-moderate weight loss, and the early 12-month endoscopic images have confirmed anchor durability. Patients were actively followed up to document the long-term durability of this intervention in the entire patient subset.

Video: natural orifice translumenal endoscopic surgery (NOTES): creation of a gastric valve for safe and effective transgastric surgery in humans.

INTRODUCTION: NOTES has become a clinical reality. There remain, however, many challenges that need to be addressed in order to refine the technique. One of the most feared potential complications of transgastric surgery is a leak from the port of entry into the peritoneum. When withdrawing the endoscope into the gastric lumen it is difficult to make a secure closure due to the loss of pneumogastrium. We present a novel and safe technique for creating a gastrotomy developed in our animal laboratory and applied in all of our human NOTES cholecystectomies. METHODS: Using an aggressive grasping and needle-delivery device, full-thickness bites create an imbricated ridge of tissue that acts as a valve, allowing visualization while maintaining pneumogastrium when the endoscope is withdrawn from the peritoneum into the lumen. At closure, full-thickness serosa-to-serosa approximation is easily achieved due to excellent visualization. RESULTS: With this technique we have been able to accomplish consistent results in ten pig models. In our series of five patients who have undergone NOTES transgastric cholecystectomy, there have been no leaks to date using the same technique. Video footage presents this technique performed on humans. CONCLUSIONS: Creation of a gastric valve during transgastric surgery has proved to be a safe approach. This technique allows maintenance of insufflation and visualization during the procedure and provides a feasible and safe means of closure at the end of the procedure.

The trade-off between flexibility and maneuverability: task performance with articulating laparoscopic instruments.

BACKGROUND: Laparoscopic instruments are rigid and thus cannot provide the degrees of freedom (DOF) needed by a surgeon in certain situations. A new generation of laparoscopic instruments with the ability to articulate their end effectors is available. Although these instruments offer the flexibility needed to perform complex tasks in a constricted surgical site, their control may be hampered by their increased complexity. METHODS: This study compared the task performance between articulating and conventional laparoscopic instruments. Surgeons with extensive laparoscopic experience (8 experts) and staff with no surgical experience (8 novices) were recruited for the test. Both groups were required to perform three standardized tasks (peg transfer, left-to-right suturing, and up-and-down suturing) in a bench top model using conventional and articulating instruments. Performance was scored using a standardized 100-point scale based on movement speed and accuracy. After the initial trials with conventional and articulating instruments, each participant was given a short orientation on how to use the articulating instrument advantageously. The participant then was retested with the articulating instrument. RESULTS: As expected, the expert group scored significantly better than the novice group (p < 0.001). The combined data from both groups showed better performance with the conventional instruments than with the articulating instruments (p = 0.074). The experts maintained their proficient laparoscopic performance using conventional instruments in their first attempts with the articulating instruments (91 vs. 84), whereas the novices had greater difficulty with the articulating instruments than with the conventional instruments (46 vs. 59). After a short orientation, however, the novices outscored the expert group in terms of net improvement in performance with the articulating instrument (27 vs. 1% improvement). CONCLUSION: Experienced surgeons are readily able to transfer their skills from conventional to articulating laparoscopic instruments. To speed the learning process, the use of articulating instruments can be started at an early stage of surgical training.

Transanal endoscopic microsurgical platform for natural orifice surgery.

BACKGROUND: The excitement surrounding natural orifice transluminal endoscopic surgery (NOTES) remains tempered by concerns over safe access and closure of transvisceral enterotomies. Research in NOTES has commonly been described as using an oral transgastric access point. Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for a full-thickness resection of rectal tumors and with suture closure of the resultant defect with highly specialized instruments. This technique has been used clinically in human beings for more than 2 decades. Entry into the peritoneal cavity during a resection of rectosigmoid lesions has been described, and safe closure can be obtained. OBJECTIVE: To assess the feasibility of transrectal NOTES procedures by using TEM instrumentation. DESIGN: Three porcine and 3 human cadaver models were studied by using standard TEM instrumentation and flexible endoscopes. NOTES peritoneal access, a peritoneoscopy, a liver biopsy, and colorectal resections were performed. RESULTS: True NOTES procedures facilitated with TEM instrumentation were successfully completed. LIMITATIONS: This was a preclinical study, and several challenges to bridging to human clinical use exist: TEM instruments are currently designed for intraluminal tasks low in the pelvis, with 5-mm to 10-mm port sizes; the cost of the TEM instruments and insufflation system; and the learning curve to perform TEM closure. CONCLUSIONS: Our preclinical study demonstrated the feasibility of several transrectal NOTES procedures, colorectal resection, and anastomosis when using TEM instrumentation. We, therefore, suggest TEM as a portal for NOTES.

Multimedia article. Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax.

BACKGROUND: Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise. METHODS: When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair. RESULTS: The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings. CONCLUSIONS: The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon.