Transoral laser exoscopic surgery of the larynx: state of the art and comparison with traditional transoral laser microsurgery.

Objective: To evaluate the efficacy of transoral laser exoscopic surgery (TOLES) in a unicentric series of patients affected by benign and malignant glottic and supraglottic lesions, and compare outcomes with those of transoral laser microsurgery (TOLMS). Methods: To demonstrate the non-inferiority of TOLES in terms of operative time, margin status and complication rates, we compared outcomes of 93 patients treated by TOLES between July 2021 and July 2023 with those of a match-paired group of 107 historical patients treated by TOLMS. To perform a multiparametric ergonomic evaluation of TOLES vs TOLMS, we used observational methods for biomechanical overload risk assessment and wearable technologies comparing 15 procedures with TOLES vs a paired match of 13 surgeries performed with TOLMS by the same surgeon. Results: No significant differences were found in terms of surgical duration, positive margins, or complications between TOLES and TOLMS. Ergonomics assessment by inertial measurement units and electromyographic surface electrodes demonstrated a reduced biomechanical overload with TOLES compared to TOLMS. Conclusions: The many advantages of TOLES, such as its superior didactic value, better digital control of light even through small-bored laryngoscopes, improved binocular vision, and increase in surgical performance by 3 or 4-hand techniques, are difficult to be quantified. In contrast, its non-inferiority in terms of oncological results and better ergonomics compared to TOLMS are demonstrated herein.

Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy.

INTRODUCTION: Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA). MATERIALS AND METHODS: Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab. RESULTS: The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34). CONCLUSIONS: TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.

Feasibility experiment of a novel deformable self-assembled magnetic anastomosis ring (DSAMAR) for gastrointestinal anastomosis through a natural orifice.

Although the application of magnetic compression anastomosis is becoming increasingly widespread, the magnets used in earlier studies were mostly in the shape of a whole ring. Hence, a deformable self-assembled magnetic anastomosis ring (DSAMAR) was designed in this study for gastrointestinal anastomosis. Furthermore, its feasibility was studied using a beagle model. The designed DSAMAR comprised 10 trapezoidal magnetic units. Twelve beagles were used as animal models, and DSAMARs were inserted into the stomach and colon through the mouth and anus, respectively, via endoscopy to achieve gastrocolic magnamosis. Surgical time, number of failed deformations, survival rate of the animals, and the time of magnet discharge were documented. A month later, specimens of the anastomosis were obtained and observed with the naked eye as well as microscopically. In the gastrocolic anastomosis of the 12 beagles, the procedure took 65-120 min. Although a deformation failure occurred during the operation in one of the beagles, it was successful after repositioning. The anastomosis was formed after the magnet fell off 12-18 days after the operation. Naked eye and microscopic observations revealed that the anastomotic specimens obtained 1 month later were well-formed, smooth, and flat. DSAMAR is thus feasible for gastrointestinal anastomosis under full endoscopy via the natural orifice.

Intracorporeal antimesenteric ancillary trocar: an anastomotic technique facilitating natural orifice specimen extraction in left-sided colorectal surgery.

AIM: Natural orifice specimen extraction (NOSE) in left-sided colorectal surgery requires application of the circular stapler anvil to the proximal bowel without exteriorization through an additional abdominal incision. We describe an intracorporeal method to secure the stapler anvil, termed the intracorporeal antimesenteric ancillary trocar (IAAT) technique. METHOD: The ancillary trocar is attached to the stapler anvil before introduction into the abdominal cavity through the anal or vaginal orifice. The colon is incised before the trocar spike is brought out through the antimesenteric surface 3-4 cm within the cut edge. A linear stapler is used to seal the bowel end. The ancillary trocar is detached and retrieved via the NOSE conduit. Following the NOSE procedure, a side-to-end colorectal anastomosis is performed with the transanal circular stapler. RESULTS: Ten consecutive patients underwent elective left-sided colorectal resection with IAAT for NOSE (seven transanal, three transvaginal) from January to June 2023. Median age and body mass index were 66 (range 47-74) years and 24.3 (range 17.9-30.8) kg/m2 respectively. Two (20%) patients underwent sigmoid colectomy for sigmoid volvulus while eight (80%) underwent anterior resection for colorectal cancer. Median operating time, operative blood loss and postoperative length of hospital stay were 170 (range 140-240) min, 20 (range 10-40) mL and 1 (range 1-3) day respectively. There were no postoperative complications, readmissions or reoperations. Median follow-up duration was 3 (range 1-6) months. CONCLUSION: The IAAT double-stapling side-to-end anastomotic technique is safe and feasible for patients undergoing left-sided colorectal resection with NOSE, resulting in good outcomes.

Natural Orifice Endosonographic Colposuspension With Rectopexy for Combined Pelvic Organ Prolapse: A Feasibility Study.

BACKGROUND: We describe a natural orifice technique for simultaneous endoluminal lateral suspension of apical vaginal wall and rectal prolapse fixation with ultrasound and fluoroscopic assistance. IMPACT OF INNOVATION: The technique is minimally invasive, can be performed under regional anaesthesia, and avoids laparotomy or use of a mesh in addition to preserving the uterus. TECHNOLOGY MATERIALS AND METHODS: This technique involves suprapubic transvaginal ventral suture colposuspension, fixation of the anterior rectal wall to the undersurface of the anterior abdominal wall and tack fixation of the posterior rectal wall to the underlying sacral promontory through a submucosal tunnel performed endoscopically with fluoroscopic and ultrasound assistance. PRELIMINARY RESULTS: Seven patients with a mean age of 63 years were followed between 3 to 11 months. CONCLUSIONS: This is a novel minimally invasive transluminal procedure that repairs concomitant rectal and vaginal prolapse in the same sitting. FUTURE DIRECTIONS: Improvement in the instrument design and incorporation of endoluminal robotic systems will enhance the technical ease. The study needs validation in larger series of patients with longer follow-up.

Endoscopy-assisted magnetic navigation of biohybrid soft microrobots with rapid endoluminal delivery and imaging.

High-precision delivery of microrobots at the whole-body scale is of considerable importance for efforts toward targeted therapeutic intervention. However, vision-based control of microrobots, to deep and narrow spaces inside the body, remains a challenge. Here, we report a soft and resilient magnetic cell microrobot with high biocompatibility that can interface with the human body and adapt to the complex surroundings while navigating inside the body. We achieve time-efficient delivery of soft microrobots using an integrated platform called endoscopy-assisted magnetic actuation with dual imaging system (EMADIS). EMADIS enables rapid deployment across multiple organ/tissue barriers at the whole-body scale and high-precision delivery of soft and biohybrid microrobots in real time to tiny regions with depth up to meter scale through natural orifice, which are commonly inaccessible and even invisible by conventional endoscope and medical robots. The precise delivery of magnetic stem cell spheroid microrobots (MSCSMs) by the EMADIS transesophageal into the bile duct with a total distance of about 100 centimeters can be completed within 8 minutes. The integration strategy offers a full clinical imaging technique-based therapeutic/intervention system, which broadens the accessibility of hitherto hard-to-access regions, by means of soft microrobots.

Transoral Robotic Surgery (TORS) Versus Non-TORS Tongue Resection for Obstructive Sleep Apnea.

OBJECTIVE: To compare transoral robotic surgery (TORS) versus non-TORS tongue resection procedures performed for obstructive sleep apnea from January 2010 to September 2015 using a national database, focusing on patient characteristics, performance of concurrent procedures, operative time, length of hospital stay, and postoperative complications. METHODS: A cohort of adults undergoing TORS and non-TORS tongue resection procedures was identified in the Nationwide Inpatient Sample, a publicly-available national administrative database incorporating a stratified sample of hospital discharge records. Outcomes were annual case volumes, prolonged (≥3 days) hospital stay, and complications. Statistical analyses examined potential associations between TORS and prolonged hospital stay and complications. RESULTS: From 2010 to 2015, 5709 hospital discharges included tongue resection surgery to treat obstructive sleep apnea. There was a gradual decline and stabilization in overall volumes, with the proportion of TORS use showing an initial increase, followed by a decrease and rebound increase. TORS patients were less likely to undergo concurrent nasal surgery (15% vs. 44%, P < .01), but there was no association between the use of TORS and concurrent palatal surgery. TORS use was not associated with concurrent hypopharyngeal surgery overall, but it was associated with specific types of hypopharyngeal surgery. TORS use was associated with patient age, payor, and certain hospital characteristics. TORS use was associated with an increased risk of prolonged hospital stay (33% vs. 25%, P = .045) but was not associated with complications. CONCLUSION: This study provides insight into TORS use in tongue resection surgery for obstructive sleep apnea during this period of early TORS adoption. LEVEL OF EVIDENCE: Level 3 (cohort study). Laryngoscope, 131:E1735-E1740, 2021.

Robotic glove port technique for the endowristed rigid instruments in robotic single-site transabdominal and transvaginal surgery.

Although robotic single-site (RSS) surgery employing cross setup of semirigid instruments allows effective triangulation of instruments, it has some limitations in performing RSS transabdominal and transvaginal surgeries. We introduced the robotic glove port technique (RGPT) using parallel setup of endowristed rigid instruments in performing RSS transabdominal surgery and transvaginal surgery in July of 2017. Thirty-five patients underwent RSS surgery with RGPT. Twenty-one patients had RSS transabdominal reconstructive or fertility-preserving surgeries such as myomectomy (12 patients), adenomyomectomy (3 patients), and ovarian endometriosis cystectomy (6 patients). Fourteen patients underwent robotic transvaginal surgery for natural orifice transluminal endoscopic surgery (NOTES) hysterectomy. All procedures were successfully performed, and no postoperative complications were observed. In all patients, the median total operative time, console time, and docking time were 160 min (range 106-240), 120 min (range 65-180), and 10 min (range 4-25), respectively. There was no conversion to another type of surgery, such as conventional laparoscopy, laparotomy, or traditional multiport robotic surgery. The findings showed that RSS surgery via the RGPT is safe and feasible, using the parallel setup of endowristed rigid instruments is easily performed on transvaginal routes and transabdominal routes. Therefore, this procedure may be an important complement to gynecologic surgeons' armamentarium in the field of robotic reconstructive or fertility-preserving surgeries such as myomectomy, adenomyomectomy, ovarian cystectomy, and transvaginal surgery for NOTES hysterectomy. Nevertheless, further prospective controlled studies are needed to determine its full clinical application.

The Fresh Frozen Cadaveric Study of Direct Pouch of Douglas Laparoscopic and Robotic Trocar Insertion for Vaginal Natural Orifice Transluminal Endoscopic Surgery.

STUDY OBJECTIVE: To determine the distances and angles that assure a safe entry into the pouch of Douglas (POD) during blind laparoscopic and robotic trocar entry. DESIGN: Trocars were inserted into the POD of 4 intact fresh frozen female pelves. Cadaveric dissection was performed, and the distance from the POD to the sacrum at rest and with maximal pressure to POD with the trocar was measured. In addition, the optimal angle for trocar insertion and entry was evaluated. SETTING: Inova Advanced Simulation and Technology Evaluation Center. PATIENTS: Fresh frozen cadavers with intact reproductive organs. INTERVENTIONS: Vaginal POD trocar insertion. MEASUREMENTS AND MAIN RESULTS: Measurements were recorded from the sacrum to the POD at rest and from the sacrum to the hymen with trocar pressure. The dissection demonstrated correct trocar placement in the POD of human cadaveric specimens. The mean distances from the sacrum to the hymen, the sacrum to the POD, and the sacrum to the POD with pressure were 18.75 cm, 9.75 cm, and 7.25 cm, respectively. After the deployment of the trocar, the tip was observed to be 2 cm below the cervix in the POD. The mean trocar angle to clear the sacral promontory and the neurovascular structures without injury to the uterus was 25° to 40° from the horizontal plane and 15° to 30° from the coronal plane. CONCLUSION: A direct trocar entry into the POD has been found to be feasible in fresh frozen cadaveric specimens. This study provided valuable information for the angle of entry into the POD to facilitate vaginal and robotic trocar entry for minimally invasive gynecologic procedures.

Transoral laser resection of hypopharyngeal liposarcoma.

Liposarcomas are rare malignant tumours of the connective tissue. Microscopically they resemble lipomas. They are usually found on the limbs or trunk. Fewer than 40 cases of hypopharyngeal liposarcoma have been reported in the literature. Surgical excision with a cervical or endoscopic approach has been the first-line treatment for these cases. We present a patient with the first documented primary excision via carbon dioxide laser using an entirely transoral approach. This case suggests a new standard of management but also highlights the difficulties with investigation and diagnosis in a rare presentation.

Evaluating a Prototype Nasolaryngoscopy Hood During Aerosol-Generating Procedures in Otolaryngology.

OBJECTIVE: During the COVID-19 pandemic, there has been considerable interest in identifying aerosol- and droplet-generating procedures, as well as efforts to mitigate the spread of these potentially dangerous particulates. This study evaluated the efficacy of a prototype nasolaryngoscopy hood (PNLH) during various clinical scenarios that are known to generate aerosols and droplets. STUDY DESIGN: Prospective detection of airborne aerosol generation during clinical simulation while wearing an PNLH. SETTING: Clinical examination room. METHODS: A particle counter was used to calculate the average number of 0.3-µm particles/L detected during various clinical scenarios that included sneezing, nasolaryngoscopy, sneezing during nasolaryngoscopy, and topical spray administration. Experiments were repeated to compare the PNLH versus no protection. During the sneeze experiments, additional measurements with a conventional N95 were documented. RESULTS: There was a significant increase in aerosols detected during sneezing, sneezing during nasolaryngoscopy, and spray administration, as compared with baseline when no patient barrier was used. With the PNLH in place, the level of aerosols returned to comparable baseline levels in each scenario. Of note, routine nasolaryngoscopy did not lead to a statistically significant increase in aerosols. CONCLUSION: This study demonstrated that the PNLH is a safe and effective form of protection that can be used in clinical practice to help mitigate the generation of aerosols during nasolaryngoscopy. While nasolaryngoscopy itself was not shown to produce significant aerosols, the PNLH managed to lessen the aerosol burden during sneezing episodes associated with nasolaryngoscopy.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video).

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique.

BACKGROUND: In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer. METHODS: Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and anal function score at 6 months after surgery were documented. RESULTS: Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points. CONCLUSIONS: PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.

Skull Base Dural Closure Using a Modified Nonpenetrating Clip Device via an Endoscopic Endonasal Approach: Technical Note.

Skull base reconstruction after an endoscopic endonasal approach into the cerebrospinal fluid (CSF) space is always challenging. Various reconstructive methods are available, but no standard technique is established. This report describes the endoscopic skull base dural closure using a modified nonpenetrating clip device with shaft length of 15 cm. Six patients with an intra-suprasellar or suprasellar tumor who underwent extended endoscopic endonasal transsphenoidal surgery were targeted. For closure of the skull base dural defect after tumor removal, fascia lata was first placed as an inlay graft and was subsequently fixed with the dura using a modified nonpenetrating clip device. No CSF leakage from the closed dura with an inlay fascia lata fixed with clips was confirmed by the Valsalva maneuver. To complete skull base reconstruction, fascia lata was then positioned as an overlay graft and covered with vascularized pedicled nasoseptal flaps. Five of six patients experienced no CSF rhinorrhea postoperatively. The modified nonpenetrating clip device may achieve effective dural closure in the deep and narrow nasal cavity. We introduce this clip device technique as one of the endoscopic skull base dural closure methods.