Abstrakt Ostatní Červen 2009

“Commentary on Complete transvaginal NOTES nephrectomy using magnetically anchored instrumentation. Raman JD, Bergs RA, Fernandez R, Bagrodia A, Scott DJ, Tang SJ, Pearle MS, Cadeddu JA, Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.”

Anderson, J. K. (2009).

Urologic Oncology: Seminars and Original Investigations 27(3): 344.

Evolution of minimally invasive techniques has prompted interest in natural orifice transluminal endoscopic surgery (NOTES). Challenges for NOTES include loss of instrument rigidity, reduction in working envelopes, and collision of instrumentation. Magnetic anchoring and guidance system (MAGS) is one surgical innovation developed at our institution whereby instruments that are deployed intra-abdominally are maneuvered by the use of an external magnet. We present our initial animal experience with complete transvaginal NOTES nephrectomy using MAGS technology. Transvaginal NOTES nephrectomy was performed in two female pigs through a vaginotomy, using a 40-cm dual-lumen rigid access port inserted into the peritoneal cavity. A MAGS camera and cauterizer were deployed through the port and manipulated across the peritoneal surface by way of magnetic coupling via an external magnet. A prototype 70-cm articulating laparoscopic grasper introduced through the vaginal access port facilitated dissection after deployment of the MAGS instruments. The renal artery and vein were stapled en-bloc using an extra-long articulating endovascular stapler. NOTES nephrectomies were successfully completed in both pigs without complications using MAGS instrumentation. The MAGS camera provided a conventional umbilical perspective of the kidney; the cauterizer, transvaginal grasper, and stapler preserved triangulation while avoiding instrument collisions. Operative duration for the 2 cases was 155 and 125 minutes, and blood loss was minimal. NOTES nephrectomy using MAGS instrumentation is feasible. We believe this approach improves shortcomings of previously reported NOTES nephrectomies in that triangulation, instrument fidelity, and visualization are preserved while hilar ligation is performed using a conventional stapler without need for additional transabdominal trocars. © 2009 Elsevier Inc. All rights reserved.

“Novel magnetically guided intra-abdominal camera to facilitate laparoendoscopic single-site surgery: initial human experience.”

Cadeddu, J., R. Fernandez, et al. (2009).

Surgical Endoscopy: 1-6.

Background: Magnetic anchoring guidance systems (MAGS) are composed of an internal surgical instrument controlled by an external handheld magnet and do not require a dedicated surgical port. Therefore, this system may help to reduce internal and external collision of instruments associated with laparoendoscopic single-site (LESS) surgery. Herein, we describe the initial clinical experience with a magnetically anchored camera system used during laparoscopic nephrectomy and appendectomy in two human patients. Methods: Two separate cases were performed using a single-incision working port with the addition of a magnetically anchored camera that was controlled externally with a magnet. Results: Surgery was successful in both cases. Nephrectomy was completed in 120 min with 150 ml estimated blood loss (EBL) and the patient was discharged home on postoperative day 2. Appendectomy was successfully completed in 55 min with EBL of 10 ml and the patient was discharged home the following morning. Conclusions: Use of a MAGS camera results in fewer instrument collisions, improves surgical working space, and provides an image comparable to that in standard laparoscopy. © 2009 Springer Science+Business Media, LLC.

“Laparoendoscopic single-site surgery (LESS) in gynecologic oncology: Technique and initial report.”

Fader, A. N. and P. F. Escobar (2009).

Gynecol Oncol 114(2): 157-61.

OBJECTIVES: Recent reports suggest that laparoendoscopic single-site surgery (LESS), also known as single-port surgery, is technically feasible in treating a variety of disease processes. The purpose of this study was to assess the feasibility of LESS for the surgical treatment of various gynecologic cancers or precancerous conditions through both laparoscopic and robotic-assisted approaches. METHODS: A single institution retrospective review of patients treated with LESS on the gynecologic oncology service in 2009 was performed. Patients underwent surgery through a single 2-3 cm umbilical incision with a multi-channel SILS port for laparoscopic cases or a single-channel Gelport(R) for robotic cases on the daVinci(R) Surgical System. RESULTS: Thirteen patients had LESS surgery performed, nine done laparoscopically and four robotically. Procedures included endometrial cancer staging (n=1), ovarian cancer staging (n=1), retroperitoneal pelvic lymph node dissection (n=1), risk-reducing extrafascial hysterectomy/bilateral salpingo-oophorectomy (BSO, n=2) and BSO alone (n=5), and an ovarian cystectomy (n=1) and BSO (n=2) for complex adnexal masses. Median patient age and BMI were 47 years and 28, respectively. Median operating time was 65 min. All procedures were successfully performed via a single incision and no post-operative complications occurred. The majority of patients required no narcotics post-operatively. CONCLUSION: We present the first series of laparoendoscopic single-site surgery for the treatment of various gynecologic oncology conditions. LESS is feasible in select patients by laparoscopic or robotic-assisted techniques. Further studies are needed to better define the ideal gynecologic procedures for single-site surgery and to assess the benefits of LESS compared with more conventional minimally invasive approaches.

“Laparoendoscopic Single Site Surgery in Urology.”

Irwin, B. H., P. P. Rao, et al. (2009).

Urologic Clinics of North America 36(2): 223-235.

Laparoendoscopic single site (LESS) surgery is a recently coined term that refers to a group of techniques that perform laparoscopic intervention through a single abdominal incision often hidden within the umbilicus. The relative ease and swiftness of early success of LESS surgery is in large part because of the familiarity of current practitioners with advanced laparoscopic techniques and the advent of several technologic advances in the areas of instrumentation, camera systems, and access devices. As ongoing advancements in instrumentation and future robotics platforms are incorporated, the scope and application of LESS surgery is likely to expand. Ultimately, prospective studies that compare the safety and effectiveness of this new approach with the standard conventional laparoscopic approach will determine the future role in surgical practice. © 2009 Elsevier Inc. All rights reserved.

“Navigation systems and platforms in natural orifice translumenal endoscopic surgery (NOTES).”

Karimyan, V., M. Sodergren, et al.

International Journal of Surgery.

Introduction: The latest evolution in minimally invasive surgery is to avoid skin incisions by using natural orifices, called natural orifice translumenal endoscopic surgery (NOTES). However, to safely and efficiently perform NOTES, the requirements of the operating platform used need to be modified from the conventional endoscope. The aim of this paper is to systematically review specialised operating platforms used or in development for NOTES procedures. Methods: A review of the literature was conducted using Ovid EMBASE, Ovid MEDLINE, ISI Current Contents Connect and PubMed, a search tool of the National Library of Medicine and the national institute of Health, until the 1st of December 2008. Data was extracted to specifically characterise the available platforms, their availability, advantageous characteristics and potential disadvantages. Results: There were 9 studies included in this review describing 6 different navigation platforms and 3 robotic systems for NOTES. Based on this analysis, it is our opinion that although the described surgical systems and navigation platforms possess some attractive characteristics, such as maneuverability, stability, enhanced optics, and the ability to provide triangulation and insufflation with proper suction/irrigation maintenance, there does not appear to be one platform which is clearly superior to others. Conclusion: Current instruments are not suited for effective surgery in a NOTES environment. There are several important requirements for NOTES platform: 1) to provide safe access to the peritoneal cavity; 2) to provide a stable channel for instrumentation passageway and safe navigation, 3) to provide good visualization and illumination, thereby decreasing disorientation, 4) to maintain proper insufflation and suction/irrigation, and 5) to provide maneuverability and triangulation of the instruments. Effective collaborations between clinicians, engineering departments and industry are essential to maximise and expedite the innovative process in producing an optimal NOTES platform. © 2009 Surgical Associates Ltd.

“Single-port laparoscopic retroperitoneal surgery: initial operative experience and comparative outcomes.”

White, W. M., R. K. Goel, et al. (2009).

Urology 73(6): 1279-82.

OBJECTIVES: To present the initial operative outcomes and comparative data among patients undergoing single-port laparoscopic retroperitoneal surgery (SPLRS). METHODS: A prospective, observational study of all patients who underwent SPLRS was performed. The salient demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative visual analog pain scale scores were recorded. Patients who underwent cryoablation were then retrospectively compared to a contemporary, matched cohort of patients undergoing traditional laparoscopic retroperitoneal cryosurgery. Statistical analyses were performed. RESULTS: From September 25, 2007 to July 15, 2008, 8 patients underwent SPLRS. Five patients underwent SPLR cryoablation and 1 underwent SPLR partial nephrectomy for radiographic evidence of an enhancing renal mass. One patient underwent SPLR metastectomy for isolated recurrence of renal cell carcinoma. The remaining patient underwent SPLR cyst decortication for unrelenting pain. The mean patient age was 63.5 years. The mean body mass index was 28.9 kg/m(2). The mean operative time and estimated blood loss was 165 +/- 23 minutes and 134 +/- 152 mL, respectively. No intraoperative or postoperative complications were noted. The mean hospitalization was 1.4 days. The mean visual analog pain scale score at discharge was 0.4 of 10 (range 0-2). No significant difference was noted between the single-port and standard retroperitoneal cryotherapy cohorts with respect to age, body mass index, estimated blood loss, and length of hospitalization (P > .05). Patients who underwent SPLR cryoablation reported lower visual analog pain scale scores (P = .023). CONCLUSIONS: The results of our study have shown that SPLRS is feasible and offers comparable surgical outcomes and superior cosmesis and pain control compared with traditional retroperitoneoscopy.