Cholecystectomy using a rigid-hybrid transvaginal natural orifice transluminal endoscopic surgery (NOTES) approach (tvNCC) reduces abdominal wall incisions and might decrease surgical trauma by ...combining endoluminal access and laparoscopic techniques. We assessed the feasibility and safety of rigid-hybrid tvNCC in routine practice for symptomatic cholecystolithiasis or acute cholecystitis in a patient population with low selection.
From September 2008 to July 2009, all female patients with cholecystectomy indications were evaluated for tvNCC. Exclusion criteria were: refusal of tvNCC; inability to give informed consent; gynecological or urological contraindications; lack of preoperative gynecological examinations; need for cholangiography/choledochus revision; anesthesiological contraindications to pneumoperitoneum; liver failure; or coagulopathy. Age, obesity, previous surgery, or degree of gallbladder inflammation were not exclusion criteria. Preoperative and 2-weeks' postoperative gynecological examinations were performed. Sexual function was assessed preoperatively and at 6 weeks postoperatively.
102 of 137 consecutive patients (74.5 %) with symptomatic cholecystolithiasis (n = 74) or cholecystitis (n = 28) were scheduled for rigid-hybrid tvNCC with nine different surgeons. Patient mean age was 52.3 +/- 17.8 years (range 18 - 87) and mean body mass index 27.3 +/- 6.3 kg/m (2) (17.6 - 43.8). Two patients had conversion to conventional laparoscopic cholecystectomy. There were no intraoperative complications. Two major complications occurred: one stroke and one herniation within the transumbilical access. Minor complications were reported in 13 patients (12.7 %) and there were no serious postoperative gynecological findings. At 6 weeks postoperatively, there were fewer dyspareunia symptoms than preoperatively ( P = 0.049).
Rigid-hybrid tvNCC is feasible and safe in routine practice for symptomatic cholecystolithiasis and acute cholecystitis.
Purpose
Emergency surgical strategies for acute left-sided colonic perforation are evolving preferring primary anastomosis (PA) with ileostomy to Hartmann’s procedure (HP) based on the morbidity and ...reversal rates. However, HP is still commonly performed. Hartmann’s reversal is associated with considerable morbidity. It is of interest whether laparoscopic reversal results in a lower morbidity as retrospective data suggest. Here, we compared the combined morbidity rates for two surgical strategies: strategy A, HP followed by laparoscopic reversal, and strategy B, sigmoid resection with PA followed by ileostomy closure.
Methods
Prospectively collected data of all consecutive patients undergoing HP for benign left-sided colonic perforation between 2010 and 2014 were retrospectively compared to data of patients undergoing PA. Groups were matched for age and Charlson comorbidity index. Additionally, patients were analyzed for American Society of Anesthesiologists score, body mass index, and peritonitis stage. End points were morbidity, operation time, reversal rate, time to reversal, and length of hospital stay.
Results
The study included 32 patients for whom Hartmann’s reversal was planned, along with 32 matched patients who underwent PA and diverting ileostomy. Median age was 75 and 72 years, Charlson score was 6 (4–9) and 6 (5–7), and patients classified by the American Society of Anesthesiologists (ASA) higher than III were 81 % in both groups. Combined major morbidity rates were 21 % for strategy A and 20 % for strategy B (
p
= 1.0). Combined comprehensive complication index was 16.4 ± 14.1 and 12.3 ± 19.1 (
p
= 0.08). HP reversal by laparoscopy was achieved in 71 %. The colostomy reversal rate was 75 % compared to ileostomy closure rate of 88 % (
p
= 0.34).
Conclusions
Laparoscopic Hartmann’s reversal is achievable in a high proportion of patients. Strategy B tends to have lower overall morbidity; meanwhile, major morbidity seems to be similar. Yet, in critically ill patients and in the absence of expertise of the surgeon on call, HP followed by elective laparoscopic reversal represents a viable alternative.
Laparoscopic transgastric stapler-assisted mucosectomy (SAM) has been described for minimally invasive circumferential en bloc resection of Barrett's esophagus (BE). Conceivably long-term disease ...control might be achieved by adding antireflux surgery after resection of BE by SAM. The aim of this study was to assess the feasibility of combined SAM and fundoplication in one laparoscopic procedure in six pigs. Furthermore, the competence of the gastroesophageal junction (GEJ) was assessed at baseline, after SAM, and after subsequent laparoscopic fundoplication. At each measuring point reflux measurements were repeated 6 times in each pig. Blue-colored water was infused into the stomach to provoke reflux. Intragastric yield pressure and volume were recorded until drainage of blue solution (DBS) was noted. Time to reflux was measured by DBS and by multichannel intraluminal impedance (MII). In all animals SAM followed by laparoscopic fundoplication was feasible in a single session. A weakening of the GEJ was found after SAM, indicated by decreased yield pressure (11.5 mmHg vs. 8.5 mmHg; P < 0.001), time to DBS (90 seconds vs. 60 seconds; P = 0.008) and MII (80 seconds vs. 33 seconds; P < 0.001). After additional Nissen fundoplication the GEJ competence was restored, with measurements returning to baseline values (time to DBS 99 seconds; P = 0.15; MII 76 seconds; P = 0.84). The yield pressure increased from 11.5 mmHg at baseline to 19.7 mmHg after SAM and fundoplication (P < 0.001). Laparoscopic fundoplication and SAM may be combined in a single laparoscopic session. Although the GEJ was weakened after SAM, Nissen fundoplication restored the GEJ as an effective reflux barrier in this experiment. For clinical validation, the results need to be confirmed in a prospective human trial.
Animal data and limited clinical evidence suggest a low incidence of infection following transvaginal natural orifice transluminal endoscopic surgery (NOTES). However, a systematic microbiological ...evaluation has not yet been carried out. The aim of this prospective cohort study was to evaluate the extent of microbiological contamination of the peritoneal cavity caused by the transvaginal access for NOTES and the impact of preoperative vaginal disinfection on vaginal colonization.
Consecutive female patients with symptomatic cholecystolithiasis were offered either transvaginal rigid-hybrid cholecystectomy (tvCCE) or conventional laparoscopic cholecystectomy. Patients who opted for tvCCE were prospectively evaluated between February and June 2010. Disinfection in patients undergoing tvCCE included hexetidine tablets and octenidine applied vaginally. All patients received a single dose of perioperative cefuroxime. Swabs were obtained from the posterior fornix and the peritoneal cavity at different intervals.
Of 32 patients, 27 (84 %) opted to undergo tvCCE. One patient (4 %; 95 % confidence interval CI 0.7 % - 18.3 %) had a positive bacterial culture in the Douglas pouch prior to transvaginal access compared with two patients (7 %; 95 %CI 2.1 % - 23.4 %) following colpotomy closure (P = 1.000). Vaginal disinfection significantly decreased vaginal bacterial load (P = 0.001) and bacterial growth in routine cultures (P < 0.001); in 16 patients (59 %; 95 %CI 40.7 % - 75.5 %) vaginal swabs were sterile after disinfection. No postoperative surgical site infections occurred (95 %CI 0 % - 12.5 %).
In selected patients and following vaginal antisepsis, transvaginal access for NOTES is associated with microbiological contamination of the peritoneal cavity in a minority of patients, indicating a low risk of peritoneal contamination caused by the transvaginal access.
Background
Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a ...positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease GERD or nonerosive reflux disease NERD) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery.
Methods
For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27–74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone.
Results
Preoperatively, MII-pH monitoring identified 71.9 ± 8.4 reflux episodes, whereas pH monitoring identified only 51.0 ± 7.8 (
p
< 0.05). Postoperatively, MII-pH monitoring identified 35.5 ± 6.6 reflux episodes, whereas pH monitoring identified only 19.6 ± 4.7 (
p
< 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%,
p
= 0.006; postoperative 50% vs 16.7%,
p
= 0.012).
Conclusion
Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.
Objective of the study:
The NOTES hype of the last few years did not lead to any adoptions in daily routine with the exception of the hybrid NOTES cholecystectomy which has become a standard ...procedure in several institutions. In our opinion the rigid hybrid NOTES technique is the perfect tool to convert laparoscopically assisted operations into totally laparoscopic procedures, avoiding the need of a minilaparotomy.
Methods and procedures:
Although, in standard laparoscopy, we can usually perform the operation with a few five millimetres incisions and one ten millimetre trocar (for insertion of the Endostapler), there remains the need for a minilaparotomy for specimen removal. This lead to the idea of removing specimen through natural orifices avoiding additional harm to the abdominal wall. As the transvaginal route is an old and well known surgical pathway since decades, it was obvious to develop the technique of transvaginal retrieval of colorectal specimens. When this technique was introduced, the proximal stapling of the specimen and the insertion of the anvil in the proximal lumen was performed extracorporally in the vagina. We advanced this technique and meanwhile we perform an intracorporal purse-string suture after insertion of the anvil in order to avoid any compromises concerning the length of the specimen. The transrectal pathway is a good alternative for retrieval of the specimen in men or in women with contraindications for a transvaginal route.
Results:
In our experience after more than hundred transvaginal and transrectal laparoscopic anterior resections it is a safe and feasible method for daily routine.
Conclusions based on the results:
In our opinion these techniques are the consequent evolution of the standard laparoscopic surgery in colorectal surgery. Combining standard laparoscopic operative techniques with specimen retrieval through natural orifices, eliminates the need for a minilaparotomy, allowing a totally laparoscopic operation with only small incisions. This significantly minimizes the risk of scar hernias, reduces postoperative pain and leads to quicker recovery of the patients. The transvaginal laparoscopic (rigid hybrid NOTES) anterior resection has become a routine procedure in our clinic. In near future, the transrectal laparoscopic resection will become our standard procedure in men. We demonstrate our technique of intracorporal purse-string suture combined with transvaginal removal and report a first series of transrectal laparoscopic anterior resection with operative video sequences.
Natural orifice transluminal endoscopic surgery (NOTES) describes surgical procedures through a natural orifice. In hybrid-NOTES small transabdominal trocars are combined with a NOTES access.
To ...evaluate hybrid-NOTES sigmoidectomy as a standard procedure for diverticulitis.
Elective laparoscopic sigmoidectomies performed between May 2011 and January 2016 were prospectively collated. Primary endpoint was the feasibility of hybrid-NOTES sigmoidectomy. The reasons for planning a laparoscopically-assisted sigmoidectomy (LAS), intraoperative change of treatment and reactive conversion were evaluated. Secondary endpoints were complications and operative time.
Out of 130 laparoscopic sigmoidectomies 83% were planned for hybrid-NOTES and 8 out of 52 (15%) transvaginal (TVS) and 14 out of 56 (25%) transrectal (TRS) sigmoidectomies were intraoperatively changed to LAS. The reason for the change in 64% was that the specimen was too bulky and 80% of scheduled hybrid-NOTES procedures were carried out as planned. The operative time for TVS (146.8 ± 44.5 min) was shorter compared to LAS (173.2 ± 58.8 min, P = 0.016). The morbidities of TVS (15.3%) and TRS (14.9%) were not significantly different from LAS (23.9%, P = 0.501 and P = 0.537, respectively).
Hybrid-NOTES for diverticular disease may be indicated in more than 80% of cases. In respect of intraoperative change of treatment, hybrid-NOTES is feasible in two thirds of patients. Given a high level of expertise, hybrid-NOTES can be provided as a standard procedure in sigmoidectomy for diverticular disease.
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