NOTES NOTES???? 9/7/2009. M. Hagen. Center for the Future of Surgery University of California San Diego

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1 NOTES M. Hagen Center for the Future of Surgery University of California San Diego NOTES???? 1

2 NOTES!!! Natural Orifice Translumenal Endoscopic Surgery: - Intentional puncture of one of the viscera (e.g., stomach, rectum, vagina, urinary bladder) to access the abdominal cavity - With an endoscope (flexible or stiff) - To perform an intraabdominal operation Pearl JP, Ponsky JL: J Gastrointest Surg Dec 5 2

3 3

1901;15:1045 1049 Dimitri Oskarovich Ott

4 NOTES before NOTES I Ott, Ventroscopia. Zhurnal Akusherstva I Zhenskikh Boleznel. 1901;15: Dimitri Oskarovich Ott performed the first endoscopic examination of the abdominal cavity through a posterior vaginal incision using a head mirror and speculum: st VENTROSCOPY

5 NOTES before NOTES II Decker A, Cherry T. Culdoscopy, a new method in diagnosis of pelvic disease. Amer J Surg. 1944;64:40 44 Culdoscopy NOTES before NOTES I Tsin DA, J Am Assoc Gynecol Laparosc Aug;8(3): Operative Culdolaparoscopy (MA-NOS)

6 Open surgery Operating Theater 6

7 Surgical Instruments Development of Laparoscopy Georg Kelling 1st experimental laparoscopy in 1910 in dogs 7

8 Robotic Surgery Single Incision Laparoscopy I 8

9 Single Incision Laparoscopy II Single Incision Laparoscopy III 9

10 Single Incision Robotic Laparoscopy I Single Incision Robotic Laparoscopy II 10

11 Single Incision Robotic Laparoscopy III 11

12 NOTES 2007/2008 Basic experiments First patients: Rao`s AE 2004 More complex and detailed lab research Clinical NOTES In 1st world Kalloo`s first Publication 2004 T Acute and survival models in pigs: - Transgastric access - Peritoneal cavity exploration - Liver biposy - Gastric closure Kalloo AN, Gastrointest Endosc Jul;60(1):

NOTES 2007/2008 Basic experiments First patients: Rao`s AE 2004 More complex and detailed lab research Clinical NOTES In 1st world Kalloo`s first Publication 2004 T NOTES: First

13 NOTES 2007/2008 Basic experiments First patients: Rao`s AE 2004 More complex and detailed lab research Clinical NOTES In 1st world Kalloo`s first Publication 2004 T NOTES: First Patients Reddy & Rao «Per oral transgastric endoscopic appendectomy in human.» 45th Annual Conference of the Society of Gastrointestinal Endoscopy of India; February, 2004; Jaipur, India. 13

14 NOTES 2007/2008 Basic experiments First patients: Rao`s AE 2004 More complex and detailed lab research Clinical NOTES In 1st world Kalloo`s first Publication 2004 T NOTES: Further Research Tubal Ligation Cholecystectomie Gastrojejunostomie Oophorectomie Tubectomie Splenectomie Nephrectomie Pankreatic Resection 14

15 NOTES 2007/2008 Basic experiments First patients: Rao`s AE 2004 More complex and detailed lab research Clinical NOTES In 1st world Kalloo`s first Publication 2004 T Research and clinical NOTES in USA UCSD 15

16 Why NOTES??? Rationale for NOTES - No abdominal wall incisions - No wound infections and hernias - Less pain - Less adhesions Is NOTES less invasive than any other kind of surgery??? - NO scars perfect cosmetic outcomes 16

Importance of cosmetics Geneva Cosmesis Study Onsight poll at "day of

issues in abdominal surgery - Satisfaction with previous scars -

are increased - Accepted percentage of risk rise - Importance of further

17 Importance of cosmetics Geneva Cosmesis Study Onsight poll at "day of open wards + ongoing interviews Questionnaire: - Importance of cosmetic issues in abdominal surgery - Satisfaction with previous scars - Favoritism of scarless surgery - Favoritism of scarless surgery if risks are increased - Accepted percentage of risk rise - Importance of further research and investments Questions answered on VAS from 0 to more than 100% or 1 to 10 17

Conclusion Geneva cosmesis study - People strongly favor the idea of scarless abdominal surgery - No differences between genders have been found - Certain risks are accepted in order to achieve

18 Conclusion Geneva cosmesis study - People strongly favor the idea of scarless abdominal surgery - No differences between genders have been found - Certain risks are accepted in order to achieve scarless surgery - Further research and investments seems important People have a desire for NOTES!!! Rationale for NOTES II The NOTES-concept : Human ingenuity and technological advance can continue to reduce the trauma and discomfort of effective surgery 18

19 NOTES Today at UCSD Cholecystectomy 19

20 Transvaginal Cholecystectomy I Gastric Sleeve Resection 20

21 Transvaginal Gastric Sleeve Resection Umilical Hernia Repair 21

22 Transvaginal Umbilical Hernia Repair Appendectomy 22

23 Transgastric Appendectomy Transresctal Surgery I 23

24 Transresctal Surgery II NOTES Limitations Safe Access Installation and Maintanance of Pneumoperitoneum Unstable Vision & Operating Platform Insufficient Tools Limited Retraction Closure 24

25 NOTES: Access Conventional laparoscopic trocars NOTES: Access without trocars 25

26 NOTES: Access I NOTES: Access II 26

27 NOTES: Access III NOTES: Access III 27

28 NOTES: Operating Platforms I USGI, USA NOTES: Operating Platforms II USGI, USA Boston Scientific, USA 28

29 NOTES: Operating Platforms III D. Scott, USA NOTES: Tools I 29

30 NOTES: Tools II NOTES: Retraction 30

31 NOTES: Closure I NOTES: Closure II 31

equivalency to surgery with advantages for adhesion formation

32 NOTES: Closure III T-tag applier + knotting element 2.8 mm channel Closure of porcine colon perforation demonstrates equivalency to surgery with advantages for adhesion formation Ethicon Endosurgery, USA BUT: All instrumentation not designed for intraabdominal surgery 32

33 Robots for NOTES Project "ARAKNES" Array of robots augmenting the Kinematics of Endo-luminal surgery 33

The future is hard to predict Does NOTES have a future?

next logical progression of surgical development, a key

Improvements Hybrids Endoscopically- Assisted Laparoscopy

Non- Invasive Cholecystectomy Appendectomy Ventral Hernia

??? Sources of Invasion Abdominal wall incisions Post-op

34 The future is hard to predict Does NOTES have a future? NOTES, by addressing Sources of Invasion, represents the next logical progression of surgical development, a key step along the MIS continuum Open Laparoscopic/ Sustaining Improvements Hybrids Endoscopically- Assisted Laparoscopy Laparoscopically- Assisted Endoscopy NOTES Intralumenal Non- Invasive Cholecystectomy Appendectomy Ventral Hernia Diagnostic Peritoneoscopy???? Sources of Invasion Abdominal wall incisions Post-op recovery/rtna General anesthesia Financial burden Site of care Infrastructure requirements Clinician skill level 34

We must not say every mistake is a foolish one Cicero (106 BC 43 BC) The effect of NOTES 3 2.

35 We must not say every mistake is a foolish one Cicero (106 BC 43 BC) The effect of NOTES Less invasive - New approaches T Laparoscopy Flexible Endoscopy - More invasive - New, effective instruments for intralumenal manipulation 35

36 Protecting valuables! Thank you very much for your attention! 36

Hybrid Transvaginal Nephrectomy

european urology 53 (2008) 1290 1294 available at www.sciencedirect.com journal homepage: www.europeanurology.com Case Study of the Month Hybrid Transvaginal Nephrectomy Anibal W. Branco a, Alcides J.