Evidence - Hybrid-NOTES - Sigmaresektion - general and visceral surgery
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Literature summary
NOTES (“natural orifice transluminal endoscopic surgery”) is a minimally invasive surgery technique that uses only natural body openings, such as the mouth, vagina or rectum, as portal of entry into the body in order to reduce surgical access trauma. If the NOTES technique is combined with other techniques (e.g., NOTES + standard laparoscopy or SILS), this is known as hybrid NOTES or NOSE (“natural orifice specimen extraction”).Here, only certain steps of the procedure are executed via the NOTES access, e.g., stapler insertion or specimen extraction. Otherwise, the hybrid technique is the same as that in standard laparoscopy. The main benefits of both techniques are less postoperative pain, quicker convalescence as well as fewer wound complications and incisional hernias [4, 10, 12, 14].
The term NOTES was first used in 2004 by Antonie Kallo from Baltimore for a transgastric peritoneoscopy technique [6]. The first transvaginal cholecystectomy in humans was published as a case report in 2007 [11]. In that same year, Zornig et al. described the first transvaginal cholecystectomy with rigid instruments in hybrid NOTES technique in Germany [16] and already the following year reported on a series of 20 patients [15]. The first NOTES sigmoidectomy was performed in 2007 by Whiteford et al. on a cadaver model [13]. In 2009, Leroy et al. reported on a combined transgastric and transanal NOTES sigmoidectomy on a porcine model that survived the procedure [9].
NOTES databases
NOTES surgery, which has only a short learning curve for experienced laparoscopy surgeons, evolved within a few years from animal models to its clinical application. Online databases were set up such as the “German Registry for Natural Orifice Transluminal Endoscopic Surgery (GNR)” or the “EURO-NOTES Clinical Registry for Natural Orifice Transluminal Endoscopic Surgery (ECR)” [1], where departments enter their results and can contribute to the safe implementation of NOTES techniques. At present, the national NOTES registry of the German Society for General and Visceral Surgery (DGAV) holds the records of 4,270 patients (as of January 14, 2017).
Transgastric and transvaginal NOTES techniques
The transgastric NOTES technique has now been discontinued. The reasons for this include problems with maintaining the pneumoperitoneum and extraction of larger specimens via the esophagus. Safe closure of the gastrostomy, which is potentially associated with high morbidity, has proved to be a particular problem [2]. In a literature review from 2012, Coomber et al. reported on 61 patients who had undergone a transgastric procedure (35 cholecystectomies and 26 appendectomies). With rates of 24% after cholecystectomy and 21.4% after appendectomy, the morbidity rate was well above the 4–10% after standard laparoscopic surgery [5].
The majority of NOTES interventions are transvaginal procedures which, unlike transgastric interventions, have a good safety profile [2]. Colpotomy and instrument insertion are performed under direct vision and the gynecological transvaginal interventions in the lesser pelvis, which have been carried out for over 120 years, demonstrate that infections and hernias are quite rare. Due to the elasticity of the vaginal walls, surgical implements with a larger diameter can be inserted and larger specimens extracted [3].
Technical aspects of hybrid NOTES sigmoidectomy
The range of transvaginal NOTES interventions includes cholecystectomy; appendectomy; nephrectomy; sigmoidectomy; and now also splenectomies, liver resections and sleeve gastrectomy in bariatric surgery [5]. According to the national NOTES Registry of the German Society for General and Visceral Surgery (DGAV), the majority of operations in 2015 (almost 88%) involved gallbladder disease [8].
While colon resection in NOTES technique is less common, numerous German departments have applied the NOTES concept to elective sigmoidectomy in diverticulitis, hemicolectomy and anterior rectal resection in colorectal carcinoma. The actual dissection is performed by standard laparoscopy or SILS and the specimens are extracted through natural body orifices (transvaginally, more rarely transrectally) [8].
In NOTES sigmoidectomy, three different surgical modifications are employed:
- Vaginal extraction with preparation for extracorporeal anastomosis
- Vaginal extraction with preparation for intracorporeal anastomosis
- Transrectal extraction with preparation for intracorporeal anastomosis
The laparoscopic intraabdominal dissection of the sigmoid is the same in all three modifications.
1. Vaginal extraction with preparation for extracorporeal anastomosis
Since preparation for extracorporeal anastomosis requires transvaginal extraction of the colon, the left colonic flexure must be freed completely. The rectum is divided with a transvaginally inserted linear cutter and the resected specimen extracted transvaginally with sponge forceps. After placing a purse-string clamp at the proximal resection margin of the descending colon, the marginal artery is ligated and the colon divided. The anvil is secured by tying the purse-string suture and the descending colon is returned into the abdomen. Following colpotomy closure, descendorectostomy is performed as usual.
2. Vaginal extraction with preparation for intracorporeal anastomosis
The left flexure is mobilized only when necessary. Following sigmoid dissection, the rectum is divided as in the previous technique. After intracorporeal division of the marginal artery of the descending colon, the colon is opened antimesenterically somewhat distal to the planned resection margin and the transvaginally inserted anvil is positioned into the colon lumen with its trocar facing first. The anvil trocar is pushed through the antimesenteric colon wall about 5–7 cm proximal to the planned resection line. The colon is divided just distal to the anvil with a transvaginally inserted articulated liner cutter. After specimen extraction and colpotomy closure, the side-to-end descendorectostomy is fashioned.
3. Transrectal extraction with preparation for intracorporeal anastomosis
This variant technique does not require routine freeing of the left colonic flexure either. A 12 mm trocar in the right lower quadrant is needed for stapler access. The rectum is opened with some scissors approx. 2 cm proximal to the intended resection line, before inserting the anvil, introduced transanally into the abdominal cavity, with an anvil grasper. The anvil is inserted into the descending colon as described in no. 2 above. After dividing the descending colon with the linear cutter, the specimen is extracted transrectally. The open rectum is closed with the stapler. The 1–2 cm wide transected segment is placed in an extraction bag and extracted from the abdominal cavity via the 12 mm trocar access. After closing the trocar access site, fashion the side-to-end descendorectostomy.
The significance of NOTES techniques in elective sigmoidectomy
The joint Sk2 guideline for diverticular disease / diverticulitis of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society for General and Visceral Surgery (DGAV) from 2014 assesses the NOTES techniques for elective sigmoid resection as follows [7]:
The technical feasibility of single-port, NOS and NOTES sigmoidectomy in the management of diverticular disease has been established. The significance of these techniques in comparison with laparoscopic techniques is unclear and should be investigated in clinical trials.
Strength of consensus: Strong consensus
Since there are no comparative trials with a high level of evidence, adequate comparative assessment of the various techniques is not possible here. However, new techniques should be tested in clinical trials, ideally in comparison with standard laparoscopic techniques […].
Ongoing trials on this topic
References on this topic
1: Arezzo A, Zornig C, Mofid H, Fuchs KH, Breithaupt W, Noguera J, Kaehler G, Magdeburg R, Perretta S, Dallemagne B, Marescaux J, Copaescu C, Graur F, Szasz A, Forgione A, Pugliese R, Buess G, Bhattacharjee HK, Navarra G, Godina M, Shishin K, Morino M. The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report. Surg Endosc. 2013 Sep;27(9):3073-84.
2: Benhidjeb T, Burghardt J, Stark M. Novel technologies for natural orifice surgery: an overview. Minim Invasive Ther Allied Technol. 2008;17(6):346-54.
3: BENHIDJEB T, Gerntke IC, Stark M. Scarless Surgery by using natural Orifices of the body: rationale and results. Arab Health Magazine Issue 5, 2013, pages 080-082.
4: Bulian DR, Knuth J, Lehmann KS, Sauerwald A, Heiss MM. Systematic analysis of the safety and benefits of transvaginal hybrid-NOTES cholecystectomy. World J Gastroenterol. 2015 Oct 14;21(38):10915-25.
5: Bulian DR, Runkel N, Burghardt J, Lamade W, Butters M, Utech M, Thon KP, Lefering R, Heiss MM, Buhr HJ, Lehmann KS (2014) Natural Orifice Transluminal Endoscopic Surgery (NOTES) for colon resections–analysis of the first 139 patients of the German NOTES Registry (GNR). International journal of colorectal disease 29:853-861
6: Coomber RS, Sodergren MH, Clark J, Teare J, Yang GZ, Darzi A. Natural orifice translumenal endoscopic surgery applications in clinical practice. World J Gastrointest Endosc. 2012 Mar 16;4(3):65-74.
7: Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004 Jul;60(1):114-7.
8: Kruis W, Germer CT, Leifeld L; German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society for General and Visceral Surgery. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion. 2014;90(3):190-207.
9: Lehmann KS, Zornig C, Arlt G, Butters M, Bulian DR, Manger R, Burghardt J, Runkel N, Pürschel A, Köninger J, Buhr HJ. [Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]. Chirurg. 2015 Jun;86(6):577-86.
10: Leroy J, Cahill RA, Perretta S, Forgione A, Dallemagne B, Marescaux J. Natural orifice translumenal endoscopic surgery (NOTES) applied totally to sigmoidectomy: an original technique with survival in a porcine model. Surg Endosc. 2009 Jan;23(1):24-30.
11: Ma B, Huang XZ, Gao P, Zhao JH, Song YX, Sun JX, Chen XW, Wang ZN. Laparoscopic resection with natural orifice specimen extraction versus conventional laparoscopy for colorectal disease: a meta-analysis. Int J Colorectal Dis. 2015 Nov;30(11):1479-88.
12: Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg. 2007 Sep;142(9):823-6; discussion 826-7.
13: Sodergren MH, Markar S, Pucher PH, Badran IA, Jiao LR, Darzi A. Safety of transvaginal hybrid NOTES cholecystectomy: a systematic review and meta-analysis. Surg Endosc. 2015 Aug;29(8):2077-90.
14: Whiteford MH, Denk PM, Swanström LL. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc. 2007 Oct;21(10):1870-4.
15: Xu B, Xu B, Zheng WY, Ge HY, Wang LW, Song ZS, He B. Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis. World J Gastroenterol. 2015 May 7;21(17):5393-406.
16: Zornig C, Mofid H, Emmermann A, Alm M, von Waldenfels HA, Felixmüller C. Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients. Surg Endosc. 2008 Jun;22(6):1427-9.
16: Zornig C, Emmermann A, von Waldenfels HA, Mofid H. Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach. Endoscopy. 2007 Oct;39(10):913-5.
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