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Surgical videos in NOTES
Access / Closure
Perretta S, Allemann P, Dallemagne B, Marescaux J. NOTES left nephrectomy: retroperitoneal transvaginal approach. Epublication: WeBSurg.com, Apr 2008;8(4). URL: http://www.eats.fr/doi-vd01en2313.htmThis video shows how to perform nephrectomy in the porcine model with a novel transvaginal retroperitoneal NOTES technique.
Conceivably, nephrectomy performed through a natural orifice could enhance cosmesis and minimize postoperative recovery. The vagina has been considered a viable route for kidney retrieval following laparoscopic nephrectomies. While NOTES nephrectomy has been previously described, the transvaginal retroperitoneal route has not been explored yet.
Under general anesthesia, with the pig supine, the left retroperitoneal space was entered with a double channel endoscope (Storz™) through a posterior colpotomy. A retroperitoneal tunnel was created with blunt dissection with the assistance of insufflation set at 12mm Hg. To prevent penetration of the peritoneal sac, the dissection is carried out in close contact with the psoas muscle up to the Gerota's fascia, which was opened to access the renal hilum. Renal vessels and the ureter were dissected and taken separately between clips. The kidney was dissected free bluntly. Limitations imposed by the porcine anatomy prevented transvaginal specimen retrieval.
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Perretta S, Dallemagne B, Allemann P, Nassif J, Zacharopoulou C, Wattiez A, Marescaux J. Transvaginal access to the retroperitoneum. Epublication: WeBSurg.com, Mar 2008;8(3). URL: http://www.eats.fr/doi-vd01en2304.htmThis video demonstrates the transvaginal approach to the retroperitoneal space.
A posterior colpotomy is carried out with the needle-knife. The retroperitoneal space is entered digitally enlarging the posterior vaginal incision. In order to avoid peritoneal entering, precise identification of key anatomical landmarks is mandatory. A retroperitoneal tunnel is created using both blunt and balloon dissection with the assistance of CO2 insufflation set at 12mmHg. Demonstrated herein are the technical steps of right adrenalectomy, left nephrectomy and a right latero-caval lymphadenectomy.
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This video displays the creation and closure of a gastrotomy for any transgastric approach step by step. It also illustrates a clever way to maintain the pneumogastrium. This video details the main obstacles and achievements so far in determining the safety and efficacy of both gastric access and closure.
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This video shows the technique of a NOTES hybrid sleeve gastrectomy performed live during the NOTES course. The intra-abdominal access is made via a transvaginal approach (double channel KARL STORZ endoscope and one grasper) combined with one abdominal trocar. The main steps of the procedure are discussed extensively.
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Vix M, Solano C, Asakuma M, Perretta S, Marescaux J. One trocar sleeve gastrectomy using the air-seal port in a porcine model. Epublication: WeBSurg.com, Jan 2008;8(1). URL: http://www.eats.fr/doi-vd01en2256.htmThis video demonstrates the stepwise technique for performing a one trocar sleeve gastrectomy in a porcine model. The procedure is achieved through the air-seal device (which functions as a single trocar and insufflation system at the same time) and with the aid of different length instruments that improved the ergonomics of the working space.
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This video shows the formatting of gastric sleeve surgery via a hybrid NOTES technique in a porcine model. A transvaginal approach is used along with one single transabdominal trocar with additional retraction aided by both an intraluminal gastroscope and an intragastric magnet (anchored by a second extracorporeally).
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This recording of a recent masterclass in NOTES held at the IRCAD demonstrates the salient steps of several NOTES operations performed simultaneously and includes the comments of a live audience and input from expert observers. The 'PEG' method of obtaining access to the peritoneum via a gastrotomy is shown in a stepwise manner as well as more advanced transluminal procedures such as cholecystectomy, nephrectomy, distal pancreatectomy and sigmoidectomy. All operations are performed by pioneers in this specialist field from around the world and so this video record presents an exceptional opportunity to witness a state-of-the-art workshop.
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Marescaux J, Dallemagne B, Perretta S, Mutter D, Wattiez A, Coumaros D. First NOTES cholecystectomy. Epublication: WeBSurg.com, Apr 2007;7(4). URL: http://www.eats.fr/doi-vd01en2128.htmThis video shows the first totally NOTES cholecystectomy via a transvaginal approach in a 30-year-old woman with symptomatic cholelithiasis. The operation was performed by a multidisciplinary team, which included a gynecologist who performed and closed the colpotomy. The peritoneal cavity was entered through an incision in the posterior vaginal cul-de-sac. The transvaginal access to the peritoneal cavity and the introduction of the double channel gastroscope (KARL STORZ-Endoskope®, Germany) were performed under laparoscopic control by a 2 mm needle-scope.
The placement of this 2 mm needle-port was mandatory to insufflate CO2 and to monitor the pneumoperitoneum and it turned out helpful for further retraction of the gallbladder. Complete identification of the structures of Calot’s triangle was achieved. The dissection began in close proximity of the gallbladder at the junction between the infundibulum and the cystic duct. The peritoneum covering the cystic duct was incised anteriorly and posteriorly and gently brushed away with blunt dissection. Once sufficiently skeletonized, the cystic duct and artery were clipped twice on patient side and once on gallbladder side and divided with endoscopic scissors. Using an endoscopic grasper and a Storz unipolar round-tip electrode, the gallbladder was dissected away from the intrahepatic fossa and placed in a specimen retrieval bag prior to removal through the vagina. The operative site was checked to ensure hemostasis and rule out any inadvertent injury to the adjacent organs. The colpotomy was closed with interrupted 2/0 Vicryl stitches.
All the procedure was carried out using a standard double channel video flexible gastroscope and standard endoscopic instruments. All the principles of laparoscopic cholecystectomy were strictly respected. At no stage of the procedure there was a need of laparoscopic assistance. No complications occurred during the procedure. The advantages of laparoscopy, namely minimal postoperative pain and abdominal scarring appeared to be enhanced by this approach. The patient had no postoperative pain, “no scars” and was discharged on the second postoperative day.
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In this video, a technique for the creation and closure of a gastrostomy to facilitate transgastric peritoneoscopy is demonstrated. It includes discussion of all the key steps of the procedure.
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Leroy J, Perretta S, Forgione A, Dallemagne B, Marescaux J. NOTES sigmoidectomy in a pig model: a stepwise approach. Epublication: WeBSurg.com, Oct 2007;7(10). URL: http://www.eats.fr/doi-vd01en2191.htmThis video demonstrates a number of different NOTES techniques for performing sigmoidectomy in a porcine model. The principal trans-gastric approach is combined with a trans-vaginal, trans-rectal and laparoscopic approach in 3 different animals. Different methods of vascular dissection and colonic division are discussed.
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NOTES left nephrectomy: retroperitoneal transvaginal approach
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