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NOTES

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.


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Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
SH Kong
Lecture
2 years ago
1823 views
113 likes
0 comments
22:10
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
Pure NOTES: Transvaginal tubal sterilization with flexible endoscope
Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. The patient is 32 years old with a history of one previous vaginal delivery and one previous cesarean delivery. Her BMI is 20. The procedure was fully explained to the patient and written consent was obtained.
J Mejías, H Almau, P Rosales, R de la Fuente, N García, C Bravo
Surgical intervention
7 years ago
404 views
13 likes
0 comments
07:05
Pure NOTES: Transvaginal tubal sterilization with flexible endoscope
Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. Tubal sterilization is a permanent method of contraception, performed using several current approaches, including laparotomy, mini-laparotomy, colpotomy, laparoscopy and hysteroscopy. Two new approaches, LESS and transgastric or transvaginal NOTES, are being used today. This video shows our surgical technique for pure NOTES transvaginal sterilization. The patient is 32 years old with a history of one previous vaginal delivery and one previous cesarean delivery. Her BMI is 20. The procedure was fully explained to the patient and written consent was obtained.
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
S Perretta, M Diana, B Dallemagne, R Cahill, J Marescaux
Surgical intervention
7 years ago
122 views
3 likes
0 comments
02:28
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
S Perretta, P Allemann, B Dallemagne, A Lobontiu, D Coumaros, J Marescaux
Surgical intervention
8 years ago
434 views
7 likes
0 comments
04:53
Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
Optical coherence tomography (OCT) of the colon and its mesentery (including virtual sentinel node biopsy) by natural orifice transluminal endoscopic surgery
Optical coherence tomography (OCT) is capable of 2–3mm slicing in opaque samples and so provides real-time cross-sectional images from the specimen. OCT can also achieve resolutions approaching that of conventional histology (c. 2–5μm) as it employs very short wave near-infrared light with precise interferometric detection. Although now mainly used in ophthalmology, OCT has already been found to have clinical applications in dermatology, cardiology, neurology, gynecology and gastroenterology. Dr. Ronan Cahill have deployed a commercially available probe (NIRIS™, Imulax Corporation, Cleveland OH, USA) via the working channel of a gastroscope used as a N.O.T.E.S. peritoneoscope in an experimental model. By this means, high-resolution real-time images mesenteric sentinel nodes have been obtained. Placing such a probe on the surface of the node should provide examination of the tissue to a depth of 2mm. In this video, we show the application of this technique in an experimental model.
R Cahill, M Asakuma, J Trunzo, SJ Schomisch, J Leroy, B Dallemagne, J Marescaux, J Marks
Surgical intervention
9 years ago
181 views
2 likes
0 comments
07:42
Optical coherence tomography (OCT) of the colon and its mesentery (including virtual sentinel node biopsy) by natural orifice transluminal endoscopic surgery
Optical coherence tomography (OCT) is capable of 2–3mm slicing in opaque samples and so provides real-time cross-sectional images from the specimen. OCT can also achieve resolutions approaching that of conventional histology (c. 2–5μm) as it employs very short wave near-infrared light with precise interferometric detection. Although now mainly used in ophthalmology, OCT has already been found to have clinical applications in dermatology, cardiology, neurology, gynecology and gastroenterology. Dr. Ronan Cahill have deployed a commercially available probe (NIRIS™, Imulax Corporation, Cleveland OH, USA) via the working channel of a gastroscope used as a N.O.T.E.S. peritoneoscope in an experimental model. By this means, high-resolution real-time images mesenteric sentinel nodes have been obtained. Placing such a probe on the surface of the node should provide examination of the tissue to a depth of 2mm. In this video, we show the application of this technique in an experimental model.
Transvaginal hybrid sleeve gastrectomy in a patient with a BMI of 40: live surgery during a NOTES course
Laparoscopic sleeve gastrectomy is a relatively new procedure, which is gaining popularity for the treatment of morbid obesity. In this live video demonstration from the March 2009 NOTES Advanced Course at IRCAD in Strasbourg, Dr. Michel Vix performs a hybrid natural orifice transluminal endoscopic sleeve gastrectomy using the vagina as the natural orifice and only two operative 5mm ports. It is a very interesting video demonstration showing that sleeve gastrectomy for the treatment of morbid obesity is feasible and safe in selected patients using the hybrid transvaginal mini-laparoscopic-assisted natural orifice surgery.
M Vix, B Dallemagne, D Coumaros, Gf Donatelli
Surgical intervention
9 years ago
424 views
9 likes
0 comments
15:54
Transvaginal hybrid sleeve gastrectomy in a patient with a BMI of 40: live surgery during a NOTES course
Laparoscopic sleeve gastrectomy is a relatively new procedure, which is gaining popularity for the treatment of morbid obesity. In this live video demonstration from the March 2009 NOTES Advanced Course at IRCAD in Strasbourg, Dr. Michel Vix performs a hybrid natural orifice transluminal endoscopic sleeve gastrectomy using the vagina as the natural orifice and only two operative 5mm ports. It is a very interesting video demonstration showing that sleeve gastrectomy for the treatment of morbid obesity is feasible and safe in selected patients using the hybrid transvaginal mini-laparoscopic-assisted natural orifice surgery.
Gastric lymphatic mapping for sentinel node biopsy by natural orifice transluminal endoscopic surgery (NOTES)
This video demonstrates fully how NOTES can facilitate 'cherry-picking' of sentinel nodes from the perigastric lymph basins (including the retropyloric space) after gastroscopic lymphatic mapping of a site in the stomach in an experimental model. It is proposed that this could be partnered with advanced endoscopic resective techniques such as Submucosal Endoscopic Dissection (SED) in order to allow definitive endoscopic excision of early stage gastric cancers.
This video is reproduced here by kind permission of Surgical Endoscopy.
2008 Sep 24. [Epub ahead of print]. PMID: 18813997 [PubMed - as supplied by publisher]

R Cahill, M Asakuma, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
9 years ago
220 views
3 likes
0 comments
07:16
Gastric lymphatic mapping for sentinel node biopsy by natural orifice transluminal endoscopic surgery (NOTES)
This video demonstrates fully how NOTES can facilitate 'cherry-picking' of sentinel nodes from the perigastric lymph basins (including the retropyloric space) after gastroscopic lymphatic mapping of a site in the stomach in an experimental model. It is proposed that this could be partnered with advanced endoscopic resective techniques such as Submucosal Endoscopic Dissection (SED) in order to allow definitive endoscopic excision of early stage gastric cancers.
This video is reproduced here by kind permission of Surgical Endoscopy.
2008 Sep 24. [Epub ahead of print]. PMID: 18813997 [PubMed - as supplied by publisher]

NOTES approach to lymphatic mapping in the sigmoid mesocolon
This video fully demonstrates all the technical aspects of performing sentinel node biopsy in the sigmoid mesocolon by NOTES. A transgastric access to the peritoneum allows a flexible gastroscope observe the lymphatic mapping in real-time and then to perform excisional nodal biopsy while magnetic retraction provides full exposure of the sigmoid mesentery. Such a totally NOTES procedure could be used to supplement colonoscopic intraluminal dissection (e.g. ESD) or prompt transmural localized resection (perhaps also by NOTES).

This video is reproduced here by kind permission of the Annals of Surgical Oncology and Springer Verlag.
Publication citation: Lymphatic mapping and sentinel node biopsy in the colonic mesentery by NOTES. RA Cahill, S Perretta, J Leroy, B Dallemagne, J Marescaux. Annals of Surgical Oncology 2008 Oct;15(10):2677-2683. Epub 2008 May 20.
Note: This work is also the subject of an invited editorial in the same issue: i.e. Takeuchi H, Kitagawa Y. Sentinel Node Biopsy Without Scars: Does Natural Orifice Transluminal Endoscopic Surgery Herald a New Era for Early GI Cancer? Ann Surg Oncol 2008 Oct;15(10):2639-40.
R Cahill, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
10 years ago
372 views
0 likes
0 comments
05:16
NOTES approach to lymphatic mapping in the sigmoid mesocolon
This video fully demonstrates all the technical aspects of performing sentinel node biopsy in the sigmoid mesocolon by NOTES. A transgastric access to the peritoneum allows a flexible gastroscope observe the lymphatic mapping in real-time and then to perform excisional nodal biopsy while magnetic retraction provides full exposure of the sigmoid mesentery. Such a totally NOTES procedure could be used to supplement colonoscopic intraluminal dissection (e.g. ESD) or prompt transmural localized resection (perhaps also by NOTES).

This video is reproduced here by kind permission of the Annals of Surgical Oncology and Springer Verlag.
Publication citation: Lymphatic mapping and sentinel node biopsy in the colonic mesentery by NOTES. RA Cahill, S Perretta, J Leroy, B Dallemagne, J Marescaux. Annals of Surgical Oncology 2008 Oct;15(10):2677-2683. Epub 2008 May 20.
Note: This work is also the subject of an invited editorial in the same issue: i.e. Takeuchi H, Kitagawa Y. Sentinel Node Biopsy Without Scars: Does Natural Orifice Transluminal Endoscopic Surgery Herald a New Era for Early GI Cancer? Ann Surg Oncol 2008 Oct;15(10):2639-40.
NOTES left nephrectomy: retroperitoneal transvaginal approach
This 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.
S Perretta, P Allemann, B Dallemagne, J Marescaux
Surgical intervention
10 years ago
890 views
4 likes
0 comments
04:43
NOTES left nephrectomy: retroperitoneal transvaginal approach
This 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.
In what ways can NOTES be compared to the single port approach?
Compared to NOTES, single port approach, or transumbilical endoscopic surgery (TUES) can obtain the same cosmetic results. It is relatively simple and safe, and can avoid all the complications appeared in NOTES. TUES can be easily be performed by laparoscopic surgeons without the help of endoscopic physicians. Furthermore, TUES technique may save on expensive devices and OR space. NOTES is attractive because it is an endoscopic therapy: the gallbladder can be removed through a gastroscopic examination! Right now it is simply too difficult for most surgeons. But I am sure it could be widely used as the technology and instruments are further improved.
JF Zhu
Expert opinion
10 years ago
81 views
0 likes
0 comments
01:00
In what ways can NOTES be compared to the single port approach?
Compared to NOTES, single port approach, or transumbilical endoscopic surgery (TUES) can obtain the same cosmetic results. It is relatively simple and safe, and can avoid all the complications appeared in NOTES. TUES can be easily be performed by laparoscopic surgeons without the help of endoscopic physicians. Furthermore, TUES technique may save on expensive devices and OR space. NOTES is attractive because it is an endoscopic therapy: the gallbladder can be removed through a gastroscopic examination! Right now it is simply too difficult for most surgeons. But I am sure it could be widely used as the technology and instruments are further improved.