Notes
- 1. NOTES(NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY) BY: DR SIVAKUMAR REDDY K MODERATOR:DR ASHWIN.
- 2. INTRODUCTION
- 3. INTRODUCTION • Minimally invasive surgical techniques have been evolving since 100 yrs. • First laparoscopic cholecystectomy was done by ERICH MUHE in 1985. • Kalloo et al given the initial description of transgastric peritoneoscopy in 2004. • Rao and Reddy have performed transgastric appendicectomy in Hyderabad India 2007. • ASGE,SAGES both came together and formed NOSCAR in 2005 .
- 4. INTRODUCTION • NOSCAR(Natural orifice surgery consortium for assessment and research). • NOTES includes diagnostic or therapeutic interventions performed via existing orifices of the human body(mouth,anus,urethra,vagina). • Trans abdominal surgeries such as single port surgeries are modification of laparoscopic surgery ,it is not subset of NOTES.
- 5. INTRODUCTION • HYBRID procedures include both endoluminal and laparoscopic aproaches. • Routes to do NOTES surgery are : • Transvaginal • Trans gastric • Transvesical • Transcolic • Transesophageal.
- 6. INTRODUCTION • Comparison of transluminal approaches; Parameter Esphageal Gastric Colic Vesical vaginal Bacterial load + + +++ - + Size ++ ++ +++ + +++ Injury potential +++ + ++ +++ ++ Access to upper abdomen - + +++ +++ +++ Access to lower abdomen - +++ + + +
- 7. TRANSGASTRIC APPROACH • INDICATIONS: • Peritoneoscopy • Liver biopsy • Cholecystectomy • Cholecystogastric anastomosis. • Oophorectomies. • Tubal ligations.
- 8. TRANGASTRIC NOTES • Pre op preparation:Overnight fasting,pre op antibiotics and stomach and esophagus wash with povidine iodine. • Gastrotomy mostly done on ant wall to avoid gastroepiploic arteries and its branches. • In retroperitoneal surgeries post wall gastrotomy is indicated.
- 9. TRANSGASTRIC NOTES • Gastrotomy done by a needle knife by putting 2mm-4mm incision by electrocautery catheter is guided through it. • It is dilated by ballon dilator which is passed over the catheter ,peritoneal cavity is entered. • In hybrid procedures gastrotomy done under vision via laparoscopic transabdominal port.
- 11. TRANSGASTRIC NOTES TV VIEW UMBILICAL VIEW
- 12. NOTES -CHOLECYSTECTOMY 1 • Transgastric entry into peritoneal cavity • Scope is turned to right by 90 degrees to locate gall bladder. 2 • Dissection is done by dissector,monoplar cautery • Cystic duct is ligated and cystic artery is clipped. 3 • Gallbaldder is cut and disected off from gallbladder bed . • By using specimen retrieval bag specimen Is drawn into stomach
- 13. Closure of access site • Methods of closure include endoscopic clips,over the scope clip system(OTSC),septal occluders,T tags ,T bar,G-prox system,and linear endoscopic staples. • Laparoscopic closure is still the most common method of closure in hybrid procedures. • Reapir is tested by instilling methyline blue saline monitored by laparoscope,or pneumogastrium by gastroscope.
- 14. TG NOTES • Post operative care is same as lap cholecystectomy except for PPI for 1 month after surgery.
- 15. TRANSGARSTIC ENDOSCOPIC PERITONEOSCOPY • Transgastric endoscopic peritoneoscopy done in--Staging pancreatic /liver cancers -Adhesiolysis -Trochar placement in abd wall. • Over 70 procedures done till date .
- 16. COMPLICATIONS TG NOTES • Hemorrhage due to inability to visulalise the blood vessels from within. • Bacterial contamination.
- 17. TG NOTES NEEDLE KNIFE SPECIMEN RETRIVAL BAG
- 18. TG NOTES G PROX DEVICE ENDOSCOPIC CLIPS
- 19. TRANSVAGINAL APPROACH • PRE OP PREPARATION:under GA patient positioned in low lithotomy (Lloyd – davies)with allen stirrups.shoulder holders applied in steep trendelenburg position. • Vagina is incised through the psoterior fornix in the place of traingle of safety. • In hybrid procedures vagina is incised under vision from laproscope through umbilical port.
- 20. TV NOTES
- 22. TV NOTES
- 23. TV NOTES
- 24. TV NOTES • After removing the specimen pneumoperitoneum is released. • Colpotomy wound is closed with running absorbable sutures.
- 25. TRANSVAGINAL APPENDICECTOMY • Through the colpotomy wound multichannel port is inserted ,using laparoscopic instruments . • appendix is dissected ,mesoappendix is clamped with ligasure. • appendix is divided with endoscopic stapler.
- 27. TRANSVAGINAL NEPHRECTOMY • Done in 2007. • Done by 3 cm colpotomy incision,and one umbilical port ,three trocars and standard laparoscopic instruments. • Specimen is removed through transvaginal route .Operative time:420 min.
- 28. COMPLICATIONS OF TV NOTES STUDY SURGERY MAJOR COMPLICATION MINOR COMPLICATION ZORING ET AL TVC ABSCESS WOUND INFECTION HENSEL ET AL TVC BLADDER INJURY COLPOTOMY BLEED LEHMAN ET AL TVC RECTAL INJURY,BLADDER INJURY,POST OP BLEEDING,ABSCESS VAGINAL BLEED ,UTI,VAGINAL MYCOSIS,BACTERIAL VAGINITIS. LINKE ET AL TVC CVA ,UMBILICLA HERNIA PLEURAL EFFUSION,BACTERAIL VAGINITIS,COLPOTOM Y DEHISCENCE. ZORRON ET AL TVC BILIARY LEAK,GASTRIC WALL PERFORATION, CYSTIC ARTERY BLEED ,INTRA ABD HTN,VAGINAL DYSPAREUNIA. TVA APPENDIX VESSEL BLEED
- 29. TRANSRECTAL NOTES • Appied to both genders. • Direct visual/spatial access to upper abdomen. • Size of lumen and anal orifice allows large access colostomy enabling multiple instrument introduction and specimen extraction. • Access and closure can be done with trans anal endoscopic microsurgery instruments (TEMS)
- 30. TRANS RECTAL NOTES • Surgeries done • 1)hybrid transanal resection of rectum and mesorectum(TEMS-trans anal endoscopic microsurgery) • 2)pull through sugery for hirschprung disease. • 3)trans rectal hybrid nephrectomy. • PRE OP PREPARATION:bowel prepaartion,lithtomy position,irrigation of rectosigmoid with 10% povidine iodine.
- 31. TRANSRECTAL NOTES • ACCESS :about 15cm from the anal verge an anterior transverse rectotomy incision (2cm)made with a harmonic scalpel.posterior incision given for nephrectomy. • CLOSURE:colostomy closure can be avoided by incorporating into colo anal anastomosis. • By applying endoloops ,endoclips.or by endoscopic /laparoscopic suturing/stapling devices..
- 32. TEM INSTRUMENT
- 33. • Higher bacterial load of colon is the disadavntage ,need of reliable sterilisation technique is key for future TR NOTES
- 34. TRANSVESICAL NOTES • Applies to both males and females . • provides a normally sterile tract . • has adequate visualisation of majority of abdominal cavity. • No need of preop prophylactic antibiotics. • ACCESS:needle knife to ant bladder wall.
- 35. TRANSVESICAL NOTES • Passage of guide wire through the defect followed by ballon dilator. • Cystoscope is replaced with flexible ureteroscope. • CLOSURE:done by laparoscopic port with 2-0 vicryl sutures in figure of eight fashion. • Reliable closure technique is necessary for broader application of transvesical NOTES.
- 36. TRANSESOPHAGEAL/PERORAL ESOPHAGEAL MYOTOMY(POEM) • POEM done for achalasia patients endoscopic myotomy done through a submucosal tunnel. • Alternative to the lap heller myotomy. • PREOP PREP:EGD to clean esophagus and rule out other patholgies.pre op antibiotics. • PROCEDURE: • Submucosal injection of saline in ant mid esophagus
- 37. POEM • 2 cm longitudinal incision to create submucosal plane. • Dissection in submucosal plane to reach GE junction. • Inner circular muscle layer of distal esophagus and LES is divided approx 2 cm distal to GEJ. • Mucosal entry closed with hemostatic clips. • P/o look for esophageal leak.,give double dose PPI.
- 38. POEM
- 39. POEM
- 40. COMPLICATIONS • Transmural dissection leading to pneumomediastinum and pneumoperitoneum. • Advantage over lap heller myotomy is no need of no need of antirefulx procedure (partial fundoplication)as hiatus attachment ,and the angle of his is maintained and surrounding structures are not distrubed.
- 41. COMPLICATIONS OF NOTES • Sec to increaed intrabdominal pressure ,decreased cardiac output,tachycardia,decreased renal blood flow. • Infection (10-20%) sec to non sterile endoscope,improper seal between wall of access of organ and scope or improper closure leading to leakage.
- 42. SUMMARY • The field of minimal invasive surgery has matured but continues to evolove with the addition of technology and innovation. • With adequate assessment ,research,protocol development ,NOTES may demonstrate improvement in patient care . • Current level of investigation in technology and development is insufficient to support the concept of NOTES.
- 43. REFERENCES • MASTERY OF ENDOSCOPY AND LAPAROSCOPIC SURGERY BY LEE L.SWANSTORM ,NATHANIEL J.SOPER ( 4TH EDITION.) • SURGICAL CLINICS OF NORTH AMERICA VOL 88 • MASTERY OF SURGERY BY FISCHER 5TH EDITION.