Progress Of Notes

Objective:With the aim of performing incision-less surgery and decreasing morbidity related to incisions, minimally invasive surgery has been developed. Its current progress has led to the birth of the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES). This technique enables the surgeon to gain access to the abdominal cavity by puncturing the hollow organ (stomach, rectal, vaginal wall and urinary bladder) through the body’s natural orifices (mouth, anus, vulva and urethra) and to perform various operations by using equipment under endoscopic guidance. Thus, it results in no abdominal scar, less postoperative pain, and more minimally invasive aesthetic effect. While having many advantages, NOTES still faces problems concerning abdominal infection, fistula formation, and spatial orientation amongst others so, further research is required to perform NOTES procedures and to develop new special equipment and devices. Currently worldwide, various NOTES procedures are being studied in animal experiments and have attained clinical stage exploration. After repeated studies and full preparation, we successfully carried out transgastric, transvaginal, and transrectal NOTES in female pig models and positive results were obtained. At the same time, according to the operation characteristics, we also designed and built the NOTES model and special equipment and device with independent intellectual property rights, which have laid a solid foundation for the development of clinical operation. On this basis, in 2009 we have successfully carried out Asia’s first transvaginal endoscopic cholecystectomy and China’s first endoscopic appendectomy. Since then, we have performed Total Transtracheal Endoscopic thyroidectomy in live animals.Materials and Methods:From May 2009 to April 2010, a total of 182 cases of cholecystectomy were performed in female patients in our hospitals (Pakistan & China).In respect to the patient’s right to know and right to choose,86 patients underwent transvaginal endoscopic cholecystectomy among which 62 cases were cases of gallstone. Amidst the gallstone cases,25 patients had prior lower abdominal operation, the existence of serious pelvic adhesion; 7 patients had radical resection of rectal cancer (Dixon operation); 8 patients had total hysterectomy, pelvic structural abnormalities; 10 had multiple cholelithiasis with sub-acute cholecystitis, severe cystic wall edema; and 12 had multiple cholelithiasis with anatomical variation. The other 24 cases were gallbladder polyps. The remaining 96 patients underwent laparoscopic cholecystectomy.From May 2010 to April 2012, a total of 52 female patients underwent appendectomy in our hospital. Respecting the patient’s right to know and right to choose,16 patients underwent transvaginal endoscopic appendectomy, the remaining patients underwent laparoscopic appendectomy.In July 2011, endoscopic thyroidectomy was done in Bama miniature pigs and Beagles dogs.Method:Clinical cholecystectomyNOTES Group:at the lower edge of the umbilicus, the skin and fascia were incised to make a 2mm opening to insert the needle for inflation of CO2.1cm incision was made on the vaginal fornix through which an 8.8mm Olympus electronic gastroscope (GIF TYPE Q180) and a 7mm silicon tube were introduced, via this silicon tube, special NOTES apparatus (Tonglu Yoshi Company) were introduced into the abdominal cavity. After completing the cholecystectomy operation under the endoscopic monitoring, the specimen was extracted from the posterior vaginal fornix incision. The vaginal fornix incision was then sutured with uninterrupted sutures and the vagina was packed with sterile gauze. Intraoperative manipulation was smooth, strictly preventing bleeding and bile fistula formation. After the operation, no drainage was placed.Laparoscopic group:A pneumoperitoneum needle was inserted in the conventional transumbilical lower edge; pneumoperitoneum was established, followed by the placement of laparoscope through a 5mm incision for the abdominal exploration, at the xiphoid, subcostal midclavicular line and the anterior axillary line respectively. Openings were made for laparoscopic instruments to perform the operation.Clinical appendectomyNOTES group:The silicon tube method for endoscopic appendectomy is similar to the endoscopic cholecystectomy.Laparoscopic group:A pneumoperitoneum needle was placed in the conventional transumbilical lower edge, the pneumoperitoneum was established, followed by the placement of a 5mm laparoscope for exploration. In the McBurney point and anti McBurney point, incisions were made for laparoscopic instruments for performing the operation.Thyroidectomy in animal experiment:This was done on 3 Bama miniature pigs and 14 Beagle dogs, using self-made dual channel tracheal intubation under general anesthesia. The endoscope and operating instruments were inserted. A longitudinal incision on the anterior wall of the trachea above the thyroid cartilage ring was made. Under endoscopic monitoring partial thyroid or subtotal thyroid resection was done. After the operation, continuous or interrupted sutures were done on the anterior wall of the trachea.Statistical analysis:SAS 9.1.3 Statistical software was applied for analysis, grouping t test was done using this set of data, P< 0.05 had statistical significance.Result:NOTES clinical trials:All the NOTES procedures were successfully completed without conversion to laparotomy. Operation process was done rigorously and meticulously. No postoperative drainage was required. No hemorrhage, biliary fistula and other complications occurred. After 24 hours, vaginal packing of sterile gauze was removed. Compared with the traditional laparoscopic operation, abdominal incision was small, pain was mild with less analgesic dosage, early postoperative ambulation, patients with rapid recovery of intestinal function, average hospitalization days, and the treatment cost were reduced accordingly, abdominal wall with almost no visible operation scar. The treatment effect was quite satisfactory but the operation time of NOTES operation was significantly longer than the conventional laparoscopic operation.Thyroid animal experiment:All animal experiments were successfully completed with no intraoperative hypoxia, asphyxia, airway obstruction or death. After extubation the experimental animal woke up naturally. After the animals were sacrificed, the tracheal incision suture was explored and there was no subcutaneous emphysema or hematoma formation.CONCLUSION:Compared to Laparoscopy, NOTES does not only provide better cosmetic results but also maintains the reliability of the peritoneum along with posterior fornix and umbilical sensory nerve sparse, less postoperative pain and the use of less analgesics. The minor NOTES incision has less effect on the abdominal viscera, which causes less blood loss, faster recovery with normal bowel movements, early ambulation, shorter average hospital stay and less treatment costs. Due to lack of current dedicated NOTES surgical instruments, the NOTES surgery needs the coordination and cooperation of medicine, surgery, obstetrics, and gynecology, that’s why the operative time can be significantly longer. Hence, natural orifice transluminal endoscopic surgery is still in its exploratory clinical stage and on its way towards clinical application, which needs gradual futuristic improvement and advancement in technology and related instruments. We believe that until specifically designed instruments to perform pure NOTES are not available, NOTES can be carried out by the hybrid techniques. Regarding the transtracheal endoscopic thyroidectomy through NOTES procedure, it is safe and feasible. Use of natural lumen (trachea) as thyroid surgical approach, maintaining the integrity of the skin and cervical muscles with cosmetic outcomes, opens up a new field of NOTES. We believe that, with sophisticated technology improvement in related equipment and devices, the surgery can have a broad clinical application as it has the potential to be a substitute to the thyroid surgeries in the future. However, further research and development is required to apply these techniques in wide range, clinically.