Transcript Folie 1 - SBV TOA

Fachtagung
Fachtagung
SBV TOA,
SBVZürich
TOA,2008
Zürich 2008
NOTES – Chirurgie ohne Narben
M. Hagen
University Hospital Geneva, Switzerland
University of California San Diego
Fachtagung SBV TOA, Zürich 2008
What is NOTES?
Natural Orifice Translumenal Endoscopic Surgery:
- Intentional puncture of one of the viscera (e.g., stomach,
rectum, vagina, urinary bladder) to access the abdominal
cavity
- With an endoscope (flexible or stiff)
- To perform an intraabdominal operation
Pearl JP, Ponsky JL: J Gastrointest Surg. 2007 Dec 5
Fachtagung SBV TOA, Zürich 2008
NOTES access sites
To reach lower abdomen:
To reach upper abdomen:
- Stomach
- Vagina
- Rectum
- Bladder
- Tubes
To reach heart/thorax:
- Oesophagus
Fachtagung SBV TOA, Zürich 2008
NOTES
Dimension of NOTES
2007/2008
Basic
experiments
First
patients:
Rao`s AE
2004
More complex and
detailed lab research
Kalloo`s first
Publication 2004
T
Clinical
NOTES
In 1st
world
Fachtagung SBV TOA, Zürich 2008
Acute and survival
models in pigs
Transgastric access
Peritoneal cavity
exploration
Liver biposy
Gastric closure
Kalloo AN, Gastrointest Endosc. 2004 Jul;60(1):114-7
Fachtagung SBV TOA, Zürich 2008
NOTES
Dimension of NOTES
2007/2008
Basic
experiments
First
patients:
Rao`s AE
2004
More complex and
detailed lab research
Kalloo`s first
Publication 2004
T
Clinical
NOTES
In 1st
world
Fachtagung SBV TOA, Zürich 2008
NOTES: First Patients
Reddy & Rao
« Per oral transgastric
endoscopic appendectomy
in human. »
45th Annual Conference of
the Society of Gastrointestinal
Endoscopy of India;
February, 2004;
Jaipur, India.
Fachtagung SBV TOA, Zürich 2008
NOTES
Dimension of NOTES
2007/2008
Basic
experiments
First
patients:
Rao`s AE
2004
More complex and
detailed lab research
Kalloo`s first
Publication 2004
T
Clinical
NOTES
In 1st
world
Fachtagung SBV TOA, Zürich 2008
NOTES: Further Research
•
•
•
•
•
•
•
•
Tubal ligation
Cholecystectomie
Gastrojejunostomie
Oophorectomie
Tubectomie
Splenectomie
Nephrectomie
Pankreatic resection
Fachtagung SBV TOA, Zürich 2008
NOTES
Dimension of NOTES
2007/2008
Basic
experiments
First
patients:
Rao`s AE
2004
More complex and
detailed lab research
Kalloo`s first
Publication 2004
T
Clinical
NOTES
In 1st
world
Fachtagung SBV TOA, Zürich 2008
NOTES: Media reaction
Mark Besslar
New York Times
Jaques Marescaux
Le Monde
“The patient was grateful but wanted to point out
that she had only gone in for a flu shot”
Fachtagung SBV TOA, Zürich 2008
NOTES before NOTES I
Ott, Ventroscopia. Zhurnal Akusherstva I Zhenskikh Boleznel.
1901;15:1045–1049
Dimitri Oskarovich Ott performed the first
endoscopic examination of the abdominal cavity
through a posterior vaginal incision using a head
mirror and speculum:
1901
1st VENTROSCOPY
1900 1950 1990 2000 2002 2004 2006 2008
Fachtagung SBV TOA, Zürich 2008
NOTES before NOTES II
Decker A, Cherry T. Culdoscopy, a new method in diagnosis of pelvic
disease. Amer J Surg. 1944;64:40–44
Culdoscopy
1944
1900 1950 1990 2000 2002 2004 2006 2008
Fachtagung SBV TOA, Zürich 2008
NOTES before NOTES I
Tsin DA, J Am Assoc Gynecol Laparosc. 2001 Aug;8(3):43841
Operative Culdolaparoscopy (MA-NOS)
2001
1900 1950 1990 2000 2002 2004 2006 2008
Fachtagung SBV TOA, Zürich 2008
The Wilk-Patent 1994
US Patent
5297536
Wilk Peter, 1994
Method for use in
intra-abdominal surgery
Fachtagung SBV TOA, Zürich 2008
Rationale for NOTES
- No abdominal wall incisions
- No wound infections and hernias
- Less pain
- Less adhesions
- NO scars  perfect cosmetic outcomes
www.noscar.org
Is NOTES less
invasive than any
other kind of
surgery???
Fachtagung SBV TOA, Zürich 2008
Importance of cosmetics
Fachtagung SBV TOA, Zürich 2008
Importance of cosmetics
Fachtagung SBV TOA, Zürich 2008
Geneva Cosmesis Study
Onsight poll at "day of open wards“ + ongoing interviews
Questionnaire:
- Importance of cosmetic issues in abdominal surgery
- Satisfaction with previous scars
- Favoritism of scarless surgery
- Favoritism of scarless surgery if risks are increased
- Accepted percentage of risk rise
- Importance of further research and investments
Questions answered on VAS from 0 to more than 100% or 1 to 10
Fachtagung SBV TOA, Zürich 2008
Conclusion Geneva cosmesis study
- People strongly favor the idea of scarless abdominal surgery
- No differences between genders have been found
- Certain risks are accepted in order to achieve scarless
surgery
- Further research and investments seems important
 People have a desire for NOTES!!!
Fachtagung SBV TOA, Zürich 2008
Rationale for NOTES II
The NOTES-concept :
Human ingenuity and
technological advance can
continue to reduce the
trauma and discomfort of
effective surgery
Fachtagung SBV TOA, Zürich 2008
Transvaginal gastric
bypass
Geneva, Switzerland 2007 - 2008
Fachtagung SBV TOA, Zürich 2008
Transrectal ventral hernia repair
Geneva, Switzerland 2008
Fachtagung SBV TOA, Zürich 2008
NOTES: Perform with what?
Current technology:
- Overtubes
- Flexible endoscopes
- Guidewires
- Rigid Scopes
- Stents
- Limited number of flexible
- Balloons
instrumentation
- Limited hemostatic devices
- Cautery
- Bands
BUT:
- Clips
 All instrumentation not designed
for intraabdominal surgery
Fachtagung SBV TOA, Zürich 2008
Gastroenterologists & NOTES
Fachtagung SBV TOA, Zürich 2008
Technical problems of NOTES
• Access to abdominal cavity
• Pneumoperitoneum
• Intra-peritoneal navigation
• Orientation
• Stable platform
• Tissue manipulation
• Specimen extraction
• Access site closure
No specific NOTES
instrumentation on the
market!!!
Fachtagung SBV TOA, Zürich 2008
Access: Endoscopic Trocar
• Endoscopic Veress
Needle + Overtube
Cannula
• Reduced instrument
exchanges
• (Re)intubation pathway
• Insufflation and
desufflation
• Supports scope shaft
Ethicon Endosurgery, USA
Fachtagung SBV TOA, Zürich 2008
Flexible endoscopic suturing devices
USGI, USA
Fachtagung SBV TOA, Zürich 2008
Closure: TAS
Tissue Apposition System
• T-tag applier + knotting
element
• 2.8 mm channel
• Closure of porcine colon
perforation demonstrates
equivalency to surgery with
advantages for adhesion
formation
Ethicon Endosurgery, USA
Fachtagung SBV TOA, Zürich 2008
Development of platforms for NOTES I
USGI, USA
Fachtagung SBV TOA, Zürich 2008
Development of platforms for NOTES II
USGI, USA
Boston Scientific, USA
Fachtagung SBV TOA, Zürich 2008
Magnetic retraction, external hand magnet
controlled dissection with hydraulically
elevated cautery knife
D. Scott, USA
Fachtagung SBV TOA, Zürich 2008
Robots for NOTES
Fachtagung SBV TOA, Zürich 2008
Project "ARAKNES"
Array of robots augmenting the Kinematics of Endo-luminal surgery
Fachtagung SBV TOA, Zürich 2008
“Every day you may make
progress. Every step may be
fruitful....You know you will never
get to the end of the journey. But
this, so far from discouraging, only
adds to the joy and glory of the
climb.”
Sir Winston Churchill
British politician (1874 - 1965)
Fachtagung SBV TOA, Zürich 2008
The State of NOTES – 11/2008
• Extreme skepticism has been replaced with optimism
• Acute feasibility in animals, across a wide range of procedures, is
proven; human cases are starting to be performed with ethical
approval in prestigious institutions (Worldwide experience ~ 300
cases).
• Questions of “can we” yielded to “should we” and are now yielding
to questions of “how can we do this responsibly?”
• “Killer applications” are becoming clearer with cholecystectomy
and bariatric procedures being targeted
• NOSCAR has been formed, bridging SAGES and ASGE with new
European and Latin American associations
Fachtagung SBV TOA, Zürich 2008
Does NOTES have a future?
NOTES, by addressing “Sources of Invasion”, represents the next logical progression of
surgical development, a key step along the MIS continuum
EndoscopicallyAssisted
Laparoscopy
Open
Laparoscopic/
Sustaining “Hybrids”
Improvements
NOTES
Intralumenal
NonInvasive
LaparoscopicallyAssisted Endoscopy
Cholecystectomy
Appendectomy
Ventral Hernia
Diagnostic
Peritoneoscopy
?
?
?
?
Sources of Invasion
• Abdominal wall incisions
• Post-op recovery/RTNA
• General anesthesia
• Financial burden
• Site of care
• Infrastructure requirements
• Clinician skill level
Fachtagung SBV TOA, Zürich 2008
The future is hard to predict…
Fachtagung SBV TOA, Zürich 2008
“We must not say every mistake is a
foolish one”
Cicero (106 BC – 43 BC)
Fachtagung SBV TOA, Zürich 2008
The effect of NOTES
3
- Less invasive
- New approaches
Invasiveness
2.5
2
Laparoscopy
1.5
Flexible Endoscopy
1
0.5
0
T
- More invasive
- New, effective
instruments for
intralumenal
manipulation
Fachtagung SBV TOA, Zürich 2008
Protecting valuables!
Fachtagung SBV TOA, Zürich 2008
Thank you very much for your
attention!
Fachtagung SBV TOA, Zürich 2008
Results: Total population I
Importance of cosmetic issues in abdominal surgery: 7,4 (mean)
VAS 1
10
X
Satisfaction with previous scars: 7 (mean)
VAS 1
10
X
Favoritism of scarless surgery: 8,9 (mean)
VAS 1
X
10
Favoritism of scarless surgery if risks are increased: 4,5 (mean)
VAS 1
X
10
Fachtagung SBV TOA, Zürich 2008
Results: Total population II
Accepted percentage of risk rise: 21% (mean)
0%
100 %
X
Importance of further research: 7,6 (mean)
VAS 1
10
X
Importance of further investments: 8 (mean)
VAS 1
X
10
Fachtagung SBV TOA, Zürich 2008
NOTES in humans: perhaps 300 cases
world-wide
– Hydrabad: Rao/Reddy Appendectomy, liver biopsy, tubal ligation: 22 cases.
– Brazil: Galvao and Amino: Endoscopically-assisted transgastric and transvaginal
laparoscopic cholecystectomy 10 cases. Zorron 4 transvaginal cholecystectomies and
a transgastric laparoscopy for cancer
– Ohio: Transgastric peritoneoscopy before Whipples (Melvin) (n=16)
– New York: lap-assisted transvaginal chole (Stevens – GI, Besslar – Bariatric
surgeon) (n=3)
– Oregon Transgastric cholecystectomy (Swanstrom) (n=4)
– Argentina and San Diego (Horgan) Transvaginal cholecystectomy (n=4)
Transgastric cholecystectomy (n=2) Transgastric appendicectomy (n=2)
– Mayo Clinic Transvesical (urinary bladder) peritoenoscopy (n=1) Gettman
– Chicago (Soper) Transgastric cholecystectomy (n=2)
– Brazil. (Branco) Transvaginal hybrid nephrectomy (n=1)
– Zorron data base of 150 cases in South America mostly cholecystectomy