NOTES Natural Orifice Transluminal Endoscopic Surgery The next generation of ‘Least Invasive Surgical therapy’ Dr. Onkar Singh, Dr. Shilpi Gupta, Dr. Ankur Hastir, Dr. Mohan Soni, Dr. Praveen Baghel

NOTES PERFORMING SURGICAL PROCEDURES WITHOUT MAKING INCISIONS ON THE SURFACE OF THE BODY and LEAVING NO SCARS

PERFORMING SURGICAL PROCEDURES WITHOUT MAKING INCISIONS ON THE SURFACE OF THE BODY and LEAVING NO SCARS

SURGEONS WITHOUT SCALPEL

NOTES: DEFINITION An experimental surgical technique - "scarless" abdominal operations performed with an multi-channel endoscope passed through a natural orifice ( mouth , urethra , anus , vagina etc.)

An experimental surgical technique - "scarless" abdominal operations performed with an multi-channel endoscope passed through a natural orifice ( mouth , urethra , anus , vagina etc.)

NOTES: A STEP FORWARD emerging surgical approach  ‘ viewed as a step forward’ utilize the body’s natural openings.

emerging surgical approach 

‘ viewed as a step forward’

utilize the body’s natural openings.

NOTES Latest craze among todays surgeons. Highest level of minimal invasiveness. Can be ‘Future of Surgery’ -Minimal invasive surgery -Least invasive surgery

Latest craze among todays

surgeons.

Highest level of minimal invasiveness.

Can be ‘Future of Surgery’

-Minimal invasive surgery

-Least invasive surgery

NOTES: HISTORY That endoscopy can be used to do procedures beyond the wall of the GIT was known since 1980 when the first transluminal feeding gastrostomy was described by Gauderer et al.

That endoscopy can be used to do procedures beyond the wall of the GIT was known since 1980 when the first transluminal feeding gastrostomy was described by Gauderer et al.

NOTES: HISTORY Kozarek et al. reported first of successful endoscopic drainage of pancreatic pseudocyst in 1985. The first report of oral peritoneoscopy done in animals was published by Kalloo et al. in 2004.

Kozarek et al. reported first of successful endoscopic drainage of pancreatic pseudocyst in 1985.

The first report of oral peritoneoscopy done in animals was published by Kalloo et al. in 2004.

NOTES: HISTORY In September 2007, Novare announced the successful completion of the first NOTES gallbladder removal (TV) procedures.

In September 2007,

Novare announced

the successful

completion of the first

NOTES gallbladder removal (TV) procedures.

NOTES: HISTORY In March 2008, Dr Ricardo Zorron, of Brazil, performed the first series of NOTES cholecystectomy on four patients via transvaginal route.

In March 2008, Dr Ricardo Zorron, of Brazil, performed the first series of NOTES cholecystectomy on four patients via transvaginal route.

NOTES: IN INDIA transgastric appendectomy in humans in India By Dr. G V Rao and Dr. N Reddy . ( Hyderabad, India)

transgastric appendectomy in humans in India By Dr. G V Rao and Dr. N Reddy . ( Hyderabad, India)

NOTES: IN INDIA Famous bollywood actress ‘Shilpa Shetty’ and south Indian actress ‘Khusboo’ have recently undergone transgastric appendicectomy.

Famous bollywood actress ‘Shilpa Shetty’ and

south Indian actress ‘Khusboo’ have recently undergone transgastric appendicectomy.

NOTES: HISTORY Since then , multiple investigators have used transluminal endoscopy in animal models to perform various intraperitoneal surgical procedures, ranging from tubal ligation to splenectomy.

Since then , multiple investigators have used transluminal endoscopy

in animal models to perform various intraperitoneal surgical procedures, ranging from tubal ligation to splenectomy.

NOTES: THE IDEA Idea of NOTES-developed in response to facts that patients would- 1) realize the benefits of this least invasive technique of surgery. 2) experience less physical discomfort than traditional procedures. 3) have virtually no visible scarring following this type of surgery.

Idea of NOTES-developed in response to facts that patients would-

1) realize the benefits of this least invasive technique of surgery.

2) experience less physical discomfort than traditional procedures.

3) have virtually no visible scarring following this type of surgery.

NOTES: THE IDEA When given an option - no scars - not only for cosmetic reasons, but because scars indicate treatment because of illness. NOTES, with its general idea to minimizing the trauma .

When given an option - no scars - not only for cosmetic reasons, but because scars

indicate treatment

because of illness.

NOTES, with its general idea to minimizing the trauma .

NOTES: THE CONCEPT Gain access to surgical field thro’ a natural orifices—AVOIDINNG— external incision… Through the NOTES many surgeries could eventually become outpatient procedures, patients might even be able to return to a normal routine immediately.

Gain access to surgical

field thro’ a natural

orifices—AVOIDINNG—

external incision…

Through the NOTES

many surgeries could

eventually become outpatient procedures, patients might even be able to return to a normal routine immediately.

NOTES: THE CONCEPT By avoiding incisions on the abdominal wall, risks of infection, pain and disability will be minimized and recovery either shortened or eliminated .

By avoiding incisions on the abdominal wall, risks of infection, pain and disability will be minimized and

recovery either

shortened or

eliminated .

NOTES: THE CONCEPT NOTES - safe and feasible - same efficacy as traditional laparoscopic procedures.

NOTES - safe and feasible

- same efficacy

as traditional laparoscopic procedures.

NOTES: INSTRUMENTS

NOTES: INSTRUMENTS

NOTES: INSTRUMENTS

NOTES: INSTRUMENTS

NOTES Result of active cooperation between minimally invasive surgeons and interventional gastroenterologists.

Result of active cooperation between minimally invasive surgeons and interventional gastroenterologists.

NOTES Internal incision is over stomach , vagina , bladder or colon , thus completely avoiding any external incisions or scars.

Internal incision is over stomach , vagina , bladder or colon , thus completely avoiding any external incisions or scars.

INTERNAL INCISION

NOTES Continued evolution of flexible endoscopy + Growing awareness about invasiveness of surgery having impact on patient outcomes Lead to Endoscopy and Surgery - working together as NOTES

Continued evolution of flexible endoscopy + Growing awareness about invasiveness of surgery having impact on patient outcomes

Lead to

Endoscopy and Surgery - working together as NOTES

NOTES: ROUTES NOTES has been mostly practised on animals, for diagnosis and treatments, including transgastric organ removal.

NOTES has been

mostly practised

on animals, for diagnosis

and treatments, including

transgastric organ

removal.

NOTES: ROUTES

DEMONSTRATING TRANSGASTRIC ROUTE

DEMONSTRATING

TRANSGASTRIC ROUTE

DEMONSTRATING TRANSVAGINAL ROUTE

DEMONSTRATING

TRANSVAGINAL ROUTE

NOTES: ROUTES Acc. To some transvesical and transcolonic approaches- more suited to access upper abdominal structures, which are often more difficult to work with if using a transgastric approach.

Acc. To some transvesical and transcolonic approaches- more suited to access upper abdominal structures, which are often more difficult to work with if using a transgastric approach.

NOTES: ROUTES Transvaginal access appears to be the safest and most feasible. potentially less complications, but only possible in women.

Transvaginal access appears to be the safest and most feasible.

potentially less complications, but only possible in women.

PROCEDURES DESCRIBED TILL NOW Laboratory reports Cholecystectomy, Splenectomy, Tubal ligation, Gastrojejunostomy , Pyloroplasty, Staging peritoneoscopy, Liver biopsy, Distal pancreatectomy , Ventral hernia repair, Gastric sleeve resection , Colectomy (right and left)

Laboratory reports

Cholecystectomy, Splenectomy,

Tubal ligation, Gastrojejunostomy ,

Pyloroplasty,

Staging peritoneoscopy, Liver biopsy,

Distal pancreatectomy ,

Ventral hernia repair,

Gastric sleeve resection ,

Colectomy (right and left)

PROCEDURES DESCRIBED TILL NOW Human cases TG- appendectomy, TV- cholecystectomy, TG- cholecystectomy, TG- gastro-enterostomy, Cancer staging.

Human cases

TG- appendectomy,

TV- cholecystectomy,

TG- cholecystectomy,

TG- gastro-enterostomy,

Cancer staging.

FIRST ‘NOTES’ (TRANS-VAGINAL) CHOLECYSTECTOMY

FIRST ‘NOTES’

(TRANS-VAGINAL)

CHOLECYSTECTOMY

NOTES: THE EASE

NOTES: THE EASE Improving surgical procedure outcomes . Improving patient recovery time. Improving the time frame in which hospitals discharge patients.

Improving surgical procedure outcomes .

Improving patient recovery time.

Improving the time frame in which hospitals discharge patients.

NOTES: THE EASE Reducing hospital bed occupancy rates. Reducing patient trauma. Many procedures may become OPD procedures.

Reducing hospital bed occupancy rates.

Reducing patient trauma.

Many procedures may become OPD procedures.

NOTES: ADVANTAGES Wound infection- 2%-25% in laparoscopic S X - thus--> tremendous adverse impact on patient recovery and health care costs. Eliminating all skin incisions would completely eliminate this risk.

Wound infection- 2%-25% in laparoscopic S X - thus--> tremendous adverse impact on patient recovery and health care costs.

Eliminating all skin incisions would completely eliminate this risk.

NOTES: ADVANTAGES Incisional hernias - correlate with the size of incisions. Incidence 4%–18% with open surgery, and 0.2%–3% with laparoscopic S X will be eliminated with NOTES.

Incisional hernias - correlate with the size of incisions.

Incidence

4%–18% with open surgery, and

0.2%–3% with laparoscopic S X

will be eliminated with NOTES.

NOTES: ADVANTAGES Small-bowel obstruction- Incidence due to P/O adhesions 7.7%- open surgery 3.3%- laparoscopic surgery will perhaps be further ed with NOTES.

Small-bowel obstruction-

Incidence due to P/O adhesions

7.7%- open surgery

3.3%- laparoscopic surgery

will perhaps be further ed with NOTES.

NOTES: ADVANTAGES Other potential benefits: Decreased PO pain -Less need for PO analgesia, -Shorter hospital stay, and -Faster recovery. Thus a major cost savings.

Other potential benefits:

Decreased PO pain

-Less need for PO analgesia,

-Shorter hospital stay, and

-Faster recovery.

Thus a major cost savings.

NOTES: ADVANTAGES In specific sub-populations: -Easy alternative access to the peritoneal cavity in morbidly obese patients, and Could possibly reduce the lifetime risk of incision-related complications in children.

In specific sub-populations:

-Easy alternative access to the peritoneal cavity in morbidly obese patients, and

Could possibly reduce the lifetime risk of incision-related complications in children.

MODIFICATION OF NOTES FOR OBESITY

MODIFICATION OF NOTES

FOR OBESITY

NOTES: Current Challenge Change is part of surgery but it is never easy to accept.

Change is part of surgery but it is never easy to accept.

NOTES: Current Challenge At the dawn of surgery, excellence of a surgeon was associated with big incisions: "Big scar, big surgeon” .

At the dawn of surgery, excellence of a surgeon was associated with big incisions:

"Big scar, big surgeon” .

NOTES: Current Challenge 1882- open chole 1985- first laparoscopic chole-- strongly criticized. 1992- lap chole- declared t mt of choice for GB-stones.

1882- open chole

1985- first laparoscopic chole-- strongly criticized.

1992- lap chole- declared t mt of choice for GB-stones.

NOTES: Current Challenge But now with NOTES moving one step further: philosophy of surgery will be dramatically changed, as surgical trauma & associated pain - physical barrier for surgery.

But now with NOTES moving one step further: philosophy of surgery will be dramatically changed, as surgical trauma & associated pain - physical barrier for surgery.

NOTES: Current Challenge NOTES will break this barrier of surgical trauma and pain, thus representing an epical evolution in surgery.

NOTES will break

this barrier of surgical

trauma and pain, thus

representing an epical

evolution in surgery.

NOTES: Current Status Initially -lack of Training / Practice -Not well versed with the equipment. -Time consuming -Need of multidisciplinary team, for possible complications

Initially -lack of Training / Practice

-Not well versed with the equipment.

-Time consuming

-Need of multidisciplinary team, for possible complications

NOTES witnessing a true remarkable shift in their lifetime i.e. N atural O rifice T ransluminal E ndoscopic S urgery ( NOTES ).

witnessing a true remarkable shift in their lifetime i.e. N atural O rifice T ransluminal E ndoscopic S urgery ( NOTES ).

THANKYOU