Notes by dr mahipal

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  • 1. NOTES Natural Orifice Transluminal Endoscopic Surgery The next generation of ‘Least Invasive Surgical therapy’ DR.MAHIPAL REDDY INDIA
  • 2. NOTES
    • PERFORMING SURGICAL PROCEDURES WITHOUT MAKING INCISIONS ON THE SURFACE OF THE BODY and LEAVING NO SCARS
  • 3. SURGEONS WITHOUT SCALPEL
  • 4. 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.)
  • 5. NOTES: A STEP FORWARD
    • emerging surgical approach 
    • ‘ viewed as a step forward’
    • utilize the body’s natural openings.
  • 6. NOTES
    • Latest craze among todays
    • surgeons.
    • Highest level of minimal invasiveness.
    • Can be ‘Future of Surgery’
    • -Minimal invasive surgery
    • -Least invasive surgery
  • 7. 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.
  • 8.  
  • 9. 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.
  • 10. NOTES: HISTORY
    • In September 2007,
    • Novare announced
    • the successful
    • completion of the first
    • NOTES gallbladder removal (TV) procedures.
  • 11. NOTES: HISTORY
          • In March 2008, Dr Ricardo Zorron, of Brazil, performed the first series of NOTES cholecystectomy on four patients via transvaginal route.
  • 12. NOTES: IN INDIA
    • transgastric appendectomy in humans in India By Dr. G V Rao and Dr. N Reddy . ( Hyderabad, India) Now the peformed highest in the world about 1000 procedures
  • 13. NOTES: IN INDIA
    • Famous bollywood actress ‘Shilpa Shetty’ and
    • south Indian actress ‘Khusboo’ have recently undergone transgastric appendicectomy.
  • 14. 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.
  • 15. 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.
  • 16. 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 .
  • 17. 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.
  • 18. 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 .
  • 19. NOTES: THE CONCEPT
    • NOTES - safe and feasible
    • - same efficacy
    • as traditional laparoscopic procedures.
  • 20. NOTES: INSTRUMENTS
  • 21. NOTES: INSTRUMENTS
  • 22. NOTES: INSTRUMENTS
  • 23. NOTES: INSTRUMENTS
  • 24.  
  • 25. NOTES
    • Result of active cooperation between minimally invasive surgeons and interventional gastroenterologists.
  • 26.  
  • 27.  
  • 28. NOTES
    • Internal incision is over stomach , vagina , bladder or colon , thus completely avoiding any external incisions or scars.
  • 29. INTERNAL INCISION
  • 30.  
  • 31.  
  • 32. 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
  • 33. NOTES: ROUTES
    • NOTES has been
    • mostly practised
    • on animals, for diagnosis
    • and treatments, including
    • transgastric organ
    • removal.
  • 34. NOTES: ROUTES
  • 35.
    • DEMONSTRATING
    • TRANSGASTRIC ROUTE
  • 36.  
  • 37.  
  • 38.  
  • 39.
    • DEMONSTRATING
    • TRANSVAGINAL ROUTE
  • 40.  
  • 41.  
  • 42. 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.
  • 43. NOTES: ROUTES
    • Transvaginal access appears to be the safest and most feasible.
    • potentially less complications, but only possible in women.
  • 44. 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)
  • 45. PROCEDURES DESCRIBED TILL NOW
    • Human cases
    • TG- appendectomy,
    • TV- cholecystectomy,
    • TG- cholecystectomy,
    • TG- gastro-enterostomy,
    • Cancer staging.
  • 46.  
  • 47.
    • FIRST ‘NOTES’
    • (TRANS-VAGINAL)
    • CHOLECYSTECTOMY
  • 48.  
  • 49. NOTES: THE EASE
  • 50. NOTES: THE EASE
    • Improving surgical procedure outcomes .
    • Improving patient recovery time.
    • Improving the time frame in which hospitals discharge patients.
  • 51. NOTES: THE EASE
    • Reducing hospital bed occupancy rates.
    • Reducing patient trauma.
    • Many procedures may become OPD procedures.
  • 52. 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.
  • 53. 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.
  • 54. 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.
  • 55. NOTES: ADVANTAGES
    • Other potential benefits:
    • Decreased PO pain
    • -Less need for PO analgesia,
    • -Shorter hospital stay, and
    • -Faster recovery.
    • Thus a major cost savings.
  • 56. 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.
  • 57.
    • MODIFICATION OF NOTES
    • FOR OBESITY
  • 58.  
  • 59. NOTES: Current Challenge
    • Change is part of surgery but it is never easy to accept.
  • 60. NOTES: Current Challenge
    • At the dawn of surgery, excellence of a surgeon was associated with big incisions:
    • "Big scar, big surgeon” .
  • 61. NOTES: Current Challenge
    • 1882- open chole
    • 1985- first laparoscopic chole-- strongly criticized.
    • 1992- lap chole- declared t mt of choice for GB-stones.
  • 62. 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.
  • 63. NOTES: Current Challenge
    • NOTES will break
    • this barrier of surgical
    • trauma and pain, thus
    • representing an epical
    • evolution in surgery.
  • 64. NOTES: Current Status
    • Initially -lack of Training / Practice
    • -Not well versed with the equipment.
    • -Time consuming
    • -Need of multidisciplinary team, for possible complications
  • 65. NOTES
    • witnessing a true remarkable shift in their lifetime i.e. N atural O rifice T ransluminal E ndoscopic S urgery ( NOTES ).
  • 66. THANKYOU