NOTES Dr.Kamran Yousaf Meeqat Gen Hospital Madinah Munawwarah Natural Orifice Transluminal Endoscopic SurgeryThe next generation of ‘Least Invasive Surgical therapy’ Novel method of surg therapy
NOTES Scarless abd surgery Emerging field-GI surg & Interven Gastroentrologists Evolving rapidly Presenting limitless possibilities for innovation,tech & device development May revolutionize the surgical approach Proponents,Researchers believe it may well be the next Paradigm shift in surg as was laparoscopy in 80’s,90’s
NOTES: DEFINITION An experimental surg tech,scarless abd operation,performed by introducing a multi-channeled endoscope thru a natural orifice(mouth,vagina,urethra, anus),puncturing the hollow viscus & doing a diag or therapeutic procedure.
NOTES:A STEP FORWARD emerging surgical approach ‘viewed as a step forward’ utilize the body’s natural openings.History in the making????
NOTES Latest craze among todays surgeons. Highest level of minimal invasiveness. Can be ‘Future of Surgery’ -Minimal invasive surgery -Least invasive surgery SILS,,,,,NOTES
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.
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,John Hopkins,US
NOTES: HISTORY In September 2007, Novare announced the successful completion of the first NOTES gallbladder removal (TV) procedures. 2007-Bessler et all,Marescaeux et all,,TV chol Same year,Swanstrom,colleagues reported TG chole as well 2008,,TV donor kidney extraction done in John Hopkins
NOTES: HISTORY •In March 2008, Dr Ricardo Zorron, of Brazil, performed the first series of NOTES cholecystectomy on four patients via transvaginal route.
NOTES: Transgastric appendectomy in humans in India By Dr. G V Rao and Dr. N Reddy. (Hyderabad, India),,,2007
NOTES: 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,oophorectomy,nephrect omy,Gastro-jej etc
NOTES: Abd cavity access thru natural The technique route,mouth,vagina,urethra,anus An adv endoscope with multiple channels is pushed thru Hollow viscus is punctured from inside Periton insufflation is done to have wide working space Conventional laparoscopic instruments are advanced thru edosc for dissection Principles of safe access are,,,,minimal tissue inj,,,good exposure,,,safety to avoid vascular/visceral inj,,,maintain seal & manipulate instruments ???Hybrid NOTES
NOTES: WHY??? Basic human nature to keep on experimenting/research to improve the qualityof life To get the max from mini Ultimate goal of med prof is Patients welfare Advantages associated with NOTES are numerous like Less physiolog insult No question of pain
NOTES: Why?Advantages Less hospital stay Less resources Bed occupancy,rapid turn over Early return to work NOTES can be done as an outpatient Conscious sedation instead of Gen Anaesth Cosmetic result is un-matched as no incision
NOTES: ADVANTAGES No wound,no infection No infection,no incisional hernia Minimal chance for intra-abd adhesions No post op intest obs Ideal for any surgery on ICU patients Last but not the least More public/pt satisfaction
NOTES: THE CONCEPT NOTES - safe and feasible - same efficacy as traditional laparoscopic procedures.
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.
NOTES: ROUTES 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)
PROCEDURES DESCRIBED TILL NOW Human cases TG- appendectomy, TV- cholecystectomy, TG- cholecystectomy, TG- gastro-enterostomy, Cancer staging.
NOTES: The Way Forward NOSCAR Regulates progress of NOTES NOTES necessitates surg skills,endosc skills & ability to manage complications NOTES expertise,,,Dlilgent lab work- systematized training models-judicious clinical trials,,,,stepwise approach Instituitional training & fellowship in NOTES Research engineers focus Comptr assissted 3D image system Routine clinical Application-long way-steady
NOTES: The Way Forward Advance technolog develop in progress,substantial refinement A spate of new instruments more suitable,flexible Time may come when NOTES may well become the order of the day. FUTURE OF SURGERY???
NOTES: The Way ForwardThe medical fraternity & Gen public has captivated the idea of NOTES-scarless abd surgery,with great enthusiasm & interest BUT For us,the patients safety & welfare is of paramount importance,not the advancement of NOTES,,,,,no ground for over-exitement
NOTES:Current Challenge Change is part of surgery but it is never easy to accept. A lot of sceptisism,undoubt ed interest as well
NOTES:Current Challenge 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 tmt of choice for GB-stones. SILS,,,,,New dimention,,,step towards NOTES,,,,
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.
NOTES Questions??? What are the infectious complications? How reliable is the organ Closure? How practical is viscerot? contravenes surg dogma. How good are instruments Ethics/Acceptability Cogent answers needed
NOTES:Hurdles-Problems Presently NOTES cases being reported anecdotally Inadequate instruments,organ closure Ethical/Moral issues Lack of instituitional training & supervision One of basic tenets of Lap surg is tringulation of Optics & Instruments,,,,lost in NOTES result is partial loss of spatial orientation & depth perception. Who is Who?Dilema of speciality?
NOTES witnessing a true remarkable shift in their lifetime i.e. Natural Orifice Transluminal Endoscopic Surgery (NOTES).