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Lecture By Dr.Kamran Yussif
Surgeon Specialist Meeqat General Hospital.

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  • Great presentation. I would like to share our contirbution : Minilaparoscopy-Assisted Natural Orifice Surgery Daniel A. Tsin, MD, Liliana T. Colombero, MD, Johann Lambeck, MD, Panagiotis Manolas, MD JSLS (2007)11:24–29 ----100 cases (human experience)
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  1. 1. 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
  2. 2. 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
  3. 3. SURGEONS WITHOUT SCALPEL
  4. 4. 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.
  5. 5. NOTES:A STEP FORWARD emerging surgical approach  ‘viewed as a step forward’ utilize the body’s natural openings.History in the making????
  6. 6. NOTES Latest craze among todays surgeons. Highest level of minimal invasiveness. Can be ‘Future of Surgery’ -Minimal invasive surgery -Least invasive surgery SILS,,,,,NOTES
  7. 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. 8. 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
  9. 9. 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
  10. 10. NOTES: HISTORY •In March 2008, Dr Ricardo Zorron, of Brazil, performed the first series of NOTES cholecystectomy on four patients via transvaginal route.
  11. 11. NOTES: Transgastric appendectomy in humans in India By Dr. G V Rao and Dr. N Reddy. (Hyderabad, India),,,2007
  12. 12. NOTES: Famous bollywood actress ‘Shilpa Shetty’ and south Indian actress ‘Khusboo’ have recently undergone transgastric appendicectomy.
  13. 13. 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
  14. 14.  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
  15. 15.  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
  16. 16. 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
  17. 17. 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
  18. 18. NOTES: THE CONCEPT NOTES - safe and feasible - same efficacy as traditional laparoscopic procedures.
  19. 19. NOTES: INSTRUMENTS
  20. 20. NOTES: INSTRUMENTS
  21. 21. NOTES: INSTRUMENTS
  22. 22. NOTES: INSTRUMENTS
  23. 23. NOTES Result of active cooperation between minimally invasive surgeons and interventional gastroenterologists.
  24. 24. NOTES Internal incision is over stomach, vagina, bladder or colon, thus completely avoiding any external incisions or scars.
  25. 25. INTERNAL INCISION
  26. 26. 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
  27. 27. NOTES: ROUTES NOTES has been mostly practised on animals, for diagnosis and treatments, including transgastric organ removal.
  28. 28. NOTES: ROUTES
  29. 29. DEMONSTRATINGTRANSGASTRIC ROUTE
  30. 30. DEMONSTRATINGTRANSVAGINAL ROUTE
  31. 31. 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.
  32. 32. NOTES: ROUTES Transvaginal access appears to be the safest and most feasible. potentially less complications, but only possible in women.
  33. 33. 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)
  34. 34. PROCEDURES DESCRIBED TILL NOW Human cases TG- appendectomy, TV- cholecystectomy, TG- cholecystectomy, TG- gastro-enterostomy, Cancer staging.
  35. 35. FIRST ‘NOTES’(TRANS-VAGINAL)CHOLECYSTECTOMY
  36. 36. 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
  37. 37. 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???
  38. 38. 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
  39. 39. NOTES:Current Challenge  Change is part of surgery but it is never easy to accept.  A lot of sceptisism,undoubt ed interest as well
  40. 40. NOTES:Current Challenge At the dawn of surgery, excellence of a surgeon was associated with big incisions: "Big scar, big surgeon”.
  41. 41. 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,,,,
  42. 42. 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.
  43. 43. 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
  44. 44. 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?
  45. 45. NOTES witnessing a true remarkable shift in their lifetime i.e. Natural Orifice Transluminal Endoscopic Surgery (NOTES).

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