Devuelta al Lumen: Cirugía endoscópica transluminal a través de orificios naturales 2012

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2 Devuelta al Lumen: Cirugía endoscópica transluminal a través de orificios naturales 2012 Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion Colombiana de Gastroenterologia 1 de Septiembre, 2012 Pereira, Risaralda Hotel Movich John A. Martin, MD Associate Professor of Medicine and Surgery Director of Endoscopy Northwestern University Feinberg School of Medicine Chicago, Illinois

3 In the beginning

4 In the beginning

5 In the beginning

6 In the beginning Rao GV, Reddy N., 2005 Transgastric Appendectomy in Humans. Unpublished; presentation at World Congress of Gastroenterology, Montreal, Quebec, Canada, September 2005.

7 The NOTES Concept Enter body through natural orifice with standard flexible endoscope Open wall of viscus Replicate traditionally surgical intraabdominal procedure Withdraw into viscus and close visceral wall securely Remove endoscope from orifice

8 Abdominal Surgery in Perspective Open Surgery Laparoscopic Surgery (same operations, smaller incisions) Percutaneous + Endoscopic Excision, Ablation, Debridement, Drainage (Interventional radiology & endoscopy) Natural Orifice Transluminal Endoscopic Surgery (NOTES)

9 Why NOTES? Less invasive (?) Less pain Less tissue trauma Lower anesthesia requirement (?) Better postop pulmonary function (?) Decreased hernia formation Decreased wound infection Decreased immunomodulation (?)

10 Why NOTES? Faster recovery times Shorter hospital stays Outpatient procedures (?) Improved cosmesis Anticipated public demand for incisionless surgery Potential positive impact on endoluminal procedures

11 The NOTES Concept: Chapter 1 NOTES would Change laparoscopic surgery Expand the horizon of the gastroenterologist Lead to rapid development of instrumentation specific to NOTES Evolve new breed of GI interventionalist neither surgeon nor gastroenterologist

12 The NOTES Concept: Chapter 1 NOTES would Change laparoscopic surgery Expand the horizon of the gastroenterologist Lead to rapid development of instrumentation specific to NOTES Evolve new breed of GI interventionalist neither surgeon nor gastroenterologist really?

13 The NOTES Concept: Chapter 1 What actually happened? Gastroenterologists and surgeons teamed up and started to work together Industry teamed up with clinical teams of clinical investigators Conceptualization and development of new technology accelerated rapidly NOSCAR formed

14 NOSCAR Natural Orifice Surgery Consortium for Assessment and Research Joint initiative supported by both ASGE & SAGES White papers published 2006 Industry grants $2 million 3 rd annual conference held in San Francisco, July 10-12, 2008 (

15 The NOTES Concept: Chapter 1 Early animal work Liver biopsy Oophrectomy Tubal ligation Cholecystectomy Splenectomy Gastrojejunostomy

16 Closure devices: clips + clamps

17 Closure devices: T-tags

18 Closure devices: suturing

19 Closure devices: suturing

20 Closure devices: plugs 100% successful closure of standardized 1cm gastrotomy in large animal survival model Cios, et al., Surg Endosc 2007

21 Closure devices: atrial septal occluder Perretta, et al., Gastrointest Endosc 2007;66:

22 Closure devices: flexible stapler Kaehler, et al., Surg Endosc 2007;20:

23 New Generation Endoscopes Endoscopic paradigm

24 Multitasking platforms Surgical paradigm

25 Multitasking platforms Combining endoscopic & surgical paradigms

26 Proprietary platform

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28 Dedicated instrumentation

29 Human NOTES Procedures Appendectomy Cholecystectomy PEG rescue Proposed Staging for cancer Diagnosis / treatment of pain syndromes Tubal ligation / Oophrectomy Adhesiolysis Diaphragm pacing Gastric pacing

30 The NOTES Concept: Chapter 1 What did we learn? Technical limitations to current platform Flexible endoscopes Too flexible for counter-forces Small instrument channels Weak suction / insufflation Parallel (instrument and visual) access Endoscopic Instrumentation Weak graspers Small end-effectors No (or limited) independent steering Inadequate tissue approximators & hemostasis

31 NOTES Hybrid Human Chole (not the full Monty) Auyang E, Vaziri K, Martin J, Hungness E, Soper N. Human NOTES Hybrid Transgastric Cholecystectomy. DDW 2008, San Diego, CA

32 Issues: Technological & Technical

33 Issues: Efficiency & Ergonomics

34 The NOTES Concept: Chapter 1 What did we learn? Technical limitations to current platform Conceptualization and development of new technology takes time Laparoscopy is a very good technology Fundamental differences between gastroenterologist and surgeon

35 The NOTES Concept: Chapter 1 What did this lead to? Hybrid NOTES instead of pure NOTES Single laparoscopic port Other abdominally-inserted endeffectors The understanding that there must be more to NOTES than simply replicating what laparoscopy already does well

36 The NOTES Concept: Chapter 1 What was realized? (post NOSCAR 2008) Gastroenterologists are not surgeons, and surgeons are not gastroenterologists Different knowledge base Distinct skill-sets Working together in NOTES yields different rewards to each What are NOTES s rewards for the gastroenterologist?

37 Pasricha P, Hawari R, Ahmed I, Chen J, Cotton P, Hawes R, Kalloo A, Kantsevoy S, Gostout CJ. Endoscopic Submucosal Esophageal Myotomy. Endoscopy 2007;39: , and DDW 2007, Washington, DC

38 Auyang E, Vaziri K, Volckmann E, Martin J, Soper N, Hungness E. Cadaveric Rendezvous Hybrid Small Bowel Resection. Surg Endosc 2008 & SAGES 2008.

39 Desilets D, Romanelli J, Earle D. Endoscopic Stapled Cystgastrostomy. DDW 2008, San Diego, CA, May, 2008

40 What else is possible? From Kim HB, Fauza D, Garza J, Oh JT, Nurko N, Jaksic T. Serial Transverse Enteroplasty (STEP): A Novel Bowel Lengthening Procedure. J Ped Surg 2003.

41 Fluorescence Probe Endoscopy The cathepsin probe: are molecular probes the future of diagnostic endoscopy? * Cy5.5 monofunctional dye Gounaris and Khazaie, PLoS ONE 2008; 3: e2916.

42 Molecular imaging in endoscopy: Cathepsin probe endoscopy in a mouse model Gounaris and Khazaie

43 What s on the Wish List?

44 The Wish List Endoscopic stapler Better knives endoscopic directional control flexible robust Improved mucosal undermining Robust retractors, approximators, & hemostatic apparatus More secure closure Agile, versatile multitasking platforms

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46 Fly-by-Wire? From Ho, KY, et al. Endoscopic Submucosal Dissection Using a Computercontrolled Master-Slave Robot. DDW 2009

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