Removal of a guide-wire sliding into abdominal cavity via transgastric natural orifice transluminal endoscopic surgery: A case report

BACKGROUND Guidewire slippage into the peritoneal cavity during clinical operations is extremely rare.Therefore,this paper aims to report a successful case of guidewire removal using transgastric natural orifice transluminal endoscopic surgery(NOTES).The goal is to enhance physicians'understanding of the management plan for this unique scenario and provide a valuable reference for clinical practice.CASE SUMMARY A 64-year-old man presented with abdominal distension and was diagnosed with cirrhosis combined with massive ascites.To proceed with treatment,the patient underwent ultrasound-guided peritoneal puncture and underwent catheterization and drainage.Unfortunately,a 0.035-inch guidewire slipped into the abdominal cavity during the procedure.Following a comprehensive evaluation and consultation by a multidisciplinary team,the guidewire was successfully removed using NOTES.CONCLUSION This case highlights the potential consideration of transgastric NOTES removal when encountering a foreign body,such as a guidewire,within the abdominal cavity.

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery

BACKGROUND At present,laparoscopic cholecystectomy(LC)is the main surgical treatment for gallstones.But,after gallbladder removal,there are many complications.Therefore,it is hoped to remove stones while preserving the function of the gallbladder,and with the development of endoscopic technology,natural orifice transluminal endoscopic surgery came into being.AIM To compare the quality of life,perioperative indicators,adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery(EGPS)in patients with gallstones.METHODS Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected.We adopted propen-sity score matching(1:1)to compare EGPS and LC patients.RESULTS A total of 662 cases were collected,of which 589 cases underwent LC,and 73 cases underwent EGPS.Propensity score matching was performed,and 40 patients were included in each of the groups.In the EGPS group,except the gastr-ointestinal defecation(P=0.603),the total score,physical well-being,mental well-being,and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery(P<0.05).In the LC group,except the mental well-being,the total score,physical well-being,gastrointestinal digestion,the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery(P<0.05).When comparing between groups,gastrointestinal defecation had significantly difference(P=0.002)between the two groups,there was no statistically significant difference in the total postoperative score and the other three subscales.In the surgery duration,hospital stay and cost,LC group were lower than EGPS group.The recurrence factors of gallstones after EGPS were analyzed:and recurrence was not correlated with gender,age,body mass index,number of stones,and preoperative score.CONCLUSION Whether EGPS or LC,it can improve the patient’s symptoms,and the EGPS has less impact on the patient’s defecation.It needed to,prospective,multicenter,long-term follow-up,large-sample related studies to prove.

Robotic natural orifice specimen extraction surgery I-type F method vs conventional robotic resection for lower rectal cancer

BACKGROUND Robotic resection using the natural orifice specimen extraction surgery I-type F method(R-NOSES I-F)is a novel minimally invasive surgical strategy for the treatment of lower rectal cancer.However,the current literature on this method is limited to case reports,and further investigation into its safety and feasibility is warranted.AIM To evaluate the safety and feasibility of R-NOSES I-F for the treatment of low rectal cancer.METHODS From September 2018 to February 2022,206 patients diagnosed with low rectal cancer at First Affiliated Hospital of Nanchang University were included in this retrospective analysis.Of these patients,22 underwent R-NOSES I-F surgery(RNOSES I-F group)and 76 underwent conventional robotic-assisted low rectal cancer resection(RLRC group).Clinicopathological data of all patients were collected and analyzed.Postoperative outcomes and prognoses were compared between the two groups.Statistical analysis was performed using SPSS software.RESULTS Patients in the R-NOSES I-F group had a significantly lower visual analog score for pain on postoperative day 1(1.7±0.7 vs 2.2±0.6,P=0.003)and shorter postoperative anal venting time(2.7±0.6 vs 3.5±0.7,P<0.001)than those in the RLRC group.There were no significant differences between the two groups in terms of sex,age,body mass index,tumor size,TNM stage,operative time,intrao-perative bleeding,postoperative complications,or inflammatory response(P>0.05).Postoperative anal and urinary functions,as assessed by Wexner,low anterior resection syndrome,and International Prostate Symptom Scale scores,were similar in both groups(P>0.05).Long-term follow-up revealed no significant differences in the rates of local recurrence and distant metastasis between the two groups(P>0.05).CONCLUSION R-NOSES I-F is a safe and effective minimally invasive procedure for the treatment of lower rectal cancer.It improves pain relief,promotes gastrointestinal function recovery,and helps avoid incision-related complications.

Novel deformable self-assembled magnetic anastomosis ring for endoscopic treatment of colonic stenosis via natural orifice

BACKGROUND Although endoscope-assisted magnetic compression anastomosis has already been reported for colonic anastomosis,there is no report on a single-approach operation using the natural orifice.AIM To design a deformable self-assembled magnetic anastomosis ring(DSAMAR)for colonic anastomosis for use in single-approach operation and evaluate its feasibility and safety through animal experiments.METHODS The animal model for colonic stenosis was prepared by partial colonic ligation in eight beagles.The magnetic compression anastomosis of their colonic stricture was performed by endoscopically assisted transanal implantation of the DSAMAR.The anastomotic specimen,obtained 2 wk after the operation,was observed by both the naked eye and a light microscope.RESULTS The DSAMAR was successfully inserted into the proximal end of colon stenosis through the anus.The DSAMAR of seven dogs was successfully transformed into rings,while that of the remaining dog was removed after the first deformation failed.The rings were successfully retransformed after optimization.All animals underwent colonic anastomosis using the DSAMAR.No device-related or procedure-related adverse events were observed.The colostomy specimens of the experimental dogs were obtained 2 wk after the operation.Both gross and histological observations showed good anastomotic healing.CONCLUSION The DSAMAR is a safe and feasible option for the treatment of colon stenosis.Its specific deformation and selfassembly capability maximize the applicability of the minimally invasive treatment.

Safety and survival outcomes of transanal natural orifice specimen extraction using prolapsing technique for patients with middle-to low-rectal cancer

Objective:The transanal approach to specimen collection,combined with the prolapsing technique,is a wellestablished and minimally invasive surgery for treating rectal cancer.However,reports on outcomes for this approach are sparse.We compared short-and long-term outcomes of conventional laparoscopic surgery(CLS)vs.transanal natural orifice specimen extraction(NOSE)using the prolapsing technique for patients with middle-to low-rectal cancer.Methods:From January 2013 to December 2017,we enrolled consecutive patients with middle-to low-rectal cancer undergoing laparoscopic anterior resection.Totally,50 patients who underwent transanal NOSE using the prolapsing technique were matched with 50 patients who received CLS.Clinical parameters and survival outcomes between the two groups were compared.Results:Estimated blood loss(29.70±29.28 vs.52.80±45.09 mL,P=0.003),time to first flatus(2.50±0.79 vs.2.86±0.76,P=0.022),time to liquid diet(3.62±0.64 vs.4.20±0.76 d,P<0.001),and the need for analgesics(22%vs.48%,P=0.006)were significantly lower for the NOSE group compared to the CLS group.The incidences of overall complications and fecal incontinence were comparable in both groups.After a median follow-up of 44.52 months,the overall local recurrence rate(6%vs.5%,P=0.670),3-year disease-free survival(86.7%vs.88.0%,P=0.945)and 3-year overall survival(95.6%vs.96.0%,P=0.708),were not significantly different.Conclusions:For total laparoscopic rectal resection,transanal NOSE using the prolapsing technique is effective and safe,and associated with less trauma and pain,a faster recovery,and similar survival outcomes compared to CLS.

Natural orifice transluminal endoscopic surgery in urology: The Chinese experience

Objective:To describe the Chinese experience of natural orifice transluminal endoscopic surgery(NOTES)in urology.Methods:From December 2008 to May 2017,35 animal experiments and 305 clinical surgeries of NOTES or natural orifices specimen extractions(NOSE)were performed in China.The animal experiments included five kidney biopsies,24 nephrectomies and six partial nephrectomies.The clinical surgeries included 12 transvaginal NOSE(TV-NOSE),266 hybrid transvaginal NOTES(TV-NOTES)and 27 pure TV-NOTES.The TV-NOSE procedure was performed in five transumbilical laparoendoscopic single-site(U-LESS)nephrectomies,four suprapubic-assisted laparoendoscopic single-site surgery(SA-LESS)nephroureterectomies,and three laparoscopic radical cystectomies.The hybrid TV-NOTES procedure included 210 nephrectomies,31 adrenalectomies,eight nephroureterectomies,13 partial nephrectomies,and four heminephrectomies.The pure TV-NOTES procedure included five renal cyst decortications and 22 nephrectomies.Results:A total of 29 animal experiments were successfully performed.One partial nephrectomy was converted to standard laparoscopic surgery.Two kidney biopsies and two nephrectomies were unsuccessful.A total of 297 clinical surgeries were successfully performed.Six patients who underwent hybrid TV-NOTES were converted to open surgery.Two patients who underwent pure TV-NOTES were converted to SA-LESS.There were 22 major complications,16 occurred intraoperatively and six postoperatively.The mean visual analog score(VAS)of 48 h after the operation was 2.5 points in TV-NOSE,2.3 points in hybrid TV-NOTES and 1.7 points in pure TV-NOTES.The mean follow-up of 50.6(3.0-87.0)months showed that all patients were in good condition.The umbilicus scars were nearly invisible in TV-NOSE and hybrid TV-NOTES.The vaginal incision healed well.Conclusions:TV-NOSE and TV-NOTES are feasible,safe,and effective with little injury,low pain,fast recovery,and good cosmetic outcomes in properly selected patients.They are worth consideration for urological clinical practice.

Natural orifice specimen extraction with laparoscopic radical gastrectomy for distal gastric cancer: A case report

BACKGROUND This article introduces the surgical method and early experience in performing totally laparoscopic radical gastrectomy with transrectal specimen extraction for gastric cancer, and we evaluate the short-term effects and feasibility of this new procedure for gastric cancer in a 64-year-old male patient. This approach may provide new possibilities for gastric natural orifice specimen extraction(NOSE)surgery. In addition, we believe that this new procedure may further relieve pain,speed up recovery, and cause minimal physiological and psychological impact.CASE SUMMARY We performed NOSE gastrectomy in a male patient. Tumor resection, digestive tract reconstruction, and lymph node dissection were performed totally laparoscopically;the specimen was extracted from the natural orifice of the rectum-anus. This procedure reduced damage to the abdominal wall and decreased postoperative pain. We successfully performed radical gastrectomy without conversion and complications. Total operative time and blood loss were 176 min and 50 m L, respectively. The patient resumed normal activities of daily living on day 1 without pain, and passed flatus within 48 h. Postoperative hospital stay was 10 d. The number of resected lymph nodes was 0/43. During the follow-up, no stricture or anastomotic leakage was detected. Three months postoperatively, colonoscopy showed full recovery of the rectum without stricture or scar contracture. Computed tomography and laboratory test results showed no signs of tumor recurrence. There was no visible scar on the abdominal wall.CONCLUSION It is safe and reliable to perform totally laparoscopic radical gastrectomy with transrectal specimen extraction for distal gastric cancer patients.

Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer:A case report

BACKGROUND Pure natural orifice transluminal endoscopic surgery(NOTES)for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges,including loss of triangulation,in-line orientation,and instrument collision.Transvaginal(v)NOTES,however,can overcome these technical challenges.We report a case of pure vNOTES right hemicolectomy for colon cancer,attached with surgical video.CASE SUMMARY A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy.Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons.The operative time was 200 min and the estimated blood loss was 30 mL.No intraoperative or postoperative complications occurred within 30 d after the surgery.The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3.The patient was discharged at postoperative day 6.The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.CONCLUSION vNOTES right hemicolectomy,performed by well-experienced surgeons,overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.

Are laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery gallbladder preserving cholecystolithotomy truly comparable?A propensity matched study

BACKGROUND Cholecystectomy is the preferred treatment option for symptomatic gallstones.However,another option is gallbladder-preserving cholecystolithotomy which preserves the normal physiological functions of the gallbladder in patients desiring to avoid surgical resection.AIM To compare the feasibility,safety and effectiveness of pure natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving cholecystolithotomy vs laparoscopic cholecystectomy(LC)for symptomatic gallstones.METHODS We adopted propensity score matching(1:1)to compare trans-rectal NOTES cholecystolithotomy and LC patients with symptomatic gallstones.We reviewed 2511 patients with symptomatic gallstones from December 2017 to December 2020;517 patients met the matching criteria(NOTES,110;LC,407),yielding 86 pairs.RESULTS The technical success rate for the NOTES group was 98.9%vs 100%for the LC group.The median procedure time was 119 min[interquartile ranges(IQRs),95-175]with NOTES vs 60 min(IQRs,48-90)with LC(P<0.001).The frequency of post-operative pain was similar between NOTES and LC:4.7%(4/85)vs 5.8%(5/95)(P=0.740).The median duration of post-procedure fasting with NOTES was 1 d(IQRs,1-2)vs 2 d with LC(IQRs,1-3)(P<0.001).The median post-operative hospital stay for NOTES was 4 d(IQRs,3-6)vs 4 d for LC(IQRs,3-5),(P=0.092).During follow-up,diarrhea was significantly less with NOTES(5.8%)compared to LC(18.6%)(P=0.011).Gallstones and cholecystitis recurrence within a median of 12 mo(range:6-40 mo)following NOTES was 10.5%and 3.5%,respectively.Concerns regarding the presence of abdominal wall scars were present in 17.4%(n=15/86)of patients following LC(mainly women).CONCLUSION NOTES provides a feasible new alternative scar-free treatment for patients who are unwilling or unable to undergo cholecystectomy.This minimally invasive organ-sparing procedure both removes the gallstones and preserves the physiological function of the gallbladder.Reducing gallstone recurrence is essential to achieving widespread clinical adoption of NOTES.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diag- nostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.

Peroral traction-assisted natural orifice trans-anal flexible endoscopic rectosigmoidectomy followed by intracorporeal colorectal anastomosis in a live porcine model

BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and better quality of life.In 2007,Whiteford et al reported the first natural orifice trans-anal endoscopic surgery(NOTES)sigmoidectomy using transanal endoscopic microsurgery.To date,all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.AIM To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.METHODS Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection.After preoperative work-up and bowel preparation,general anesthesia combined with endotracheal intubation was achieved.One dual-channel therapeutic endoscope was used.Carbon dioxide insufflation was performed during the operation.The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps:(1)The rectosigmoid colon was tattooed with India ink by submucosal injection;(2)Creation of gastrostomy by directed submucosal tunneling;(3)Peroral external traction using endoloop ligation;(4)Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling;(5)Peroral external traction-assisted dissection of the left side of the colon;(6)Transanal rectosigmoid specimen transection,where an anvil was inserted into the proximal segment after purse-string suturing;(7)Intracorporeal colorectal end-toend anastomosis using a circular stapler by a single stapling technique;and(8)Closure of gastrostomy using endoscopic clips.All animals were euthanized immediately after the procedure,abdominal exploration was performed,and the air-under-water leak test was carried out.RESULTS The procedure was completed in all three animals,with the operation time ranging from 193 min to 259 min.Neither major intraoperative complications nor hemodynamic instability occurred during the operation.The length of the resected specimen ranged from 7 cm to 13 cm.With the assistance of a transumbilical rigid grasper,intracorporeal colorectal,tension-free,end-to-end anastomosis was achieved in the three animals.CONCLUSION Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.

Analysis of the Results of Rectal Cancer Treatment via 3D Laparoscopic Natural Orifice Specimen Extraction Surgery (NOSES IV)

Objective:To investigate the effect of 3D laparoscopic natural orifice specimen extraction surgery as rectal cancer treatment.Methods:The study was carried out in Shaanxi Provincial People’s Hospital from July 2021 to July 2022.80 rectal cancer patients were selected and divided into two groups which are the experimental group and control group.The experimental group was given 3D laparoscopic surgery while the control group was given 2D laparoscopic surgery.The results were compared and analysed.Results:The patients in the experimental group had shorter operative and evacuation times,less intraoperative bleeding,and a lower rate of complications.Conclusion:The clinical application of 3D laparoscopic radical surgery for rectal cancer via natural lumen extraction is more effective,which can promote patients'recovery and reduce the incidence of adverse events.

Outcomes after natural orifice extraction vs conventional specimen extraction surgery for colorectal cancer: A propensity scorematched analysis

BACKGROUND Natural orifice specimen extraction(NOSE)via the anus or vagina replaces conventional transabdominal specimen retrieval via the transabdominal route through a limited mid-line laparotomy or Pfannenstiel incision.Reducing the number of laparoscopic ports further decreases operative abdominal wall trauma.These techniques reduce the surgical wound size as well as the risk of incisionrelated morbidity.AIM To compare short-term outcomes following 3-port NOSE surgery with a matched cohort of conventional non-NOSE colorectal cancer surgery.METHODS Patients who underwent elective 3-port laparoscopic colorectal NOSE surgery between February to October 2021 were identified.Selection criteria for NOSE surgery was adapted from the 2019 International Consensus on Natural Orifice Specimen Extraction Surgery for colorectal cancer.Patients with clinical T4 or N2 tumors on staging computed tomography were also excluded.The propensity score-matched cohort was identified amongst patients who underwent conventional laparoscopic colorectal surgery from January 2019 to December 2020.Matching was performed in the ratio of 1:4 based on age,gender,type of resection,and p-tumor node metastasis staging.RESULTS Over the eight-month study duration,14 consecutive cases(nine female,five male)of elective 3-port laparoscopic surgery with NOSE were performed for colorectal cancer.Median age and body mass index were 70(range 43-82)years and 24.1(range 20.0-31.7)kg/m2 respectively.Six patients underwent transanal NOSE and eight had transvaginal NOSE.Median operative time,intraoperative blood loss and postoperative length of stay were 208(range 165-365)min,30(range 10-150)mL and 3(range 2-6)d respectively.Two(14%)suffered minor postoperative compilations not attributable to the NOSE procedure.Median follow-up duration was 12(range 8-15)mo.No instances of mortality,local or distant disease recurrence were recorded in this cohort.Compared to the conventional surgery cohort of 56 patients,the 3-port NOSE cohort had significantly quicker mean return of bowel function(2.6 vs 1.2 d,P<0.001),reduced postoperative pain and patientcontrolled analgesia use,and decreased length of hospital stay(6.4 vs 3.4 d,P<0.001).There were no statistical differences in surgical duration and perioperative complication rates between the NOSE and non-NOSE cohorts.CONCLUSION 3-port laparoscopic colorectal surgery with NOSE is a feasible technique,augmenting the minimally invasive nature of surgery and producing good outcomes.Appropriate patient selection and expertise in conventional laparoscopy are required.

Transvaginal natural orifice transluminal endoscopic surgery:A novel gasless technique to hysterectomy

Transvaginal natural orifice transluminal endoscopic surgery(vNOTES),as a minimally invasive surgery technique,applies CO_(2) for creating pneumoperitoneum,and uses a closed system to through smoke evacuation from a dedicated outlet or port.It has the potential to generate aerosol in the operation room,which can lead to an increased risk of transmission of SARS-CoV-2.This technical note introduces a new technique of gasless pure vNOTES to hysterectomy using silicone face mask as a modified vNOTES port.

Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer

In recent years,natural orifice specimen extraction surgery(NOSES),a novel minimally invasive surgical technique,has become a focus in the surgical field,and has been initially applied in gastric surgery in many national medical centers worldwide.In addition,this new surgical technique was launched in major hospitals in China.With an increasing number of patients who have accepted this new surgical technique,NOSES has provided new prospects for the treatment of gastric cancer(GC),which may achieve a better outcome for both patients and surgeons.More and more experts and scholars from different countries and regions are currently paying close attention to NOSES for the treatment of GC.However,there are only a few reports of its use in GC.This review focuses on the research progress in NOSES for radical gastrectomy in recent years.We also discuss the challenges and prospects of NOSES in clinical practice.

Natural orifice translumenal endoscopic surgery （NOTES）： current status and challenges

Objective To give a conceptual description of natural orifice translumenal endoscopic surgery （NOTES）, review the early efforts in the NOTES field, and discuss its challenges and limitations. Data sources The data were retrieved mainly from publications listed in MEDLINE, PubMed and China Wanfang Database from 2005 to 2009. The search term was ＂NOTES＂. Study selection The articles involved in the ＂NOTES＂ study were selected and the review articles were excluded from the comparison. Results A marked increase in quantity in articles was shown each year for NOTES studies from 2006 to 2009. Animal experiments with ＂NOTES＂ have been carried out in China from 2007, and two independent ＂NOTES＂ procedures on humans were reported in 2009. Conclusion Although still in its infancy, the ＂NOTES＂ procedure is promising as another type of minimally invasive surgery and favorable alternative to current interventions.

Infection during transgastric and transvaginal natural orifice transluminal endoscopic surgery in a live porcine model

Background The infection risk of natural orifice transluminal endoscopic surgery （NOTES） is of concern. The aim of this study was to assess the safety of NOTES by investigating the intraperitoneal bacterial load during transgastric and transvaginal procedures with antiseptic or controling perioperative preparation.Methods Forty-five female pigs were randomly assigned to five equal groups： the transgastric （TG） control group （group A）, the TG middle volume gastric lavage group （group B）, the TG high volume lavage group （group C）, the transvaginal （TV） control group （group D） and the TV study group （group E）. The study groups received gastric or vaginal lavage and abdominal antimicrobial irrigation, while the control groups received neither. All animals were administered intravenous antibiotics, underwent NOTES peritoneoscopy and transumbilical laparoscopic cholecystectomy under NOTES view with sterile instruments. The viscerotomy was closed by laparoscopic suture. The animals were observed until necropsy was performed 14 days postoperatively. Quantitative bacteriologic cultures were taken from the gastric or vaginal aspirate before and after lavage; peritoneal fluid was collected before and after peritoneal irrigation and at necropsy. Results The surgical procedures were completed for all the pigs and all of them survived. The mean operative time of the TG group and the TV group was （81±27） minutes and （66±12） minutes, respectively. All animals survived for 14 days.At necropsy, significantly more peritoneal infections were noted in group A than in group D （5：9 vs. 0：9; P 〈0.05）. Nogross evidence of intra-peritoneal infection was found in groups B, C, D and E. Bacteriological evidence was seen in all pigs in group A, 7 pigs in group B, 6 pigs in group D, and none in groups C and E.Conclusions Without gastric or vaginal lavage and antibiotic peritoneal irrigation, the TG procedure has a higher infection rate than the TV access. After antiseptic preparation, the bacterial load significantly decreased in the TG group,which seems as safe as the sterile TV approach.

Delayed assessment and eager adoption of laparoscopic cholecystectomy:Implications for developing surgical technologies

Despite the prevailing emphasis in the medical literature on establishing evidence,many changes in the practice of surgery have not been achieved using proper evidence-based assessment.This paper examines the adoption of laparoscopic cholecystectomy(LC)into regular use for the treatment of cholecystitis and the process of its acceptance,focusing on the limited role of technology assessment in its appraisal.A review of the published medical literature concerning LC was performed.Approximately 3000 studies of LC have been conducted since 1985,and there have been nearly 8500 publications to date.As LC was adopted enthusiastically into practice,the results of outcome studies generally showed that it compared favorably with the traditional,open cholecystectomy with regard to mortality,complications,and length of hospital stay.However,despite the rapid general agreement on surgical technique,efficacy,and appropriateness,there remained lingering doubts about safety,outcomes,and cost of the procedure that suggested that essential research questions were ignored even as the procedure became standard.Using LC as a case study,there are important lessons to be learned about the need for important guidelines for surgical innovation and the adoption of minimally invasive surgical techniques into current clinical and surgical practice.We highlight one recent example,natural orifice transluminal endoscopic surgery and how necessary it is to properly evaluate this new technology before it is accepted as a safe and effective surgical option.

Closure techniques in exposed endoscopic full-thickness resection:Overview and future perspectives in the endoscopic suturing era

Exposed endoscopic full-thickness resection(EFTR)without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors.To date,various techniques have been used for the closure of the transmural postEFTR defect,mainly consisting in clip-and endoloop-assisted closure methods.However,the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure.The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance,also considering the recent advent of flexible endoscopic suturing.

Robotic transanal total mesorectal excision:Is the future now?

Total mesorectal excision(TME)is the standard surgical treatment for the curative radical resection of rectal cancers.Minimally invasive TME has been gaining ground favored by the continuous technological advancements.New procedures,such as transanal TME(TaTME),have been introduced to overcome some technical limitations,especially in low rectal tumors,obese patients,and/or narrow pelvis.The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME.However,recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series.Robotic TaTME(R-TaTME)has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins,and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity.Encouraging short-term results have been reported for R-TaTME,but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes.The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature,with a special focus on the potential benefits,harms,and future perspectives for this novel approach.