An analysis of virtual reality in abdominal surgery-A scoping review.

BACKGROUND: The integration of virtual reality (VR) in surgery has gained prominence as VR applications have increased in popularity. METHODS: A scoping review was undertaken, gathering the most relevant sources, utilising a detailed literature search of medical and academic databases including EMBASE, PubMed, Cochrane, IEEE, Google Scholar, and the Google search engine. RESULTS: Of the 18 articles included, 7 focused on VR in colon surgery, 5 addressed VR in pancreas surgery, and the remaining 6 concentrated on VR in liver surgery. All the articles concluded that VR has a promising future in abdominal surgery by facilitating precision, visualisation, and surgeon training. CONCLUSIONS: Adopting VR technology in abdominal surgery has the potential to improve preoperative planning, decrease perioperative anxiety among patients, and facilitate the training of surgeons, residents, and medical students. Additional supporting studies are necessary before VR can be widely implemented in surgical care delivery.

[Intussusception and Rectal Prolapse: A Common Cause for Defecation Disorders].

INTRODUCTION: A rectal prolapse is mainly a disease of the elderly population, occurring more frequently among women. The medical practitioner has an important role in the recognition and initiation of therapy for rectal prolapse. Appropriate therapy can have an important impact on symptom reduction and healthcare resources. Surgical therapy includes perineal or transabdominal surgery, with increasing use of minimally invasive techniques such as mesh rectopexy. This operation is indicated and feasible regardless of age. The management of the rectal prolapse in specialized pelvic floor centres with interdisciplinary expertise for diagnosis and therapy is recommended.

[Fecal incontinence]. / Anale Inkontinenz.

Fecal incontinence Abstract. Fecal incontinence may be due to various pathologies and is underreported. The prevalence among females is age dependent, ranging from 16 % in younger women and up to 40 % in elderly women. Given this wide range, it is suspected there may be a high rate of undetected and / or underreported cases. The most common aetiology is pelvic floor disorders which is the focus of this article. First-line therapy for pelvic floor disorders is conservative, and may include professionally guided pelvic floor exercises supported by biofeedback training, dietary adjustments, fiber supplementation, and constipating agents. If this fails, additional treatment options include sacral nerve modulation which offers an effective, minimally invasive therapy for patients with insufficient improvement after conservative therapy.

Single-Incision and Natural Orifice Translumenal Endoscopic Surgery in Switzerland.

BACKGROUND: Single-incision laparoscopy (SIL) and natural orifice translumenal endoscopic surgery (NOTES) aim at reducing surgical access trauma. To monitor the introduction of emerging technologies, the Swiss Association for Laparo- and Thoracoscopic Surgeons launched a database in 2010. The current status of SIL and NOTES in Switzerland is reported, and the techniques are compared. METHODS: The number and type of procedures, surgeon experience, their impressions of performance, conversion, and complications between 2010 and 2015 are described. A survey was used to acquire additional data not included in the registry. RESULTS: Nine centers included 650 procedures. Cholecystectomy (55 %) and sigmoidectomy (26 %) were most prevalent in both techniques. The number of active centers declined from 9 to 2 during the study period. The frequencies of taught procedures were 4 and 43 % for SIL and NOTES (p < 0.001), and surgeon self-estimated impression of performance was perfect in 50 and 89 %, respectively (p < 0.0001). Conversions in total were 3.6 and 5.7 %, respectively, and 1.1 % to open for both techniques. Morbidity was 5 % in SIL and 2.7 % in NOTES, with 0.8 % access-related complications in NOTES and none in SIL (p = 0.29). Of laparoscopic cholecystectomy, sigmoidectomy, and right hemicolectomy, 11.4 and 15.6 % of cases were operated using SIL or NOTES, respectively (p < 0.0001). CONCLUSIONS: Although in selected specialized centers, a considerable proportion of patients were treated using novel techniques, a fading interest of the surgical community in SIL and NOTES was observed. The proportion of SIL and NOTES procedures taught is insufficient and calls for improvement.

Efficacy and Safety of Combined Ultrasonic and Bipolar Energy Source in Laparoscopic Surgery.

AIM: Energy devices represent an alternative to clips and staplers for vessel sealing. Outcome data of patients undergoing laparoscopic surgery with use of a novel combined ultrasonic and bipolar energy device (TB, Thunderbeat™) was gathered. METHODS: Consecutive patients undergoing laparoscopic surgery using TB were prospectively included between November 2011 and January 2016. Large vessels were dissected using the energy device without additional clips or staplers. The type of procedure, operative time, length of stay, complications, blood transfusions, number and type of vessels being dissected, and need for additional clips were noted. RESULTS: Six hundred eighty-three patients underwent 758 procedures with dissection of 1310 large vessels. No additional hemoclips or vascular staplers were used. There were 0.7 % (5/758) intraoperative and 2.6 % (20/758) postoperative bleeding complications. Eleven bleeding occurred at the stapler line of anastomosis, leaving 1.8 % (14/758) bleeding that were potentially related to inadequate hemostasis. Failure of large vessel dissection occurred in two cases (0.15 %, 2/1310) and device-related complications in 1.1 % (8/758). Two of 42 conversions (5.5 %) were bleeding-related. CONCLUSION: TB provides a reliable and effective hemostasis. However, ligation failure may occur. As with any kind of electrosurgery, the hot tip of the instruments bears the risk of potentially fatal thermal injuries.

[Scarless surgery: a vision becoming reality?]. / Narbenfreie Chirurgie: Wird eine Vision Realität? Viszeralchirurgie über natürliche Körperöffnungen.

As minimal invasive abdominal surgery became established in the last decades, further minimization of the surgical access is in the focus now. Although laparoscopic instruments and camera systems become diminished in size there is still a need for a minilaparotomy for extraction and anastomosis of organs. NOTES (Natural orifice transluminal endoscopic surgery) aims to avoid this minilaparotomy. Consequently, laparoscopic-assisted procedures become pure laparoscopic surgery. The transvaginal access is the most common performed NOTES procedure. The acceptance in women is high. The feasibility of NOTES cholecystectomy is scientifically proofed. The procedure is associated with less pain than the common four-port laparoscopic surgery and does not interfere with the sexual well-being. There are no access-related infections; the abdominal wound infection and incisional hernia rate are low. In left sided colonic resection the transrectal access makes NOTES available for both genders.

Anorectal Function and Quality of Life after Transrectal Rigid-Hybrid Natural Orifice Translumenal Endoscopic Sigmoidectomy.

BACKGROUND: In transrectal rigid-hybrid natural orifice translumenal endoscopic sigmoidectomy (trNS), extraction-site laparotomy is avoided, which reduces postoperative pain and improves recovery time. However, current research evaluating anorectal function after trNS is limited. This study aims to evaluate clinical continence, anorectal manometry, and quality of life in patients undergoing trNS for diverticular disease. STUDY DESIGN: Between November 2013 and October 2015, patients undergoing trNS for diverticular disease were prospectively included. Patients converted to laparoscopic resection with an extraction-site laparotomy before attempted transrectal access were excluded. Anorectal manometry, including measurement of resting pressure, squeeze pressure, and retention tests; and questionnaires on continence, defecation, quality of life, and cosmesis, were obtained before and at 3 and 6 months after surgery. RESULTS: Twenty-five patients were enrolled in the study. Four were converted and 1 was lost to follow-up, leaving 20 patients included in the study. Mean anal resting pressure before surgery was 59.3 mmHg (95% CI, 51.81-66.79 mmHg), decreasing to 48.85 mmHg (95% CI, 43.75-53.95 mmHg) at 3 months (p = 0.015). It normalized to 53.45 mmHg (95% CI, 47.78-59.12 mmHg) at 6 months (p = 0.168). Maximum anal squeeze pressure, retention tests, and St Marks incontinence score remained unchanged during the follow-up. Gastrointestinal Quality of Life Index remained high before (124 points) and at 6 months after surgery (128.8 points; p = 0.544). CONCLUSIONS: Six months after trNS, neither clinical continence nor manometric findings deteriorated. Quality of life after trNS for recurrent diverticulitis is excellent. Long-term implications of a temporary decline in resting pressure after 3 months remain unclear and warrant long-term follow-up.

Transrectal Rigid-Hybrid Natural Orifice Translumenal Endoscopic Sigmoidectomy for Diverticular Disease: A Prospective Cohort Study.

BACKGROUND: Our goal was to evaluate the feasibility of transrectal rigid hybrid natural orifice translumenal endoscopic surgery (NOTES) sigmoidectomy (trNS) in a series of consecutive prospective patients with diverticular disease. The NOTES for left colectomy offers patients reduced pain and easier recovery. Limited data are available for trNS, which is considered safe for various indications. However, the technique is not standardized, and patients in the reported series are highly selected. STUDY DESIGN: Patients scheduled for trNS were entered into a prospective registry on an intention-to-treat basis. The primary endpoint was trNS feasibility, and secondary endpoints were morbidity, pain, length of stay, and inflammatory response. A medial-to-lateral dissection with full mobilization of the splenic flexure and total intracorporeal anastomosis was performed. The rectum was covered with a wound protector for transrectal extraction. RESULTS: Of 95 elective sigmoidectomies, 81% (n = 77) were enrolled for either transvaginal NOTES resection (n = 37) or trNS (n = 40). There was no difference in body mass index or indication between patients undergoing laparoscopic-assisted sigmoidectomy (LAS), transvaginal resection, or trNS, although trNS patients were younger. Mainly because of a mismatch of bulky specimen and narrow pelvis, 17.5% of trNS were converted to LAS. Major morbidity was 10%, including 2 septic complications. During the study, the anastomosis technique was changed from double stapled end-to-end to side-to-end anastomosis. CONCLUSIONS: Transrectal rigid hybrid natural orifice translumenal endoscopic sigmoidectomy is feasible and safe in a high proportion of unselected consecutive patients with diverticular disease undergoing elective treatment. Intracorporeal side-to-end anastomosis is the preferred technique, and trNS should be offered for elective sigmoidectomy presupposing advanced laparoscopic experience.

Total inverse transgastric resection with transoral specimen removal.

BACKGROUND: Laparoscopic local excision is accepted for gastrointestinal stromal tumors (GIST) and benign lesions of the stomach. Yet, tumors at the gastroesophageal junction, on the posterior wall, or in the distal antrum are difficult to approach. Such tumors often must be exposed via gastrotomy or using a rendezvous maneuver. Our method of total intragastric laparoscopic resection using 'pneumogastrum', rigid laparoscope, and conventional laparoscopic instruments is described in an intuitive video. METHODS: Two cases of total inverse transgastric resection involved resection of a submucosal GIST, one at the front wall of the cardia and the other on the posterior wall of the antrum. The third case required excision of a large prepyloric cystic lesion leading to a gastric outlet stenosis. After insertion of three trocars under laparoscopic control, a further trocar was introduced into the stomach and 'pneumogastrum' was established. Two additional 5-mm trocars were intragastrally placed. Intragastric endoscopy with a rigid optic provided an excellent view. The tumor was exposed resected with a linear stapler. The specimen was inserted into an Endo Pouch™ which was sutured to an orally inserted gastric tube. The Endo Pouch™ was gently pulled transorally. After removal of the intragastric trocars, the entrance points were laparoscopically closed. RESULTS: From the first and second cases, we retrieved GIST tumors. In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful. CONCLUSIONS: Gastric GIST should be resected laparoscopically if negative margins are safely achieved regardless of its size. Tumors at the frontwall and exophytic backwall GIST are addressed by laparoscopic wedge resection. Tumors at the gastrojejunal junction, in the prepyloric region, and fundus as well as submucous GIST of the gastric backwall are best approached by intragastric laparoscopic resection. Transoral specimen retrieval is an interesting option in smaller tumors.

The transvaginal hybrid NOTES versus conventionally assisted laparoscopic sigmoid resection for diverticular disease (TRANSVERSAL) trial: study protocol for a randomized controlled trial.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is the consequence of further development of minimally invasive surgery to reduce abdominal incisions and surgical trauma. The potential benefits are expected to be less postoperative pain, faster convalescence, and reduced risk for incisional hernias and wound infections compared to conventional methods. Recent clinical studies have demonstrated the feasibility and safety of transvaginal NOTES, and transvaginal access is currently the most frequent clinically applied route for NOTES procedures. However, despite increasing clinical application, no firm clinical evidence is available for objective assessment of the potential benefits and risks of transvaginal NOTES compared to the current surgical standard. METHODS: The TRANSVERSAL trial is designed as a randomized controlled trial to compare transvaginal hybrid NOTES and laparoscopic-assisted sigmoid resection. Female patients referred to elective sigmoid resection due to complicated or reoccurring diverticulitis of the sigmoid colon are considered eligible. The primary endpoint will be pain intensity during mobilization 24 hours postoperatively as measured by the blinded patient and blinded assessor on a visual analogue scale (VAS). Secondary outcomes include daily pain intensity and analgesic use, patient mobility, intraoperative complications, morbidity, length of stay, quality of life, and sexual function. Follow-up visits are scheduled 3, 12, and 36 months after surgery. A total sample size of 58 patients was determined for the analysis of the primary endpoint. The confirmatory analysis will be performed based on the intention-to-treat (ITT) principle. DISCUSSION: The TRANSVERSAL trial is the first study to compare transvaginal hybrid NOTES and conventionally assisted laparoscopic surgery for colonic resection in a randomized controlled setting. The results of the TRANSVERSAL trial will allow objective assessment of the potential benefits and risks of NOTES compared to the current surgical standard for sigmoid resection. TRIAL REGISTRATION: The trial protocol was registered in the German Clinical Trials Register ( DRKS00005995) on March 27, 2014.

Routine cholangiography during rigid-hybrid transvaginal natural orifice transluminal endoscopic cholecystectomy.

BACKGROUND: Transvaginal rigid-hybrid transluminal endoscopic cholecystectomy (tvCCE) has become a routine procedure in some laparoscopic departments in recent years. Although intraoperative cholangiography is an important adjunct to cholecystectomy, its feasibility and safety in tvCCE have not been demonstrated to date. METHODS: Patients undergoing tvCCE between April and October 2012 were included in this study. An intraoperative cholangiogram was obtained routinely for all the patients. Patient characteristics, operation data, feasibility, and duration of the cholangiography as well as the postoperative course were recorded prospectively. RESULTS: For 32 (97 %) of the 33 patients enrolled in this study, intraoperative cholangiography could be performed successfully. The median duration of cholangiography was 6 min (interquartile range, 4-7 min). Common bile duct stones were detected in three patients (10 %). Laparoscopic bile duct revision with the aid of one additional port was successful in two of these patients. One patient needed postoperative endoscopic retrograde cholangiopancreatography due to the impossibility of extracting an impacted prepapillary concrement. One operation was converted to a four-port laparoscopic cholecystectomy. One additional port was used in 11 patients (33 %) and two additional ports in three patients (9 %). Three intraoperative minor complications (9 %) and one postoperative minor complication (3 %) occurred. CONCLUSIONS: Intraoperative cholangiography during tvCCE is feasible, safe, and easy to perform. The need for intraoperative cholangiography no longer represents a contraindication for tvCCE.