Natural Orifice Endosonographic Colposuspension With Rectopexy for Combined Pelvic Organ Prolapse: A Feasibility Study.

BACKGROUND: We describe a natural orifice technique for simultaneous endoluminal lateral suspension of apical vaginal wall and rectal prolapse fixation with ultrasound and fluoroscopic assistance. IMPACT OF INNOVATION: The technique is minimally invasive, can be performed under regional anaesthesia, and avoids laparotomy or use of a mesh in addition to preserving the uterus. TECHNOLOGY MATERIALS AND METHODS: This technique involves suprapubic transvaginal ventral suture colposuspension, fixation of the anterior rectal wall to the undersurface of the anterior abdominal wall and tack fixation of the posterior rectal wall to the underlying sacral promontory through a submucosal tunnel performed endoscopically with fluoroscopic and ultrasound assistance. PRELIMINARY RESULTS: Seven patients with a mean age of 63 years were followed between 3 to 11 months. CONCLUSIONS: This is a novel minimally invasive transluminal procedure that repairs concomitant rectal and vaginal prolapse in the same sitting. FUTURE DIRECTIONS: Improvement in the instrument design and incorporation of endoluminal robotic systems will enhance the technical ease. The study needs validation in larger series of patients with longer follow-up.

Endoscopy-assisted magnetic navigation of biohybrid soft microrobots with rapid endoluminal delivery and imaging.

High-precision delivery of microrobots at the whole-body scale is of considerable importance for efforts toward targeted therapeutic intervention. However, vision-based control of microrobots, to deep and narrow spaces inside the body, remains a challenge. Here, we report a soft and resilient magnetic cell microrobot with high biocompatibility that can interface with the human body and adapt to the complex surroundings while navigating inside the body. We achieve time-efficient delivery of soft microrobots using an integrated platform called endoscopy-assisted magnetic actuation with dual imaging system (EMADIS). EMADIS enables rapid deployment across multiple organ/tissue barriers at the whole-body scale and high-precision delivery of soft and biohybrid microrobots in real time to tiny regions with depth up to meter scale through natural orifice, which are commonly inaccessible and even invisible by conventional endoscope and medical robots. The precise delivery of magnetic stem cell spheroid microrobots (MSCSMs) by the EMADIS transesophageal into the bile duct with a total distance of about 100 centimeters can be completed within 8 minutes. The integration strategy offers a full clinical imaging technique-based therapeutic/intervention system, which broadens the accessibility of hitherto hard-to-access regions, by means of soft microrobots.

Precision functional sphincter-preserving surgery (PPS) for ultralow rectal cancer: a natural orifice specimen extraction (NOSE) surgery technique.

BACKGROUND: In patients with ultralow rectal cancer, surgical resection of the tumor without impairing sphincter function remains a technical challenge. The purpose of this study was to describe a new technique of transanal natural orifice specimen extraction (NOSE) surgery using our independently developed devices, aiming to achieve precise cancer resection and preserve sphincter function in patients with ultralow rectal cancer. METHODS: Precision functional sphincter-preserving surgery (PPS) was performed on nineteen patients with ultralow rectal cancer between June 2019 and April 2020. With the help of our independently developed devices, surgeons directly and accurately removed the lower edge of the tumor and retained healthy rectal tissue on the nontumorous side. Hand-sewn anastomosis with a mattress suture was used to achieve sturdy anastomosis. Preoperative baseline characteristics, operative details, 90-day postoperative complications, costs, and anal function score at 6 months after surgery were documented. RESULTS: Nineteen ultralow rectal cancer patients with a median distance to the dentate line of 2.0 cm successfully underwent PPS without serious postoperative complications. Six out of nineteen patients (31.6%) received a prophylactic stoma. The average cost was 62164.1 yuan. At 6 months after surgery, the average Wexner anal function score and the average Vaizey score were both 3 points. CONCLUSIONS: PPS can be employed to precisely resect rectal tumors and preserve sphincter function in ultralow rectal cancer patients. The use of our devices enhanced surgical efficiency, reduced the need for prophylactic stoma, reduced surgery-related costs, and prevented abdominal surgical incisions.

The Fresh Frozen Cadaveric Study of Direct Pouch of Douglas Laparoscopic and Robotic Trocar Insertion for Vaginal Natural Orifice Transluminal Endoscopic Surgery.

STUDY OBJECTIVE: To determine the distances and angles that assure a safe entry into the pouch of Douglas (POD) during blind laparoscopic and robotic trocar entry. DESIGN: Trocars were inserted into the POD of 4 intact fresh frozen female pelves. Cadaveric dissection was performed, and the distance from the POD to the sacrum at rest and with maximal pressure to POD with the trocar was measured. In addition, the optimal angle for trocar insertion and entry was evaluated. SETTING: Inova Advanced Simulation and Technology Evaluation Center. PATIENTS: Fresh frozen cadavers with intact reproductive organs. INTERVENTIONS: Vaginal POD trocar insertion. MEASUREMENTS AND MAIN RESULTS: Measurements were recorded from the sacrum to the POD at rest and from the sacrum to the hymen with trocar pressure. The dissection demonstrated correct trocar placement in the POD of human cadaveric specimens. The mean distances from the sacrum to the hymen, the sacrum to the POD, and the sacrum to the POD with pressure were 18.75 cm, 9.75 cm, and 7.25 cm, respectively. After the deployment of the trocar, the tip was observed to be 2 cm below the cervix in the POD. The mean trocar angle to clear the sacral promontory and the neurovascular structures without injury to the uterus was 25° to 40° from the horizontal plane and 15° to 30° from the coronal plane. CONCLUSION: A direct trocar entry into the POD has been found to be feasible in fresh frozen cadaveric specimens. This study provided valuable information for the angle of entry into the POD to facilitate vaginal and robotic trocar entry for minimally invasive gynecologic procedures.

Robotic glove port technique for the endowristed rigid instruments in robotic single-site transabdominal and transvaginal surgery.

Although robotic single-site (RSS) surgery employing cross setup of semirigid instruments allows effective triangulation of instruments, it has some limitations in performing RSS transabdominal and transvaginal surgeries. We introduced the robotic glove port technique (RGPT) using parallel setup of endowristed rigid instruments in performing RSS transabdominal surgery and transvaginal surgery in July of 2017. Thirty-five patients underwent RSS surgery with RGPT. Twenty-one patients had RSS transabdominal reconstructive or fertility-preserving surgeries such as myomectomy (12 patients), adenomyomectomy (3 patients), and ovarian endometriosis cystectomy (6 patients). Fourteen patients underwent robotic transvaginal surgery for natural orifice transluminal endoscopic surgery (NOTES) hysterectomy. All procedures were successfully performed, and no postoperative complications were observed. In all patients, the median total operative time, console time, and docking time were 160 min (range 106-240), 120 min (range 65-180), and 10 min (range 4-25), respectively. There was no conversion to another type of surgery, such as conventional laparoscopy, laparotomy, or traditional multiport robotic surgery. The findings showed that RSS surgery via the RGPT is safe and feasible, using the parallel setup of endowristed rigid instruments is easily performed on transvaginal routes and transabdominal routes. Therefore, this procedure may be an important complement to gynecologic surgeons' armamentarium in the field of robotic reconstructive or fertility-preserving surgeries such as myomectomy, adenomyomectomy, ovarian cystectomy, and transvaginal surgery for NOTES hysterectomy. Nevertheless, further prospective controlled studies are needed to determine its full clinical application.

Transoral laser resection of hypopharyngeal liposarcoma.

Liposarcomas are rare malignant tumours of the connective tissue. Microscopically they resemble lipomas. They are usually found on the limbs or trunk. Fewer than 40 cases of hypopharyngeal liposarcoma have been reported in the literature. Surgical excision with a cervical or endoscopic approach has been the first-line treatment for these cases. We present a patient with the first documented primary excision via carbon dioxide laser using an entirely transoral approach. This case suggests a new standard of management but also highlights the difficulties with investigation and diagnosis in a rare presentation.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video).

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

Transoral Robotic Surgery (TORS) Versus Non-TORS Tongue Resection for Obstructive Sleep Apnea.

OBJECTIVE: To compare transoral robotic surgery (TORS) versus non-TORS tongue resection procedures performed for obstructive sleep apnea from January 2010 to September 2015 using a national database, focusing on patient characteristics, performance of concurrent procedures, operative time, length of hospital stay, and postoperative complications. METHODS: A cohort of adults undergoing TORS and non-TORS tongue resection procedures was identified in the Nationwide Inpatient Sample, a publicly-available national administrative database incorporating a stratified sample of hospital discharge records. Outcomes were annual case volumes, prolonged (≥3 days) hospital stay, and complications. Statistical analyses examined potential associations between TORS and prolonged hospital stay and complications. RESULTS: From 2010 to 2015, 5709 hospital discharges included tongue resection surgery to treat obstructive sleep apnea. There was a gradual decline and stabilization in overall volumes, with the proportion of TORS use showing an initial increase, followed by a decrease and rebound increase. TORS patients were less likely to undergo concurrent nasal surgery (15% vs. 44%, P < .01), but there was no association between the use of TORS and concurrent palatal surgery. TORS use was not associated with concurrent hypopharyngeal surgery overall, but it was associated with specific types of hypopharyngeal surgery. TORS use was associated with patient age, payor, and certain hospital characteristics. TORS use was associated with an increased risk of prolonged hospital stay (33% vs. 25%, P = .045) but was not associated with complications. CONCLUSION: This study provides insight into TORS use in tongue resection surgery for obstructive sleep apnea during this period of early TORS adoption. LEVEL OF EVIDENCE: Level 3 (cohort study). Laryngoscope, 131:E1735-E1740, 2021.

Evaluating a Prototype Nasolaryngoscopy Hood During Aerosol-Generating Procedures in Otolaryngology.

OBJECTIVE: During the COVID-19 pandemic, there has been considerable interest in identifying aerosol- and droplet-generating procedures, as well as efforts to mitigate the spread of these potentially dangerous particulates. This study evaluated the efficacy of a prototype nasolaryngoscopy hood (PNLH) during various clinical scenarios that are known to generate aerosols and droplets. STUDY DESIGN: Prospective detection of airborne aerosol generation during clinical simulation while wearing an PNLH. SETTING: Clinical examination room. METHODS: A particle counter was used to calculate the average number of 0.3-µm particles/L detected during various clinical scenarios that included sneezing, nasolaryngoscopy, sneezing during nasolaryngoscopy, and topical spray administration. Experiments were repeated to compare the PNLH versus no protection. During the sneeze experiments, additional measurements with a conventional N95 were documented. RESULTS: There was a significant increase in aerosols detected during sneezing, sneezing during nasolaryngoscopy, and spray administration, as compared with baseline when no patient barrier was used. With the PNLH in place, the level of aerosols returned to comparable baseline levels in each scenario. Of note, routine nasolaryngoscopy did not lead to a statistically significant increase in aerosols. CONCLUSION: This study demonstrated that the PNLH is a safe and effective form of protection that can be used in clinical practice to help mitigate the generation of aerosols during nasolaryngoscopy. While nasolaryngoscopy itself was not shown to produce significant aerosols, the PNLH managed to lessen the aerosol burden during sneezing episodes associated with nasolaryngoscopy.

Skull Base Dural Closure Using a Modified Nonpenetrating Clip Device via an Endoscopic Endonasal Approach: Technical Note.

Skull base reconstruction after an endoscopic endonasal approach into the cerebrospinal fluid (CSF) space is always challenging. Various reconstructive methods are available, but no standard technique is established. This report describes the endoscopic skull base dural closure using a modified nonpenetrating clip device with shaft length of 15 cm. Six patients with an intra-suprasellar or suprasellar tumor who underwent extended endoscopic endonasal transsphenoidal surgery were targeted. For closure of the skull base dural defect after tumor removal, fascia lata was first placed as an inlay graft and was subsequently fixed with the dura using a modified nonpenetrating clip device. No CSF leakage from the closed dura with an inlay fascia lata fixed with clips was confirmed by the Valsalva maneuver. To complete skull base reconstruction, fascia lata was then positioned as an overlay graft and covered with vascularized pedicled nasoseptal flaps. Five of six patients experienced no CSF rhinorrhea postoperatively. The modified nonpenetrating clip device may achieve effective dural closure in the deep and narrow nasal cavity. We introduce this clip device technique as one of the endoscopic skull base dural closure methods.

Anatomic Variations From 120 Mental Nerve Dissections: Lessons for Transoral Thyroidectomy.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a promising technique for eliminating a neck incision. A new risk of TOETVA is the potential for injury to the mental nerves during placement of three oral endoscopic ports. A better understanding of the variations in mental nerve anatomy is needed to inform safer TOETVA technique. MATERIALS AND METHODS: We performed 120 dissections of mental nerve branches exiting the mental foramen in 60 human cadavers. Anatomic distances and relationships of the foramen to the midline were evaluated. Mental nerve branching patterns were studied and compared with previously reported classification systems to determine surgical safe zones free of nerve branches. RESULTS: The mean midline-to-mental foramen distance was 29.2 ± 3.3 mm, with high variability across individuals (18.8-36.8 mm). There were differences in this distance between the left and right foramina (29.8 ± 3.2 versus 28.8 ± 3.3 mm, P = 0.03). All mental nerve branches exiting the mental foramen distributed medially. The branching patterns were classified into eight distinct categories, three of which are previously undescribed. One of these novel patterns, occurring in 9.2% of cases, had a dense and wide clustering of branches traveling toward the midline. CONCLUSIONS: The location of the mental foramen and mental nerve branching patterns demonstrate high variability. To avoid mental nerve injury in TOETVA, we identify a safe zone for lateral port placement lateral to the plane of the mental foramen. Placement and extension of the middle port incision should proceed with caution, as clustering of mental nerve branches in this area can frequently be present.

Cadaveric feasibility study of a teleoperated parallel continuum robot with variable stiffness for transoral surgery.

Robot-assisted technologies are overcoming the limitations of the current approaches for transoral surgeries, which are suffering from limited vision and workspace. As a result, we develop a novel teleoperated parallel continuum robot with variable stiffness for collision avoidance. This paper focuses on the feasibility study on a cadaveric model for the robotic system as a first trial. We introduce the configuration of the robotic system, the description of the processes of the trial, including the setting of the robotic system, the test of stiffness, and the action of the manipulation. The contact force between the manipulators with different stiffness and the surrounding tissues and a series of surgical operations of the manipulator, including grasping, cutting, pushing, and pulling tissues under the master-slave control mode, were recorded and analyzed. Experimental results suggest that the typical surgical procedure on a cadaveric model was successfully performed. Moreover, the efficacy and feasibility of the developed robotic system are verified to satisfy the requirements of transoral robotic surgery (TORS). Graphical abstract.

Transoral laser microsurgery for early glottic cancer at a tertiary hospital in Mexico City.

OBJECTIVE: The objective of the study was to analyze the results of endoscopic laser microsurgery for early glottic carcinoma treatment (Stages I and II) at a Tertiary Center in Mexico City. MATERIALS AND METHODS: Descriptive, retrospective review of 40 patients with early glottic carcinoma who were treated with endoscopic laser microsurgery with curative intent at our institution from November 2003 to December 2013. RESULTS: The study yielded 4 pTis, 19 pT1a, 8 pT1b, and 9 pT2 patients. Mean patient follow-up time was 7.4 years (range 3-12.9 years). Post-operative bleeding requiring surgical intervention occurred in 1 (2.5%) patient. Kaplan-Meier results at 3 and 5-year estimates were as follows: overall survival was 92.5 and 87%, respectively; laser only local control was 94.9 and 91.6%, respectively; and disease specific survival and ultimate local control rate were 97.5% for both time periods. We found a 97.5% (39/40) organ preservation rate. CONCLUSIONS: Laser microsurgery for glottic carcinoma treatment is an emerging technique in Mexico. Our results are promising as reported by other authors in Europe and United States of America, which support the replicability of the surgical technique refined by Dr. Wolfgang Steiner.

OBJETIVO: Analizar los resultados del tratamiento del carcinoma glótico temprano (estadios I y II) con microcirugía láser en un hospital de tercer nivel en Ciudad de México. MÉTODO: Estudio descriptivo y retrospectivo en 40 pacientes con cáncer glótico temprano tratados con microcirugía láser de noviembre de 2003 a diciembre de 2013. RESULTADOS: Se estudiaron 4 pTi, 19 pT1a, 8 pT1b y 9 pT2. El tiempo promedio de seguimiento fue de 7.4 años (rango: 3 - 12.9). Se presentó un sangrado posoperatorio con revisión quirúrgica (2.5%). Las curvas de Kaplan-Meier de estimación a 3 y 5 años mostraron una sobrevida total del 92.5 y 87%, respectivamente; control local solo con láser del 94.9 y 91.6%, respectivamente; sobrevida específica de la enfermedad y control local global del 97.5%, para ambos periodos de tiempo. El porcentaje de conservación del órgano fue del 97.5% (39/40). CONCLUSIONES: La microcirugía láser para el tratamiento del cáncer glótico temprano es una técnica que se aplica paulatinamente en México. Nuestros resultados son prometedores y equiparables a los reportados por otros autores en Europa y en los Estados Unidos de América, lo que sustenta la reproducibilidad de la técnica quirúrgica implementada por el Dr. Wolgang Steiner.

Biportal endoscopic transorbital approach: a quantitative anatomical study and clinical application.

BACKGROUND: We devised a biportal endoscopic transorbital approach (BiETOA) to gain surgical freedom by making a port for the endoscope and investigated the benefits and limitations of BiETOA. METHODS: A cylindrical port was designed and 3-D printed using biocompatible material. The port was inserted through a keyhole between the superolateral side of the orbital rim and the temporal muscle. An endoscope was inserted through the port, and other instruments were inserted through the conventional transorbital route. BiETOA was used to dissect eight cadaveric heads, and the angle of attack and surgical freedom were assessed. RESULTS: The mean maximal angle of attack was significantly different in BiETOA and endoscopic transorbital approach (ETOA) (P < 0.01) but not in BiETOA and ETOA lateral orbital rim (LOR) osteotomy (P = 0.207, P = 0.21). The mean surgical freedom was significantly different in BiETOA and ETOA (P < 0.01) and in BiETOA and ETOA LOR osteotomy (P < 0.01). In the clinical cases, tumors were removed successfully without any complications. CONCLUSIONS: BiETOA provided increased surgical freedom and better visibility of deep target lesion and resulted in good surgical and cosmetic outcomes.

Consequences of Trocar Dynamics on Mental Nerve in Transoral Thyroidectomy.

BACKGROUND: Mental nerve (MN) injuries are reported during transoral endoscopic thyroidectomy vestibular approach. Effect of trocar insertion and position on MN are examined in the present study. MATERIALS AND METHODS: Ten millimeter incision was made at the center of the lower lip oral vestibule. Two 5 mm lateral incisions of the lower lip oral vestibule were made at the junction between the incisor and the canine. These 2 lateral incisions were high, just below the edge of lower lip. Nine pigs (18 MN) were randomly divided into 3 groups and MN dissection was performed. The angle between the lateral ports and median line were changed between 15 and 45 degrees among 3 groups and effect on MN was examined. RESULTS: During dissection when insertion and other ports are in neutral position visual inspection of MNs did not reveal any compression bilaterally. The distance between MN and the ports was 18.2±2.1 mm (16.3 to 21.2 mm). In group I and group II, MNs have no compression by the lateral trocars. In group III (45 degrees), left MNs were all compressed. Two MNs (66.7%) were compressed on the right side. The MN was compressed at its ramification. CONCLUSIONS: The results of the present experimental study, endorse the suggested medial and lateral vestibular incisions for transoral endoscopic thyroidectomy vestibular approach. However, during dynamic modification of the lateral port position/angle, MN compression was observed when the angle was >45 degrees.