NOTESNOTESNOTESNOTES

Natural Orifice Transluminal Natural Orifice Transluminal Endoscopic SurgeryEndoscopic Surgery

The next generation of The next generation of ‘Least Invasive ‘Least Invasive Surgical therapy’Surgical therapy’

Natural Orifice Transluminal Natural Orifice Transluminal Endoscopic SurgeryEndoscopic Surgery

The next generation of The next generation of ‘Least Invasive ‘Least Invasive Surgical therapy’Surgical therapy’

Dr. Onkar Singh, Dr. Shilpi Gupta,Dr. Ankur Hastir,Dr. Mohan Soni, Dr. Praveen Baghel

NOTESNOTESNOTESNOTES PERFORMING SURGICAL PERFORMING SURGICAL PROCEDURES WITHOUT PROCEDURES WITHOUT MAKING INCISIONS ON MAKING INCISIONS ON THE SURFACE OF THE THE SURFACE OF THE BODY and LEAVING NO BODY and LEAVING NO SCARSSCARS

SURGEONSSURGEONS WITHOUTWITHOUT SCALPELSCALPEL

NOTES:NOTES: DEFINITIONDEFINITIONNOTES:NOTES: DEFINITIONDEFINITION An experimental An experimental

surgical technique - surgical technique - "scarless""scarless" abdominal abdominal operations performed operations performed with an with an multi-channel multi-channel endoscopeendoscope passed passed through a natural through a natural orifice (mouth, urethra, orifice (mouth, urethra, anus, anus, vaginavagina etc.) etc.)

NOTES:NOTES:A STEP FORWARDA STEP FORWARDNOTES:NOTES:A STEP FORWARDA STEP FORWARD emerging surgical emerging surgical

approach approach

‘‘viewed as a step viewed as a step forward’forward’

utilize the utilize the body’s natural body’s natural openings.openings.

NOTESNOTESNOTESNOTES Latest craze among todays Latest craze among todays

surgeons.surgeons. Highest level of minimal Highest level of minimal

invasiveness.invasiveness. Can be ‘Future of Surgery’ Can be ‘Future of Surgery’

-Minimal invasive surgery-Minimal invasive surgery

-Least invasive surgery-Least invasive surgery

NOTES:NOTES: HISTORYHISTORYNOTES:NOTES: HISTORYHISTORY That endoscopy can be used That endoscopy can be used

to do procedures beyond the to do procedures beyond the wall of the GIT was known wall of the GIT was known since since 1980 when the first 1980 when the first transluminal feeding transluminal feeding gastrostomygastrostomy was described by was described by GaudererGauderer et al.et al.

NOTES:NOTES: HISTORYHISTORYNOTES:NOTES: HISTORYHISTORY Kozarek et al.Kozarek et al. reported first of reported first of

successful endoscopic drainage of successful endoscopic drainage of pancreatic pseudocyst in 1985.pancreatic pseudocyst in 1985.

The first report of oral The first report of oral peritoneoscopy done in animals peritoneoscopy done in animals was published by was published by Kalloo et al.Kalloo et al. in in 2004.2004.

NOTES:NOTES: HISTORYHISTORYNOTES:NOTES: HISTORYHISTORY

In September 2007,In September 2007,

NovareNovare announced announced

the successfulthe successful

completion of the firstcompletion of the first

NOTES gallbladder removal (TV) NOTES gallbladder removal (TV) procedures.procedures.

NOTES: NOTES: HISTORYHISTORYNOTES: NOTES: HISTORYHISTORY

•In March 2008, In March 2008, Dr Ricardo Dr Ricardo Zorron,Zorron, of Brazil, performed of Brazil, performed the first the first seriesseries of NOTES of NOTES cholecystectomy on four cholecystectomy on four patients via transvaginal patients via transvaginal route.route.

NOTES:NOTES: IN INDIAIN INDIANOTES:NOTES: IN INDIAIN INDIA

transgastric appendectomytransgastric appendectomy in in humans in humans in IndiaIndia By By Dr. G V RaoDr. G V Rao and and Dr. N ReddyDr. N Reddy. (. (Hyderabad, India)Hyderabad, India)

NOTES:NOTES: IN INDIAIN INDIA Famous bollywood actress Famous bollywood actress

‘Shilpa Shetty’‘Shilpa Shetty’ and and

south Indian actress south Indian actress ‘Khusboo’‘Khusboo’ have recently undergone have recently undergone transgastric appendicectomy.transgastric appendicectomy.

NOTES:NOTES: HISTORYHISTORYNOTES:NOTES: HISTORYHISTORY

Since thenSince then, multiple investigators , multiple investigators have used transluminal have used transluminal endoscopyendoscopy

in animal models to perform in animal models to perform various intraperitoneal surgical various intraperitoneal surgical procedures, ranging procedures, ranging from tubal from tubal ligation to splenectomy.ligation to splenectomy.

NOTES:NOTES: THE IDEA THE IDEANOTES:NOTES: THE IDEA THE IDEA Idea of NOTES-developed in response Idea of NOTES-developed in response

to facts that to facts that patients would-patients would-

1) 1) realize the benefitsrealize the benefits of this least of this least invasive technique of surgery.invasive technique of surgery.

2) experience 2) experience less physical discomfortless physical discomfort than traditional procedures.than traditional procedures.

3) have 3) have virtually no visiblevirtually no visible scarring scarring following this type of surgery. following this type of surgery.

NOTES:NOTES: THE IDEA THE IDEANOTES:NOTES: THE IDEA THE IDEA When given an option - no scars - When given an option - no scars -

not only for cosmetic reasons, but not only for cosmetic reasons, but because scarsbecause scarsindicate treatmentindicate treatmentbecause of illness.because of illness.

NOTES, with its NOTES, with its general idea to general idea to

minimizing the traumaminimizing the trauma..

NOTES:NOTES: THE CONCEPT THE CONCEPTNOTES:NOTES: THE CONCEPT THE CONCEPT Gain access to surgicalGain access to surgical

field thro’ a naturalfield thro’ a natural

orifices—AVOIDINNG—orifices—AVOIDINNG—

external incision…external incision…

Through the NOTESThrough the NOTES

many surgeries couldmany surgeries could

eventually become outpatient procedures, eventually become outpatient procedures, patients might even be able to return topatients might even be able to return toa a normal routine immediately.normal routine immediately.

NOTES:NOTES: THE CONCEPT THE CONCEPTNOTES:NOTES: THE CONCEPT THE CONCEPT By avoiding incisions on the abdominal By avoiding incisions on the abdominal

wall, wall, risks of infection,risks of infection, painpain and and disabilitydisability will be minimized will be minimized and and

recovery eitherrecovery either

shortened orshortened or

eliminatedeliminated..

NOTES:NOTES: THE CONCEPT THE CONCEPTNOTES:NOTES: THE CONCEPT THE CONCEPT

NOTES - NOTES - safe and feasiblesafe and feasible

- same - same efficacyefficacy

as traditional laparoscopic as traditional laparoscopic procedures.procedures.

NOTES:NOTES: INSTRUMENTSINSTRUMENTS

NOTES:NOTES: INSTRUMENTSINSTRUMENTS

NOTES:NOTES: INSTRUMENTSINSTRUMENTS

NOTES:NOTES: INSTRUMENTSINSTRUMENTS

NOTESNOTES Result of activeResult of active cooperation cooperation

between minimally invasive between minimally invasive surgeons and interventional surgeons and interventional gastroenterologists.gastroenterologists.

NOTESNOTESNOTESNOTES

Internal incision is over Internal incision is over stomachstomach, , vagina, bladder or colon,vagina, bladder or colon, thus thus completely avoiding any external completely avoiding any external incisions or scars.incisions or scars.

INTERNAL INCISIONINTERNAL INCISION

NOTESNOTESNOTESNOTES Continued evolution of flexible Continued evolution of flexible

endoscopy endoscopy ++ Growing awareness Growing awareness about invasiveness of surgery having about invasiveness of surgery having impact on patient outcomesimpact on patient outcomes

Lead toLead to

Endoscopy and Surgery - working Endoscopy and Surgery - working

together as together as NOTESNOTES

NOTES:NOTES: ROUTESROUTESNOTES:NOTES: ROUTESROUTES NOTES has beenNOTES has been

mostly practisedmostly practised

on animals, for diagnosison animals, for diagnosis

and treatments, includingand treatments, including

transgastrictransgastric organ organ

removal.removal.

NOTES:NOTES: ROUTES ROUTES

DEMONSTRATINGDEMONSTRATING

TRANSGASTRIC TRANSGASTRIC ROUTEROUTE

DEMONSTRATINGDEMONSTRATING

TRANSGASTRIC TRANSGASTRIC ROUTEROUTE

DEMONSTRATINGDEMONSTRATING

TRANSVAGINAL TRANSVAGINAL ROUTEROUTE

NOTES:NOTES: ROUTESROUTESNOTES:NOTES: ROUTESROUTES Acc. To some Acc. To some transvesicaltransvesical and and

transcolonictranscolonic approaches- more suited to approaches- more suited to access upper abdominal structures, access upper abdominal structures, which are often more difficult to work which are often more difficult to work with if using a transgastric approach.with if using a transgastric approach.

NOTES:NOTES: ROUTES ROUTESNOTES:NOTES: ROUTES ROUTES TransvaginalTransvaginal access appears to access appears to

be the safest and most be the safest and most feasible.feasible.

potentially less complications, potentially less complications, but but only possible in women.only possible in women.

PROCEDURES DESCRIBEDPROCEDURES DESCRIBEDTILL NOWTILL NOW

PROCEDURES DESCRIBEDPROCEDURES DESCRIBEDTILL NOWTILL NOW

Laboratory reportsLaboratory reports

Cholecystectomy, Splenectomy,Cholecystectomy, Splenectomy,

Tubal ligation, Tubal ligation, GastrojejunostomyGastrojejunostomy,,

Pyloroplasty,Pyloroplasty,

Staging peritoneoscopy, Liver biopsy,Staging peritoneoscopy, Liver biopsy,

Distal pancreatectomyDistal pancreatectomy,,

Ventral hernia repair,Ventral hernia repair,

Gastric sleeve resectionGastric sleeve resection,,

Colectomy (right and left)Colectomy (right and left)

PROCEDURES DESCRIBEDPROCEDURES DESCRIBEDTILL NOWTILL NOW

PROCEDURES DESCRIBEDPROCEDURES DESCRIBEDTILL NOWTILL NOW

Human casesHuman cases

TG- appendectomy,TG- appendectomy,

TV- cholecystectomy,TV- cholecystectomy,

TG- cholecystectomy,TG- cholecystectomy,

TG- gastro-enterostomy,TG- gastro-enterostomy,

Cancer staging.Cancer staging.

FIRST FIRST ‘NOTES’‘NOTES’

(TRANS-VAGINAL)(TRANS-VAGINAL)

CHOLECYSTECTOMYCHOLECYSTECTOMY

FIRST FIRST ‘NOTES’‘NOTES’

(TRANS-VAGINAL)(TRANS-VAGINAL)

CHOLECYSTECTOMYCHOLECYSTECTOMY

NOTES:NOTES: THE EASE THE EASENOTES:NOTES: THE EASE THE EASE

NOTES:NOTES: THE EASE THE EASENOTES:NOTES: THE EASE THE EASE Improving surgical procedure Improving surgical procedure

outcomesoutcomes..

Improving patient Improving patient recoveryrecovery time. time.

Improving the time frame in which Improving the time frame in which hospitals dischargehospitals discharge patients. patients.

NOTES:NOTES: THE EASE THE EASENOTES:NOTES: THE EASE THE EASE Reducing hospital Reducing hospital bed occupancybed occupancy

rates.rates.

Reducing patient trauma.Reducing patient trauma.

Many procedures may become OPD Many procedures may become OPD procedures.procedures.

NOTES:NOTES: ADVANTAGES ADVANTAGESNOTES:NOTES: ADVANTAGES ADVANTAGES Wound infection- Wound infection- 2%-25% in 2%-25% in

laparoscopic Slaparoscopic SXX - thus--> tremendous - thus--> tremendous adverse impact on patient recovery and adverse impact on patient recovery and health care costs.health care costs.

Eliminating all skin incisions would Eliminating all skin incisions would completely eliminate this risk.completely eliminate this risk.

NOTES:NOTES: ADVANTAGES ADVANTAGESNOTES:NOTES: ADVANTAGES ADVANTAGES Incisional herniasIncisional hernias -- correlate with the correlate with the

size of incisions.size of incisions.

IncidenceIncidence

4%–18% with open surgery, and4%–18% with open surgery, and

0.2%–3% with laparoscopic S0.2%–3% with laparoscopic SXX

will be eliminated with NOTES. will be eliminated with NOTES.

NOTES:NOTES: ADVANTAGES ADVANTAGESNOTES:NOTES: ADVANTAGES ADVANTAGES

Small-bowel obstruction-Small-bowel obstruction-

Incidence due to P/O adhesionsIncidence due to P/O adhesions

7.7%- open surgery7.7%- open surgery

3.3%- laparoscopic surgery3.3%- laparoscopic surgery

will perhaps be further ed with will perhaps be further ed with

NOTES.NOTES.

NOTES:NOTES: ADVANTAGES ADVANTAGESNOTES:NOTES: ADVANTAGES ADVANTAGES Other potential benefits:Other potential benefits:

Decreased PO painDecreased PO pain

-Less need for PO analgesia,-Less need for PO analgesia,

-Shorter hospital stay, and-Shorter hospital stay, and

-Faster recovery.-Faster recovery.

Thus a Thus a major cost major cost savings.savings.

NOTES:NOTES: ADVANTAGES ADVANTAGESNOTES:NOTES: ADVANTAGES ADVANTAGES In specific sub-populations:In specific sub-populations:

-Easy alternative access to the -Easy alternative access to the peritoneal cavity in peritoneal cavity in morbidly obesemorbidly obese patients, andpatients, and

Could possibly reduce the lifetime risk Could possibly reduce the lifetime risk of incision-related complications in of incision-related complications in children.children.

MODIFICATION OF MODIFICATION OF NOTESNOTES

FOR OBESITYFOR OBESITY

MODIFICATION OF MODIFICATION OF NOTESNOTES

FOR OBESITYFOR OBESITY

NOTES:NOTES:Current ChallengeCurrent ChallengeNOTES:NOTES:Current ChallengeCurrent Challenge

Change is part of Change is part of surgery but it is surgery but it is never easy to never easy to accept.accept.

NOTES:NOTES:Current ChallengeCurrent Challenge At the dawn of surgery, excellence of At the dawn of surgery, excellence of

a surgeon was associated with big a surgeon was associated with big incisions:incisions:

"Big scar, big surgeon”"Big scar, big surgeon”..

NOTES:NOTES:Current ChallengeCurrent ChallengeNOTES:NOTES:Current ChallengeCurrent Challenge 1882- open chole1882- open chole

1985- first laparoscopic chole-- strongly 1985- first laparoscopic chole-- strongly criticized.criticized.

1992- lap chole- declared t1992- lap chole- declared tmtmt of choice of choice for GB-stones.for GB-stones.

NOTES:NOTES:Current ChallengeCurrent ChallengeNOTES:NOTES:Current ChallengeCurrent Challenge But now with NOTES moving one But now with NOTES moving one

step further: philosophy of surgery step further: philosophy of surgery will be dramatically changed, as will be dramatically changed, as surgical trauma & associated pain - surgical trauma & associated pain - physical barrier for surgery.physical barrier for surgery.

NOTES:NOTES:Current ChallengeCurrent ChallengeNOTES:NOTES:Current ChallengeCurrent Challenge NOTES will breakNOTES will break

this barrier of surgicalthis barrier of surgical

trauma and pain, thustrauma and pain, thus

representing an epicalrepresenting an epical

evolution in surgery. evolution in surgery.

NOTES:NOTES:Current StatusCurrent StatusNOTES:NOTES:Current StatusCurrent Status Initially Initially -lack of Training / Practice-lack of Training / Practice

-Not well versed with the -Not well versed with the equipment.equipment.

-Time consuming-Time consuming

-Need of multidisciplinary team, -Need of multidisciplinary team, for possible complicationsfor possible complications

NOTESNOTESNOTESNOTES

witnessing a true remarkable shift in witnessing a true remarkable shift in

their lifetime i.e. their lifetime i.e. NNatural atural OOrifice rifice TTransluminal ransluminal EEndoscopic ndoscopic SSurgery (urgery (NOTESNOTES). ).