© Borgis - Postępy Nauk Medycznych 3/2016, s. 154-158
*Wiesław Tarnowski, Karolina Wawiernia
Co nowego w chirurgii małoinwazyjnej?
What's new in miniinvasive surgery?
Department of General, Oncologic and Digestive Tract Surgey, Centre of Postgraduate Medical Education, Warsaw
Head of Department: prof. Wiesław Tarnowski, MD, PhD
Rozwój chirurgii małoinwazyjnej przynosi nam coraz to nowe technologie i techniki operacyjne wprowadzane do codziennej praktyki klinicznej. Niewątpliwym postępem w operacjach odbytnicy jest wprowadzenie techniki „down-to-up”, czyli usuwanie odbytnicy i mezorektum przez odbyt. Wydaje się, że ta technika wprowadzi nową jakość w operacjach odbytnicy, w szczególności w guzach nisko położonych, gdzie dostęp jest trudny, a zespolenie wykonywane jest na drugim, trzecim centymetrze od zwieraczy. Zmniejsza to w istotny sposób urazowość tej operacji, jednocześnie stawia kolejne wyzwanie przed chirurgami zajmującymi się chirurgią kolorektalną. Podobnie ma się sytuacja z operacjami bariatrycznymi. Wprowadzanie do użytku klinicznego nowych endoskopów powoduje rozwój technik endoskopowych i prób leczenia endoskopowego otyłości. Technika ta wymaga ogromnej zręczności od endoskopistów i staje się ciekawą alternatywą do operacji bariatrycznych. Podobnie warte uwagi są próby zastosowania stymulatorów elektrycznych czy magnetycznego zwieracza przełyku w leczeniu choroby refluksowej przełyku. Wszystko to razem powoduje, że chirurgia minimalnie inwazyjna jest niezwykle dynamiczna i ciekawa oraz oferuje pacjentom coraz bardziej zaawansowane technologicznie rozwiązania w leczeniu chorób przewlekłych.
Progress in minimally invasive surgery brings along new technologies and operational approaches/methods to be introduced into everyday clinical practice. Introduction of a “down-to-up” method undoubtedly constitutes such progress in rectal operations. It seems that this technic will add up new quality to rectal operations, in particular in case of low located tumors with difficult access, where anastomosis is performed at the distance of two to three centimeters from sphincters. It significantly reduces operational injuries, concurrently posing challenges to colorectal surgeons. Things look similar with regard to bariatric operations. Introduction into clinical use of new endoscopes results in development of new endoscopic methods and attempts to treat obesity endoscopically. This methods requires extreme endoscopist’s skills and becomes an alternative to bariatric operations. Likewise, the attempts to use electrical stimulators or Magnetic Sphincter Augmetation in treatment of gastroesophageal reflux disease, are noteworthy. All of these things make minimally invasive surgery to be extremely dynamic and interesting and offering more and more technologically advanced solutions in treatment of chronic diseases.
Rectal surgery 2015
The “Surgical Endoscopy” included an interesting paper, entitled “Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME) – short-term outcomes in the first 20 cases" by de Lacy et al. (1). The authors summarize short-term results of the “down-to-up” modified NOTES surgery in patients with rectal cancer. Twenty patients with diagnosis of malignancy confirmed in their material histopathology were enrolled for surgery. All surgeries were carried out in the Clinical Hospital of Barcelona in 2011-2012. Preoperative radiotherapy was used in 14 patients. The following included contraindications for laparoscopic surgeries: BMI > 35 kg/m2, cT4 tumor stage, recurrence of cancer or general contraindications to create pneumoperitoneum. The surgery technique consists in creating pneumoperitoneum with the pressure of 12 mmHg in a typical manner (the authors used the Veress needle inserted through the navel), establishing trocars: 12 mm (at the site of the removed Veress needle, for a videolaparoscope) and two ports in the lower quadrants of the abdomen: 5 mm at the site of the future protectionist ileostomy and 2 mm (the site of placing the drain through the skin integument). After the initial assessment of abdominal organs (adhesions, assessment of tumor invasion), the main part of the surgery was performed, rectum dissection from the peritoneal cavity. A multiport GeoPoint Path Transanal device was established and sealed from the rectum side, through it, after carbon dioxide insufflation to a pressure of 9 mmHg, a flexible 3D (3D EndoEye 5 mm Olympus KeyMed) endoscope was passed. Transmural mesorectal dissection of the rectum (using the TME technique) was started with purse string suturing the rectal mucosa approx. 3-4 cm from the bottom margin of the tumor. In the case of colorectal tumors (i.e. the distance from the anal verge smaller than 3 cm), rectal dissection was started just above the anal sphincter muscles. The surgical technique consisted in transmural, circular rectal intersection to the avascular zone, with mesorectal collection to a preparation, as far as to the presacral fascia (at the back), then laterally towards the front, with careful maneuvering at the front (vagina, prostate) – to a complete, circular rectal mobilization. The next step was to cut the peritoneum and to reach the peritoneal cavity. Then, using laparoscopy, the rectosigmoid junction was freed, vessels were closed with clips and transected. The bowel mesentery was separated using a LigaSure knife. After the dissection, satisfactorily long enough to perform the intestine anastomosis, the transrectal port was removed. In all cases, the preparation was removed transrectally. In all cases, the proximal cleavage of the preparation was performed outside. The rectosigmoid anastomosis was performed: manually in 13 patients, using a stapler in 7 (side-to-end/end-to end) with the assistance of laparoscopic tools and visualization. The tightness of the anastomosis was confirmed with an air test. Sixteen patients underwent protective strippable Brooke ileostomy in the right mesogastrium. All patients were left with a drain in the pelvic cavity, placed through the skin integument in the left mesogastrium. The endpoint of the examination was to compare the parameters of tumor purity (TME, the distal and the circumferential margin, the number of the lymph nodes obtained for histological examination) and the surgery safety. In the results, the authors emphasize that there was no need to convert from the hybrid (laparoscopic/endoscopic) technique to a laparoscopic or open surgery. Six patients required splenic flexure. Histopathological preparations confirmed distal and circumferential margins, at least 12 lymph nodes (average 16) in 80% of patients were recovered for testing. There were no complications in 16 out of 20 patients with at least one in 4 cases: postoperative residual urine in 2 patients, postoperative ileus in 1 patient, a high degree of water and electrolyte disturbances in 1 patient, as a result of ileostomy – all of them were treated conservatively, none requires surgical intervention. During follow-up visits (15 and 30 days after the surgery), there were no other new complications. In the discussion, the authors emphasize that the proposed type of surgery significantly improves the cosmetic effects of the surgery, reduces the risk of postoperative wound infection, hernia in the scar and provides faster recovery. The proposed technique is a natural consequence of the NOTES procedures with access through the vagina (intestinal resections with the removal of even large preparations) performed by the authors.
Surgery – minimally invasive endoscopy in the treatment of obesity in 2015
The “Endoscopy” 47 (2015) issue included a paper by Lope-Nava et al. (2) on the feasibility of endoscopic gastroplasty in the treatment of obesity. The authors, in their prospective study, decided to assess the efficacy and safety of the treatment in selected patients. They emphasize that laparoscopic surgeries bypassing the gastrointestinal tract and radical sleeve gastrectomy have been considered the gold standard in the treatment of obesity, but they carry the risk of surgery and intraperitoneal access, and the changes are irreversible. Earlier studies showed that the use of endoscopic techniques for reducing the capacity of the stomach were safe, feasible and associated with changes of eating behaviors and weight loss. All of the analyzed procedures were carried out at the Madrid-Sanchinarro University Hospital. Patients with a BMI of 30 to 49 kg/m2, treated for an eating disorder for at least one year by a multidisciplinary team of physicians – nurses were included in the study. With the surgery Patients after a preliminary assessment with a gastro-camera which demonstrated potential sources of bleeding in the upper gastrointestinal tract (e.g. acute gastritis, ulcers) or preneoplastic changes, coagulation disorders, or psychological disorders were disqualified. The surgery requires a specially-designed, flexible, two-channel endoscope with an integrated suturing element (sutures were placed through the entire thickness of the wall of the stomach from the pylorus to the bottom of the stomach). Patients after the surgery were laid on the left side, under general anesthesia, with endotracheal intubation. At the beginning of the procedure, argon coagulation was performed for determining locations for sutures. Suturing started from the body of the stomach in the direction around the antrum and the fundus, from the front wall, through the greater curvature of the stomach, to the rear wall. Before the suture was finished off, approx. 3-6 sutures were placed (6-8 times towards the bottom). The aim of the procedure was to reduce the volume of the stomach with the formation of a tunnel along the lesser curve. After the procedure, endoscopic follow-up followed. Follow-up assessment of X-rays with a contrast agent soluble in water was performed: 24 hours, 3 months and 6 months post-procedure. Post-procedure recommendations included: 1-day observation of patients in the center, liquid diet from 12 hours to two weeks after the procedure, pain medications upon patients’ request. Aftercare included dietary and psychological care. Results were assessed in 1-, 3- and 6-month observations after the surgery. In the group of the 20 patients who underwent the procedure: no significant differences in the morphology of gastric contrast examination were found between day 1 after the procedure and 3 and 6 months after the procedure. There were no adverse events, apart from intra-procedure bleeding in two patients – effectively taken care of with the use of endoscopic injection. The average weight loss was 8.2 ± 2.5 kg in the first month, 13.6 ± 4.8 kg three months after the surgery and 19.3 ± 8.9 kg 6 months after the surgery, with the average BMI, respectively, initial 38.5 ± 4.8, 35.6 ± 4.7 in the first month; 33.7 ± 4.7 in the third month and 31.9 ± 4.9 kg/m2 six months after the surgery. In the discussion, the authors emphasize that there is still little reliable data on long-term follow-up. According to the authors, endoscopic gastroplasty seems to be another tool in the surgical treatment of obesity which will expand the group of patients that can be qualified for this type of treatment, specifically to be considered in patients with contraindications to surgery (prior to the creation of pneumoperitoneum), and those reluctant to undergoing more invasive surgical treatments. It is a bridge between the purely endoscopic techniques, without permanent restrictions (balloon) and surgeries.
Surgery in the gastroesophageal reflux disease 2015
In the last year, there were interesting studies supplementary to the classic treatment of the operating reflux disease – laparoscopic surgeries and comparing the conventional laparoscopy and robotic treatment. Short summaries are given below.
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1. de Lacy AM, Rattner DW, Adelsdorfer C et al.: Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME) – short-term outcomes in the first 20 cases. Surg Endosc 2013; 27: 3165-3172.
2. Lope-Nava G, Galvao MP, Bautista-Castano I et al.: Endoscopic sleeve gastroplasty for the treatment of obesity. Endoscopy 2015; 47: 449-452.
3. Rodriguez L, Rogriguez P, Gomez B et al.: Two-year results of intermittent electrical stimulation of the lower esophageal sphincter treatment of gastroesophageal reflux disease. Surg 2015; 157: 556-567.
4. Lipham JC, Taiganides PA, Louie BE et al.: Safety analysis of first 1000 patients treated with magnetic sphincter augmentation for gastroesophageal reflux disease. Dis Esophagus 2015; 28: 305-311.
5. Tolboom RC, Broeders IA, Draaisma WA: Robot-assisted laparoscopic hiatal hernia and antireflux surgery. J Sur Oncol 2015; 9999: 1-5.
6. Tam MS, Kaoutzanis C, Mullard A et al.: A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery. Surg Endosc 2016 Feb; 30(2): 455-463.
7. Hull T, Giese C, Wexner SD et al.: Long-term Durability of Sacral Nerve Stimulation Therapy for Chronic Fecal Incontinence. Dis Colon Rectum 2013; 56: 234-245.