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Dallemagne B, Perretta S, Marescaux J. Education and e-training in NOTES. Epublication: WeBSurg.com, Mar 2009;9(3). URL: http://www.eats.fr/doi-ed01en0022.htm

B Dallemagne (France), S Perretta (France), J Marescaux (France)

IRCAD / EITS, Hôpitaux Universitaires de Strasbourg, France


When a new surgical concept is established, it usually raises many questions about its usefulness, appropriatness, applicability and future. The development of minimally invasive surgery is a typical example. Every surgeon remembers the discussions and how the surgical community would take a stand, sometimes fiercely, during the description of the very first procedures performed with approaches that went against the key surgical principles, the most famous one being “great surgeon, great incisions”.

Laparoscopic cholecystectomy was the first tremor to shake the surgical community. Disparaged in 1987, it was considered a « gold standard » in 2002. However, its official recognition had not helped in avoiding a prohibitive complication rate, with the reported rate of biliary wounds being around 2 to 15 times superior to that of open surgery1, 2. The incidence of complications very clearly depended on the surgeon’s experience and these would have a major impact not only on the patient, but on the medicolegal aspects of surgery3. These events stimulated the surgical community into redefining the way a new technique should be developed and propagated, and showed them the necessity of developing new methods for education and training. Incorporating these methods into the traditional educational system and training already established surgeons inspired various initiatives. Multiple and varying teaching methods of these new techniques were then offered. The most common change was to bring back surgical training to the animal laboratory, as the first step to learning these new techniques. Studies showed that training on animal models helped to overcome the hurdles laid out by surgery in a new environment4-6. The gradual implementation of the skills acquired in the laboratory would then allow a more secure clinical application of the surgical procedures learnt.

The second initiative was to utilise the revolution that had occurred to media through the use of the Internet. Indeed, this revolution rendered information and eductional resources accessible to more people; the traditional barriers that are borders and continents no longer applied. The conjunction of this new way of communication and of the technical characteristics of laparoscopic surgery, i.e. using video recorded images to perform an operation, has provided significant educational material that some centers rapidly included in their educational programmes7. The ability and potential of a training center combining a virtual university and an institute for training in surgery has been sufficiently demonstrated by a number of institutes, such as the IRCAD-EITS in France. Since the building of this institute in 1994, more than 90 000 surgeons have followed hands-on training courses and/or have registered to online training via the website WeBSurg.com. An assessment conducted in 2007 revealed that 82 % of students considered that this combination was the most efficient educational scheme to date.

Are we at the dawn of a new surgical revolution with the emergence of surgical procedures performed via natural orifices, commonly referred to as NOTES? Even if the application of NOTES remains rare in clinical settings, should all the training means available be sollicited for education in this field? Should we anticipate concerns similar to when laparoscopic cholecystectomy was introduced? NOTES is different to laparoscopy in the way that it engages two medical groups: the gastro-enterologists and the surgeons. Which messages, what training should be offered to the one or to the other? Who should practise NOTES?

The sheer amount of questions is fascinating and this era of concern can be closely assimilated to the anarchical beginnings of laparoscopic surgery.

Two American scientific societies, the SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) and the ASGE (American Society for Gastrointestinal Endoscopy), responded very quickly by elaborating recommendations for experimental development and the clinical application of NOTES8. The IRCAD-EITS in Strasbourg has, since the beginning of 2007, enabled its educational capabilities by offering training programmes in NOTES combining theory and hands-on practice and has communicated on the experimental evolution of the concept on the Internet. An evaluation of the expectations and perspectives of the training course participants revealed that 50 % of them considered NOTES as the next surgical revolution and that it could potentially be applied clinically in the next 2 to 10 years. In the first year of its establishment, the dedicated website (http://www.eats.fr) created under the aegis of the European Association for Transluminal Surgery (EATS) had 1700 registered members and more than 85 000 visits. The gastro-enterologists are less convinced that NOTES has potential, perhaps they are more reserved, or perhaps not inclined to train with surgeons, or maybe even not very prone to see surgeons train with flexible endoscopes, as they only represent 20 % of the 400 participants at the hands-on courses.

The amount of support gathered by these varied educational methods is certainly a unique situation: potential operators wish to get information and train on a technique that is still just a concept. However, this demonstrates the willingness of physicians when it comes to acquiring skills that would allow them to integrate easily in an innovating and promising area of surgery. This response shows that the lessons arising from the introduction of laparoscopic cholecystectomy have been learned, and corroborates the educational and training decisions made by the specialised centers.

References

  1. Bernard HR, Hartman TW. Complications after laparoscopic cholecystectomy. Am J Surg 1993;165:533-5.
  2. Gouma DJ, Go PM. Bile duct injury during laparoscopic and conventional cholecystectomy. J Am Coll Surg 1994;178:229-33.
  3. Carroll BJ, Birth M, Phillips EH. Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc 1998;12:310-3.
  4. Mori T, Hatano N, Maruyama S, Atomi Y. Significance of "hands-on training" in laparoscopic surgery. Surg Endosc 1998;12:256-60.
  5. Olinger A, Pistorius G, Lindemann W, Vollmar B, Hildebrandt U, Menger MD. Effectiveness of a hands-on training course for laparoscopic spine surgery in a porcine model. Surg Endosc 1999;13:118-22.
  6. Scheeres DE, Mellinger JD, Brasser BA, Davis AT. Animate advanced laparoscopic courses improve resident operative performance. Am J Surg 2004;188:157-60.
  7. Mutter D, Rubino F, Temporal MS, Marescaux J. Surgical education and Internet-based simulation: The World Virtual University. Minimally Invasive Therapy and Allied Technologies 2005;14:267-74.
  8. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005. Gastrointest Endosc 2006;63:199-203.









Dallemagne B, Perretta S, Marescaux J. NOTES, TUES, TULA, NOTUS, .... Epublication: WeBSurg.com, Jan 2008;8(1). URL: http://www.eats.fr/doi-ed01en0019.htm

B Dallemagne (France), S Perretta (France), J Marescaux (France)

IRCAD / EITS, Hôpitaux Universitaires de Strasbourg, France



When Antony Kalloo presented his experience in transgastric surgery in 2004, he could not imagine that he and NOTES would be at the epicentre of a revolution in laparoscopic surgery.

When ASGE and SAGES created a working group to develop transluminal surgery, while some did think that NOTES would improve conventional flexible endoscopy, none of the leaders sensed that this idea would have some repercussion on laparoscopic surgery.

The initial idea behind NOTES was that of an incisionless surgery, which would de facto eliminate scars accessing the peritoneal cavity via natural orifices. This implies the use of controlled procedures that breech the lumen of a healthy hollow viscus such as the stomach, the colon, the vagina or the urinary bladder.

The first intellectual challenge begins here. How can we possibly conceive an evolution when this will be drenched with unsolved potential problems and complications?

Research has to focus on finding the best way of accessing the peritoneal cavity, on the development of leak-proof closure methods and on minimizing the potential risks related to contamination.

While secure closure of gastric or colonic incisions are critical and difficult, the experience of gynecologists performing transvaginal procedures has demonstrated the safety of this route: infection rate is 0.001%, rectal injury is 0.002%, localized bleeding is 0.2%1,2. This compares favourably with the risks related to the use of trocars in laparoscopic surgery: 0.03-0.3% of visceral and vascular injuries, 0.7-1.8% of incisional hernia3-6.

This is the reason why the first clinical application of NOTES, cholecystectomy, was performed through the transvaginal route7. The idea behind this was to create a model for NOTES, avoiding the drawbacks of new entry sites, thus allowing for an objective evaluation of the potentials of this concept.

But this approach, per se, has limitations. In addition, time is needed to develop technologies that would facilitate the procedure and to study the consequences of the breach of a hollow viscus of the GI tract.

This matter has forced us, laparoscopic surgeons, to think.

Studies have shown that postoperative pain is decreased when fewer and smaller trocars are used8.
Laparoscopic cholecystectomy with micro-instruments confirmed these findings9.
Nevertheless, this technique did not become as popular and as widespread as one would have imagined. This is mainly due to the technical challenge related to the size and lack of stability of micro-instrumentation.

Therefore, surgeons needed to rethink this and look for other solutions.
How can we possibly reduce the number of trocars, how can we improve the cosmesis in laparoscopic surgery?
How can we perform a procedure that needs several instruments and therefore multiple ports, when aiming at reducing the number of ports?

Several options are available: decrease the number of instruments, gather ports in the same incision, use multiple instruments through the same port or use an operative scope through a single port.

In the nineties, the first descriptions of cholecystectomy techniques performed through an approach that allowed to reduce the number of ports or gather them at the umbilicus10,11. Single-port laparoscopic appendectomies were reported12. These experiments were not known to all.
It was brought to the general attention with the advent of NOTES.

Now the embryologists started to think.

The umbilicus is a natural orifice, a well-healed natural scar that would allow access to the peritoneal cavity.
Natural Orifice Endoscopic Surgery can thus be carried out through the umbilicus. This would immediately overcome the technical and intellectual challenges related to the perforation of the lumen of a hollow viscus. Nevertheless, this embryological interpretation of a natural orifice does not exactly correspond to the sheer definition of NOTES because it requires an abdominal incision to enter the peritoneal cavity.

Several definitions have subsequently been crafted: Natural Orifice Trans Umbilical Surgery (NOTUS), Trans Umbilical Endoscopic Surgery (TUES), Trans Umbilical Laparoscopic Assisted (TULA)13-15.

What will these techniques bring?
Clearly the reduction of postoperative pain is related not only to the decrease in the number of ports, but also to the size of such ports.

What would then be the benefit of performing a cholecystectomy through a 20mm umbilical port that will obviously increase the risk of abdominal wall complications?
Would it then be possible to reduce the size of the instruments and scopes to make them suitable for a similar but smaller umbilical port?

Some have tried to answer this question using flexible scopes with operative channels and endoscopic instruments. Predictably, this attempt had the same disadvantages as described for the micro-instrumentation, namely a lack of efficacy. Major improvements are therefore needed.

What is clear however is that all this testifies renewed interest in finding a way to minimize bodily trauma. Improved cosmesis is an obvious additional psychological advantage for patients.

These techniques build a bridge between laparoscopic and transluminal surgery and the newly achieved developments. Most likely the technological developments that TUES and NOTES require will confer reciprocal benefits.

References

  1. Ghezzi F, Raio L, Mueller MD, Gyr T, Buttarelli M, Franchi M. Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc 2002; 16:1691-1696.
  2. Watrelot A. Place of transvaginal fertiloscopy in the management of tubal factor disease. Reprod Biomed Online 2007; 15:389-395.
  3. Bonjer HJ, Hazebroek EJ, Kazemier G, Giuffrida MC, Meijer WS, Lange JF. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 1997; 84:599-602.
  4. Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress needle injuries during laparoscopy. Surg Endosc 2001; 15:275-280.
  5. Teixeira F, Jin HY, Rodrigues Junior AJ. Incisional hernia at the insertion site of the laparoscopic trocar: case report and review of the literature. Rev Hosp Clin Fac Med Sao Paulo 2003; 58:219-222.
  6. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004; 139:1248-1256.
  7. Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 2007; 142:823-826.
  8. Matsuda T, Ogura K, Uchida J, Fujita I, Terachi T, Yoshida O. Smaller ports result in shorter convalescence after laparoscopic varicocelectomy. J Urol 1995; 153:1175-1177.
  9. Cheah WK, Lenzi JE, So JB, Kum CK, Goh PM. Randomized trial of needlescopic versus laparoscopic cholecystectomy. Br J Surg 2001; 88:45-47.
  10. Piskun G, Rajpal S. Transumbilical laparoscopic cholecystectomy utilizes no incisions outside the umbilicus. J Laparoendosc Adv Surg Tech A 1999; 9:361-364.
  11. Kagaya T. Laparoscopic cholecystectomy via two ports, using the "Twin-Port" system. J Hepatobiliary Pancreat Surg 2001; 8:76-80.
  12. Esposito C. One-trocar appendectomy in pediatric surgery. Surg Endosc 1998; 12:177-178.
  13. Cuesta MA, Berends F, Veenhof AA. The "invisible cholecystectomy": A transumbilical laparoscopic operation without a scar. Surg Endosc 2007.
  14. Zhu JF. Scarless endoscopic surgery: NOTES or TUES. Surg Endosc 2007; 21:1898-1899.
  15. Pappalepore N, Tursini S, Marino N, Lisi G, Lelli CP. Transumbilical laparoscopic-assisted appendectomy (TULAA): a safe and useful alternative for uncomplicated appendicitis. Eur J Pediatr Surg 2002; 12:383-386.









Marescaux J. Operation Anubis: A New Step in NOTES History!. Epublication: WeBSurg.com, Apr 2007;7(4). URL: http://www.eats.fr/doi-ed01en0018.htm

J Marescaux (France)

IRCAD / EITS - Université Louis Pasteur, Strasbourg, France


On April 2nd 2007, at the University Hospital of Strasbourg, Professor Jacques Marescaux and his team, B. Dallemagne, MD, S. Perretta, MD, D. Mutter, MD, PhD, FACS, A. Wattiez, MD, D. Coumaros, MD, successfully performed the first no scar surgery. This first human incisionless operation was carried out using a flexible endoscope for transvaginal cholecystectomy in a 30-year-old woman with symptomatic gallstones.

This world first, called "operation Anubis", was presented at the Japanese Congress of Surgery in Osaka on April 6th and during the Congress of the Society of American Gastrointestinal Endoscopic Surgery (SAGES) last week-end in Las Vegas.

Anubis was the ancient god in Egyptian mythology who restored Osiris to life through mummification using long, flexible instruments. The project was named after this reference.

Change is part of surgery and change is never easy to accept. At the dawn of surgery, excellence was associated with big incisions: "big scar - big surgeon".
In 1987, Philippe Mouret performed the first laparoscopic cholecystectomy. The Anglo-Saxon world called it the "second French revolution": minimally invasive surgery was born representing one of the greatest surgical evolutions of the 20th century.
Since its inception in 2004 geared up by A. Kalloo, MD, the idea of endoluminal surgery has been till now only experimental, except some cases of hybrid appendectomies performed by N. Reddy in India.

An important step was made by the Columbia group in New York, United States on March 20th, 2007 when a hybrid transvaginal cholecystectomy was performed with the assistance of three laparoscopic trocars (New York Times, April 20th, 2007 - San Francisco Chronicle, April 20th, 2007 - SAGES Annual Meeting, Las Vegas, April 22nd, 2007).


Operation Anubis performed without incision, save from using a 2mm needle allowing for insufflation and control of intra-abdominal pressure, represents an extremely important step towards totally non-invasive surgery. The next challenge will be to validate other approaches, the transgastric route being the most appealing.

The justification of this technique are: the reduction or absence of postoperative pain, ease of access to some organs, the absence of trauma to the abdominal wall, ideal cosmetic results and the psychological advantages of eliminating the bodily trauma represented by surgery. Lastly and as pointed out by P. Swain, this provides proof that there are no limits to how human ingenuity and technology can reduce the physical and emotional trauma related to the surgical act.

The successful performance of the operation at the University Hospital in Strasbourg, is the results of three years of research under the Anubis project, labelled by the "Therapeutic Innovation Biocluster".

This success exemplifies the healthy collaboration between different agencies: the government for initiating a dynamic biocluster, a world-renowned Research Institute (IRCAD-EITS University Louis Pasteur Strasbourg), a leader in the field of minimally invasive surgery (Karl Storz Endoscope ), and the University Hospital of Strasbourg a key element responsible for a rapid transition of research into a clinical application available to patients.

Access video footage of the intervention









Dallemagne B, Marescaux J. NOTES: another step forward!. Epublication: WeBSurg.com, Mar 2007;7(3). URL: http://www.eats.fr/doi-ed01en0017.htm

B Dallemagne (France), J Marescaux (France)

IRCAD / EITS - Université Louis Pasteur, Strasbourg, France



Since the editorial of July 2006, the field of NOTES has grown exponentially.
Change is part of surgery. The lesson learned from the advent of laparoscopic surgery is that we could now be witnessing the third surgical revolution. By nature surgeons are innovators and it seems that NOTES is here to stay.
A growing number of teams developed new surgical procedures of increasing complexity.
Without a doubt, the development of laparoscopic cholecystectomy was a phenomenon that changed the focus of surgery and the mindset of nearly all surgeons. For this reason the initial project focused on transgastric cholecystectomy which seemed to be the most logical and appealing clinical application. The results obtained in animal models ushered in the imminent human application of NOTES and opened the door to new, more complex procedures.

The interest in this new field was confirmed by a survey conducted among the 3000 surgeons who are trained every year at the IRCAD-EITS. When asked whether they would like to be trained in NOTES, 80 per cent of surgeons said they were interested, anticipating that this emerging field will become a real and valid alternative to laparoscopy over the next four years.
IRCAD has been actively involved in the development of NOTES since 2004.
The achievements of the past two years place IRCAD and Strasbourg among the world leaders in this field. This led to the organization of the first hands-on NOTES course, which will be taking place next May 4-5th.

The course objective is to educate and train gastroenterologists and surgeons who wish to become familiar with flexible endoscopy and this new surgical domain.
This world-renowned faculty will have the exciting task to educate the NOTES neophytes.
EATS
To this end the European Society for Translumenal Surgery EATS was created in December 2006. The aim of the Society is to gather minds and skills to provide recommendations, support and guidance to this new surgical era.









Anvari M, Marescaux J. Natural Orifice Transluminal Endoscopic Surgery (NOTES): The Dawn of a New Era. Epublication: WeBSurg.com, Jul 2006;6(7). URL: http://www.eats.fr/doi-ed01en0016.htm

M Anvari (Canada), J Marescaux (France)

The field of flexible endoscopy has undergone a major paradigm shift from a simple diagnostic tool to an advanced interventional and surgical tool capable of sophisticated diagnosis, and surgical therapies of gastrointestinal as well as peritoneal and thoracic structures.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is the extension of the flexible endoscope's capabilities to reach organs outside the lumen of the bowel for the purposes of diagnosis1, and treatment including resective therapies, such as appendectomy2, cholecystectomy3, or splenectomy4.

While still in the experimental phase, NOTES promises to complete the evolutionary arc from open to laparoscopic to no-scar surgery facilitating improved patient recovery and reduced need for anesthesia, pain medication and improved cosmetic results. Thus, the patient acceptance of such therapies is likely to be high and will likely drive the investment of time and effort and funds to quickly develop and deliver safe and effective NOTES procedures into the market. In the race to do so, however, it is important to ensure that we do not make the same mistakes which were observed at the dawn of the laparoscopic era with subsequent impact on its rapid uptake.
A factor which further complicates the NOTES era is the fact that it will be practiced by both surgeons and gastroenterologists who have not had common channels of information, training and oversight. The creation of a common task force between SAGES and ASGE to provide guidelines5 for safe conduct and adoption of these new therapies is a major step. Another is access to up-to-date educational material and information on new techniques being evaluated and the latest results available. To this end, WeBSurg has decided to dedicate a specific section on NOTES and other advanced endoscopic interventions. We will endeavour to bring to our readers the latest developments in the field of NOTES and provide training and educational material and videos to assist those interested in pursuing this field.

References

  1. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions. Gastrointest Endosc 60: 114-117.
  2. Rao & Reddy (2006) Transgastric appendectomy in humans. No publication; presentation at World Congress of Gastroentrology, Montreal September 2006.
  3. Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P (2005) Experimental studies of transgastric gall bladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 61: 601-606.
  4. Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SCC, Cotton PB, Gostout CJ, Hawes RJ, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN. Per-oral transgastric endoscopic splenectomy: is it possible? Surg Endosc (In press).
  5. Rattner D, Kalloo A, et al. (2006) White Paper: ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery. Surg Endosc 20:329-333.

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