Background The EURO-NOTES Clinical Registry (ECR) was established as a European database to allow the monitoring and safe introduction of Natural Orifice Transluminal Endoscopic Surgery (NOTES). The aim of this study was to analyze different techniques applied and relative results during the first 2 years of the ECR.

Einleitung: Die transanale endoskopische Mikrochirurgie (TEM) ist für die Behandlung rektaler Tumore ein etabliertes Verfahren. Durch das Instrumentarium kann lokal unter kontrollierten Bedingungen präzise präpariert werden. Diese Arbeit soll die Machbarkeit der transanalen Sigmaresektion mittels modifiziertem TEM-Instrumentarium zeigen.

BACKGROUND:Interest in natural orifice transluminal endoscopic surgery (NOTES) has expanded, and the first experiences with patients using different techniques have been reported. However, no work has addressed the learning process or the limitations of the procedures. The relation between inexperience and complications became a major concern after the introduction of laparoscopic surgery. This study investigates the learning process for a new technique using specially designed instruments in an ex vivo model before clinical application.METHODS:Specially designed instruments and a single-port technique using the Tuebingen Trainer were used to evaluate instrument and surgeon performance (learning curve) in terms of time and errors. A total of 90 procedures performed by three surgeons were evaluated. Group and individual learning curves were plotted.RESULTS:All the surgeons showed a reduction in both mean cholecystectomy time (subject A: 27.2 vs 16.6 min; subject B: 21.4 vs 19.22 min; subject C: 21 vs 19.7 min) and mean errors (subject A: 2.8 vs 1.6; subject B: 3.5 vs 2.6; subject C: 3.5 vs 2). A plateau was reached after approximately 15 procedures. Group learning curve analysis showed a significant reduction in time between the first group (mean, 24.97 +/- 5.8 min) and last group (mean, 19.30 +/- 3.09 min; F[1,28] = 11.83; p = 0.001) for 15 procedures, as well as reduced technical errors in the fifth group, from 3.7 +/- 1.65 to 1.6 +/- 1.04 (F[1,28] = 8.90; p < 0.01), demonstrating a learning effect. The number of optic and access port position changes were recorded, setting a standard for normal instrument performance.CONCLUSION:This study shows that the tasks of cholecystectomy can be learned safely in a reasonable number of simulations with the new instruments. Although this is a new technique, prior laparoscopic surgery experience is helpful. The technique offers an advantage over those using flexible endoscopes.

BACKGROUND:The Radius Surgical System (RSS) is a manipulator with additional degrees of freedom to enhance the dexterity of laparoscopic suturing. Our aim was to determine the feasibility and potentially added value of laparoscopic intracorporal sutured colorectal anastomosis (RSS) compared with suturing with conventional laparoscopic instruments (CLI).METHODS:A total of 72 colorectal anastomoses and 30 single sutures using RSS and CLI were performed in the study. The experiment was divided as follows: One surgeon performed 40 colorectal anastomoses using RSS to assess the learning curve and the feasibility of the technique; The same surgeon performed 10 additional colorectal anastomoses with CLI which were then compared to the last 10 cases of the 40 anastomoses with RSS; Fifteen single sutures in the horizontal plane with RSS and 15 with CLI between two segments of colon were performed to compare the traction force to disrupt the suture; Twelve anastomoses were performed by the other three participants to evaluate ergonomy.RESULTS:Three leakages (7.5%) were found in the 40 anastomoses with RSS but none after the eighth case. There was no stenosis. The mean time for the anastomoses once the learning curve was achieved was 32.7 min. After 21 anastomoses with RSS there was no improvement in the operating time. The quality of the suture was superior with RSS, with a larger anastomosis diameter, higher bursting pressure, and fewer suturing failures being found. The RSS suture withstood a higher traction force. The participants showed more discomfort suturing with CLI.CONCLUSION:This study demonstrated the feasibility of laparoscopic colorectal anastomosis using RSS. Anastomosis with RSS was shown to be safer. The three participants evaluating ergonomy reflected less discomfort in hand/wrist using RSS. Others ergonomic problems were comparable to CLI.

Intermittent jaundice and recurrent colicky upper abdominal pain in two patients, aged 46 and 48 years, were found by endoscopy to be due to an adenoma of the papilla of Vater. Transduodenal local excision with papilloplasty made both patients free of symptoms.

Die Transanale Endoskopische Mikrochirurgie (TEM) hat sich seit ihrer klinischen Einführung 1983 durch Buess zu einem Standardinstrument der minimal-invasiven, transluminalen Enddarm-Chirurgie in der Behandlung von Präkanzerosen, aber auch von Frühkarzinomen entwickelt. Die onkologische Sicherheit dieser lokalen, schonenden Therapieform wurde für die Patientengruppe mit pT1-low risk-Rektumkarzinom nachgewiesen; Langzeitergebnisse der TEM in Kombination mit einer Radiochemotherapie für lokal fortgeschrittenere Tumoren werden derzeit im Rahmen von Studien überprüft.

Die Technik der Transanalen Endoskopischen Mikrochirurgie (TEM) stand im Jahr 1983 erstmalig für den klinischen Einsatz zur Verfügung. Diese Technik ist bis heute das einzige Ein-Port-System in der endoskopischen Chirurgie, wo über einen direkten endoluminalen Zugang das Zielorgan auf einem natürlichen Weg erreicht wird. Der hier routinemäßige praktizierte Einsatz einer Stereooptik ist ebenfalls einzigartig.

Robotic technology has recently been introduced to gastrointestinal laparoscopic surgery. We prospectively evaluated early results of robotic surgery using the Da Vinci system in our department. Data were prospectively collected in 40 patients who underwent robotic surgery during a 1-year period. We performed 3 cholecystectomies, 10 anterior fundoplications for gastroesophageal reflux disease, 17 transperitoneal adrenalectomies, 2 Heller myotomies, 5 procedures for rectal prolapse, and 3 colpohysteropexies for genital prolapse. The results for robotic adrenalectomies and anterior fundoplications were compared with the results from patients who underwent these procedures laparoscopically without robotic assistance at our department during the same period. We encountered two conversions to laparotomy (5%) and one conversion to standard laparoscopy (2.5%). There was no morbidity imputable to the robotic approach and no deaths. The mean operative times were significantly longer in robotic groups compared with laparoscopic groups for adrenalectomies and fundoplications. The Da Vinci robotic system enables surgeons to perform advanced laparoscopic procedures with ease, safety, and precision. We believe that preferable indications for using this system are to perform surgery in narrow spaces (pelvic surgery) or when precise dissection is mandatory (Heller myotomy).

BACKGROUND:Ergonomics in laparoscopic surgery is an unsolved problem. Deficiencies of the instrument handles are well-known and described in several reports and studies. Today, virtual training modules for laparoscopic surgery are available. The aim of this study was to evaluate the ability of a virtual reality (VR) simulator to determine the ergonomic properties of two different laparoscopic instrument handles.METHODS:Two different types of handles, a ring and an axial handle from Richard Wolf, were used to perform the short clip and cut task of the Xitact 500 LS simulator. The task was repeated every 2 days for a period of 5 weeks. After every trial the volunteers were asked structured questions about their preferences while using the two handles.RESULTS:The axial handle was superior or equal to the ring handle in all criteria. Learning curves over the entire time and day by day were similar. No differences were found for travel distances and error rates, but task times were different for both handles. The subjects preferred the axial handle at the end of the study.CONCLUSION:It is possible to determine differences in ergonomics of handle design with a VR trainer. In this study, the Richard Wolf axial handle was superior to the ring handle.

One of the key problems in laparoscopy is the correct positioning of the monitor. In this study we tested task performance and muscle-strain of subjects in relation to monitor-position during laparoscopic surgery. 18 subjects simulated laparoscopic suturing. This was repeated in three monitor positions (15 minutes each) frontal at eye level (A), frontal in height of the operating field (B) and 45° to the right side at eye level (C). No head movements were allowed during a single session. In a fourth measurement the subjects were allowed to move the head and to look at any monitor. After the test they were asked for their preferred monitor position. During all tests the electromyographic (EMG) activity of six main neck muscles was recorded and the number of pearls was counted. The EMG activity was significantly (p<0.05) lower for position A compared to position B or C. No significant difference was found between the positions B and C. The number of threaded pearls as an indicator for task performance was highest for position B. The difference was statistically significant compared to position C but not between positions A and C or A and B. Asked for the preferred monitor position 9 subjects chose two monitors in the frontal positions A and B. No subject preferred the monitor at the side (C). Regarding EMG data the monitor positioned frontal at eye level is preferable. Reflecting personal preferences of subjects and task performance it should be of advantage to place two monitors for the surgeon: one in position A for lowest neck strain, and the other one in position B for difficult tasks with optimal task performance. The monitor position at the side is not advisable.

Background With the spread of minimally invasive surgery and training in this field, development of metrics for skills assessment and training progress has become increasingly important. Our approach was to use the tracking of motion for the definition of objectives metrics. Methods We have developed an inanimate model and tracked the 3D coordinates of the instrument tips with an ultrasound system. Besides already validated parameters (time, error time, and distance efficiency ratio) we examined the transit and the speed profile for their evidentiary power. Performances of experts (who have already performed >100 laparoscopic operations) and novices (<20 laparoscopic operations) were evaluated. Result The standardized time, the error time as a precision indicator, and the transit profile parameter for spatial perception could significantly ( p < 0.05) distinguish between experts and novices. Furthermore, these parameters and the distance efficiency ratio improved significantly during a training course in laparoscopic surgery. Conclusion Our model showed changes of the mentioned parameters with experience. According to our results, it can be used for skills assessment and as a training progress measurement system. We propose transit profile as an additional important parameter for assessment.

Sowohl Blutungen als auch Perforation im GI-Trakt stellen Notfallindikationen bei der flexiblen Endoskopie dar. Die zur Verfügung stehenden Methoden für die endoskopische Therapie sind durch die? Größe des Arbeitskanals beschränkt. Mit dem neu entwickelten OTSC- („over-the-scope“) Clipsystem (Ovesco Endoscopy GmbH, Tübingen) steht eine neue Therapiemöglichkeit zur Verfügung, die bei starken Blutungen sowie Perforationen des GI-Traktes endoskopisch einsetzbar ist.

Background: Even though the safety and efficacy of sutured anastomosis have been proved in open surgery, laparoscopic sutured anastomosis is rarely performed because it is difficult and time-consuming. We aim at description of a standardized technique for laparoscopic sutured anastomosis of the bowel and definition of its learning curve. Methods: Fifty-six laparoscopic sutured anastomoses of cow small intestine were performed in a laparoscopic simulator. In a survival animal trial, 10 end-to-end, 2 gastrojejunostomy, 2 cholecystojejunostomy, 2 colocolic, and one side-to-side anastomoses were performed, using the same technique. Results: In the survival cases, we had no leaks or obstruction, minimal adhesions, and only one stenotic gastrojejunostomy. The mean end-to-end anastomotic time was 50 min. The technique was suitable for most sites in the GIT. The learning phase required 40 anastomoses in the simulator. Conclusions: The described technique seems relatively fast, safe, and universal, and it needs about 40 anastomoses to be mastered.

BACKGROUND Intraoperative graft patency verification is of major clinical importance for quality control after coronary artery bypass grafting (CABG), especially if surgery is performed on the beating heart. This is one of the first reports of fluorescence coronary angiography (FCA) using the dye indocyanine green (ICG), a noninvasive technology for direct visualization of coronary arteries, bypass grafts, and myocardial perfusion. METHODS Twenty-three domestic pigs (weight, 45-72 kg) underwent FCA of the left anterior descending coronary artery (LAD). In the first group (n = 6 pigs), FCA was used to visualize the native coronary vessels and myocardial perfusion. In the second group (n = 8 pigs), 14 stenoses of various degrees and 4 total vessel occlusions were created by snares on different segments of the LAD, and FCA was used to visualize the effects of these obstructions. In the third group (n = 9 pigs), a coronary bypass procedure on the beating heart was performed by a left internal mammary artery or a human saphenous vein graft to the LAD, and FCA was used to visualize graft patency. Three pigs were removed from the study because of ventricular fibrillation. ICG was intravenously applied, and the heart was illuminated with near-infrared light emitted by laser diodes. The fluorescence emission was detected by an adapted charge-coupled device camera system. The images were displayed in real time on a high-resolution monitor. Subsequently, images obtained with FCA were compared to those obtained with coronary angiography (n = 10 pigs). RESULTS In all cases, high-quality FCA images of coronary arteries and myocardial perfusion were obtained. All stenoses resulted in an impairment of the myocardial perfusion visualized by FCA. Occlusion of the LAD or the diagonal branch resulted in a total perfusion defect of the corresponding anterior myocardial wall with immediate reperfusion after releasing the snare. In 5 cases a patent bypass graft with an apparent homogenous perfusion of the corresponding myocardium was detectable. In one procedure, FCA images indicated total occlusion of the bypass graft and a total perfusion deficit in the distal LAD region. Correlation between FCA and coronary angiography in detection of stenoses and graft patency was excellent. CONCLUSION With the fluorescence technique using ICG, visualization of blood flow in coronary vessels and bypass grafts, as well as of myocardial perfusion, is feasible. FCA is a highly sensitive and reproducible method and an excellent technique for intraoperative quality control in CABG.

When we analyze the tasks in surgical disciplines, dissection is a major part of the surgical procedure, usually followed by reconstruction or tissue fusion. In conventional surgery, dissection of the mesenterial vessels of the hollow organs is performed by the use of clamps and ligatures. When performing dissection of the mesentery with this technique, the tissue layers are bluntly dissected and small gaps for double clamping are created. This procedure always leads to minor oozing because small vessels are torn apart when creating the necessary gaps. When laparoscopic surgery for major resections was started it was clear that the technique of using clamps could not be transformed to this new surgical technique. Therefore the development of new dissection tools was started. All these tools apply energy to the tissue, thus heating the tissue, and, with the use of combined functions of the instrument, the tissue is cut at the end of the coagulation. Three different technologies are demonstrated in the technological and clinical papers of this section. Today, ultrasound technology is the standard dissection technique in endoscopic surgery. Mechanical energy is transformed into thermal energy, and the surface of the instrument acts first as a sealing tool, and, after sealing, as a cutting tool. The disposable ultrasonic instruments create a significant problem due to considerable costs, when applied in all laparoscopic or endoscopic procedures. The aspect of cost reduction is a significant argument for the development of reusable systems as described in the respective papers. Two other technologies are now competing with ultrasound in haemostatic dissection. LigaSure(tm) is a more refined bipolar technology and is based on longlasting experience in bipolar coagulation. Controlled heating has also been applied for decades, but new technologies allow much faster and safer application, as the results of the new instruments demonstrate. I see a clear potential for the new technologies because, in contrast to ultrasonic dissection, they allow a clear separation of the coagulation and the cutting mode, which means that connective tissue containing small vessels can be cut after short coagulation; in addition, unintentional heating of the adjacent tissue can be prevented using these technologies, which might add to future reduction of complications. Saline-enhanced coagulation of bleeding surfaces is a new technique which allows the combination of coagulation and compression, which is important for effective haemostasis. At the same time, saline can prevent the glueing effect of the electrode to the tissue, which is contraproductive for haemostasis. A new standardized technology for selective dissection of tissue with different properties is today possible with the use of water-jet dissection. This is not a haemostatic technique, but allows the removal of loose tissue parts, often fatty or mucosal parts, whereas the tissues containing higher amounts of connective tissue, such as vessels and nerves, are preserved. They are visualized after water-jet dissection and selectively cut or preserved following visualization. In summary, the new dissection technologies have proven that today, dissection can be performed more selectively, more safely, and with a minimum of blood loss. The new technologies, mostly developed for the application in endoscopic surgery, are already on their way to also allow better dissection in open surgery.

Intraoperative graft patency verification is of major clinical importance for quality control after coronary artery bypass grafting (CABG). The purpose of this study was the assessment of graft patency and stenosis of variable severity by fluorescence angiography (FA) using indocyanine green (ICG). In this study 32 domestic pigs (40 – 70 kg) were examined by FA technique. ICG induced fluorescence imaging was performed on the native coronary vessels (n = 6) and stenoses (n = 8) of the left anterior descending coronary artery (LAD). In 18 pigs CABG was performed using left internal mammary artery or vein graft to LAD on the beating heart. Artificial obstructions of LAD or bypass anastomoses at various grade were created. FA was compared to coronary angiography (CA) and transit time flowmeter (TTFM) after each intervention. In all cases coronary flow and flow reduction could be determined by FA and correlated highly to TTFM values. Additionally, FA could measure myocardial perfusion and functional impairment of coronary bypass during graded stenosis, determined by the reduction of myocardial fluorescence. FA and CA identified the different stenoses as well as total occlusion of the LAD and the bypass anastomosis in all cases. FA can determine the degree of blood flow reduction in ischemic vs. normal myocardium during graded coronary and bypass stenoses. The method is highly sensitive and reproducible and an excellent technique for intraoperative quality control in CABG.

"MITAT - Current state and future perspectives." Minimally Invasive Therapy & Allied Technologies, 11(5-6), p. 211