Endoscopic suture fixation of gastrointestinal stents: proof of biomechanical principles and early clinical experience.

Background And Study Aims: Gastrointestinal stents have become an important therapeutic option for several indications. However, migration in up to 40 % of cases represents a significant drawback, especially when covered prostheses are used. We hypothesized that a novel endoscopic suturing device could enable endoluminal stent fixation, which might increase attachment and thereby potentially reduce migration.

Quantifying mental workloads of surgeons performing natural orifice transluminal endoscopic surgery (NOTES) procedures.

Background: During natural orifice transluminal endoscopic surgery (NOTES), surgeons often have difficulties orienting the surgical view and manipulating instruments accurately, which increases their level of mental and physical fatigue. This study quantified mental workload by measuring the spared mental resources of surgeons performing NOTES training tasks.

Methods: Assessment of mental workload was conducted in both a benchtop and a hybrid animal model.

A novel technique for natural orifice endoscopic full-thickness colon wall resection: an experimental pilot study.

Background: Natural orifice endoscopic full-thickness colon resection attempts to overcome the need for invasive surgery in selected colorectal indications. Because basic technical requirements have not been met so far, the aim of this study was to develop a novel technique for endolumenal colon-wedge resection addressing current shortcomings.

Study Design: Endoscopic full-thickness colon resection was attempted in a human cadaver model (n = 2), explanted porcine colon stumps (n = 10), and 3 acute pig models.

A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy.

Background: A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP).

Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needleknife dissection.

Background: Zenker's diverticulum (ZD) is the most common diverticulum of the upper gastrointestinal tract. Various flexible endoscopic techniques have been used for division of the septum. However, the learning curve associated with these techniques might be difficult to overcome given the overall rarity of this condition.

A triangulating operating platform enhances bimanual performance and reduces surgical workload in single-incision laparoscopy.

Background: Single-site laparoscopy (SSL) attempts to further reduce the surgical impact of minimally invasive surgery. However, crossed instruments and the proximity of the endoscope to the operating instruments placed through one single site leads to inevitable instrument or trocar collision. We hypothesized that a novel, single-port, triangulating surgical platform (SPSP) might enhance performance by improving bimanual coordination and decreasing the surgeon's mental workload.

Transcervical heller myotomy using flexible endoscopy.

Introduction: Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy.

Mediastinal surgery in connective tissue tunnels using flexible endoscopy.

Background: Mediastinal surgery most often is performed via a transthoracic or transabdominal approach; however, the pre- and paratracheal mediastinum can be readily accessed with a transcervical approach. The purpose of this study was to evaluate the feasibility, safety, and success rate of using a transcervical approach and flexible endoscopes to perform mediastinal surgery also in the retro- and paraesophageal mediastinum.

Methods: Mediastinal operations on four live pigs and one human cadaver were performed using standard endoscopes through a small cervical incision.

A comparison of early learning curves for complex bimanual coordination with open, laparoscopic, and flexible endoscopic instrumentation.

Background: This study takes an initial step towards understanding the learning process of flexible endoscopic surgery. Bimanual coordination learning curves were contrasted between three different surgical paradigms. We hypothesized that use of an open or laparoscopic paradigm would result in better performance and a shorter learning process (reaching a learning plateau earlier) than an endoscopic paradigm.

Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos).

Background: Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight.

Video: natural orifice translumenal endoscopic surgery (NOTES): creation of a gastric valve for safe and effective transgastric surgery in humans.

Introduction: NOTES has become a clinical reality. There remain, however, many challenges that need to be addressed in order to refine the technique. One of the most feared potential complications of transgastric surgery is a leak from the port of entry into the peritoneum.

Measuring mental workload during the performance of advanced laparoscopic tasks.

Introduction: Mental workload is a finite resource and is increased while learning new tasks and performing complex tasks. Measurement of a surgeon's mental workload may therefore be an indication of expertise. We hypothesized that surgeons who were expert at laparoscopic suturing would have more spare mental resources to perform a secondary task, compared with surgeons who had just started to learn suturing.

Bimanual coordination in natural orifice transluminal endoscopic surgery: comparing the conventional dual-channel endoscope, the R-Scope, and a novel direct-drive system.

Background: The devices used for natural orifice transluminal endoscopic surgery procedures are endoscopes or inspired by endoscopic design, which makes it difficult to accomplish bimanual coordination.

Objective: We evaluated 3 operating systems in simulated natural orifice transluminal endoscopic surgery procedures requiring complex bimanual coordination.

Design: Operators were required to perform an identical bimanual task by using 3 operating systems: a dual-channel endoscope (DCE); the R-Scope, which has 2 elevators for independent movement of endoscopic instruments; and the Direct Drive Endoscopic System (DDES), which allows separation of instruments and vision, emulating more of a laparoscopic surgery paradigm.

The trade-off between flexibility and maneuverability: task performance with articulating laparoscopic instruments.

Background: Laparoscopic instruments are rigid and thus cannot provide the degrees of freedom (DOF) needed by a surgeon in certain situations. A new generation of laparoscopic instruments with the ability to articulate their end effectors is available. Although these instruments offer the flexibility needed to perform complex tasks in a constricted surgical site, their control may be hampered by their increased complexity.

Surgical time independently affected by surgical team size.

Background: Team size and composition provide essential data for the study of operating room (OR) efficiency.

Methods: Laparoscopic procedures between July 2005 and July 2007 were reviewed retrospectively to record the number of OR personnel and the procedure time (PT).

Results: Of 399 procedures reviewed, 360 cases with complete data were analyzed.

A quantitative study of disruption in the operating room during laparoscopic antireflux surgery.

Background: Many activities performed by team members in the operating room (OR) are not directly related to the achievement of the surgical goal.

Methods: A video-aided observational field study was conducted in the OR to examine disruptive events during laparoscopic antireflux surgery. Disruptive events were categorized into one of six groups: instrument change, surgeon position change, nurse duty shift, conversation, phone/pager answering, and extraneous interruption.

Verbal communication improves laparoscopic team performance.

The impact of verbal communication on laparoscopic team performance was examined. A total of 24 dyad teams, comprised of residents, medical students, and office staff, underwent 2 team tasks using a previously validated bench model. Twelve teams (feedback groups) received instant verbal instruction and feedback on their performance from an instructor which was compared with 12 teams (control groups) with minimal or no verbal feedback.

Building an efficient surgical team using a bench model simulation: construct validity of the Legacy Inanimate System for Endoscopic Team Training (LISETT).

Background: Complex laparoscopic tasks require collaboration of surgeons as a surgical team. Conventionally, surgical teams are formed shortly before the start of the surgery, and team skills are built during the surgery. There is a need to establish a training simulation to improve surgical team skills without jeopardizing the safety of surgery.