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Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Single Port Access Surgery (SPA): Implications of new paradigms in Minimally Invasive Surgery

Abstract

Description

In recent years there has been an increasing amount of interest and focus on two new approaches in surgery, Single Port Access Surgery (SPA) and Natural Transluminal Endoscopic Surgery (NOTES). Both NOTES and SPA also have the advantage of an improvement in cosmesis It is also believed that NOTES could offer all the benefits of laparoscopic surgery with the included advantage of not requiring any abdominal wall incisions and therefore, eliminating the possibility of wound infection and incisional hernias. Other proposed benefits of SPA surgery are similar to those proposed for NOTES surgery, these being reduced post operative pain, faster recovery, and a reduced need for analgesia; at present evidence to support these suggested benefits is limited.

This reports examines the applications and challenges of both of these novel approaches to surgery and investigates the technological barriers, and some of the solutions that have been developed to overcome these barriers including access ports, camera solutions, hand instruments, multi-tasking platforms and robotic solutions.

The report also examines the future directions that minimally invasive surgery may take and the implications of this for medical device manufacturers.

Table of Contents

Executive summary

Introduction

  • Historical context and background
  • Advantages over current approaches
    • NOTES
    • SPA
  • Challenges for NOTES and SPA
    • Notes Challenges
      • Risk of infection
      • Peritoneal access
      • Visceral closure
    • SPA challenges
      • Costs
      • Operating time

Approaches and applications:

NOTES

  • Approaches
    • Transvaginal access
    • Transgastric access
    • Transcolonic / Transanal access

SPA

  • Applications
    • Cholecystecomy
    • Appendectomy
    • Paraumbilical and incisional umbilical hernia repair
    • Inguinal hernia repair
    • Experimental phase procedures:
    • Ventral hernia repair
    • Sleeve gastrectomy
    • Oophorectomy
    • Hysterectomy
    • Nephrectomy

Overview NOTES and SPA Approaches and Applications.

  • Obstacles and potential solutions
    • Obstacle - Instrument Triangulation (SPA and NOTES):
      • Solution 1 (SPA) change trocar to allow better manipulation
      • Solution 2 (SPA) use low profile trocars, reduce number of trocars,
      • Solution 3 (SPA) use specially adapted trocars
      • Solution 4 (SPA & NOTES) Articulating instruments
      • Solution 5 - (SPA & NOTES) Curved instruments
      • Solution 6 - choice of camera
      • Solution 7 - Magnetic Anchoring Guidance Systems (MAGS)
      • Solution 8 Robotic platforms
    • Obstacle - Closure of the access site NOTES
      • Solution 1 - No closure approach
      • Solution 2 - Submucosal endoscopy with mucosal flap safety valve
      • Solution 3 - Endoclips
      • Solution 4 - Endoloops
      • Solution 5 - The Queens closure
      • Solution 6 - Endoscopic suturing devices
      • Solution 7 - Occlutech Occluder
      • Solution 8 - Over the scope clip
      • Solution 9 - T-tag Tissue anchors
      • Solution 10 - RD 180
      • Solution 11 - PEG tubes
      • Solution 12 - Tri-Staple
      • Solution 13 - Tissue Glue
      • Solution 14 - Omentplasty
    • Obstacle - Peritoneal Insufflation NOTES
      • Solution 1 - laparoscopic / peritoneal insufflators Obstacle - Training NOTES & SPA
      • Solution - Euro-NOTES / NOSCAR

Technological applications and development

  • Access Ports
    • Specialised ports
      • Tri-Port & Quad-Port - Advanced Surgical Concepts /
      • Olympus
      • SILS Port - Covidien
      • Airseal System - Surgiquest
      • Octo Port - Dalim Surgnet
      • SSL Access System - Ethicon Endo Surgery
      • Gelpoint - Applied Medical
      • X-Cone / ENDOcone - Karl Storz
    • Access Ports Summary
      • Low profile trocars
      • Homemade port for SPA
  • Camera Solutions
    • Modified laparoscopes
    • EndoEYE - Olympus / Eyemax CCD Endoscope - Richard Wolf
    • Ideal Eyes HD, Stryker Magnetic camera guidance
  • Hand instruments
    • Curved instruments
    • Articulated instruments
    • Radius Surgical System - Tuebingen Scientific
    • Semi-Robotic hand instruments
    • Retractors
  • Multi-tasking platforms for NOTES/ SPA
  • Robotic solutions
    • Da Vinci Robot
    • Robotic camera manipulators
    • Miniature robots for NOTES

Future directions

SPA / NOTES:

  • Reduced Port Surgery, hybrid approach - Is this the future?
  • Strategic evaluation of market and implications for product manufacturers

Table of tables

  • Table 1: Advantages and Disadvantages - SPA and NOTES
  • Table 2: Closure of access sites: NOTES
  • Table 3: Technical applications and development a summary: specialized ports
  • Table 4: Technical applications and development a summary: other access port solutions
  • Table 5: Technical applications and development a summary: camera solutions
  • Table 6: Technical applications and development a summary: hand instruments
  • Table 7. Technological applications and developments a summary: robotic solutions

Table of figures

  • Figure 1 - Mickey mouse configuration
  • Figure 2: current procedures performed using SPA Surgery
  • Figure 3: Using three trocars for SPA
  • Figure 4: Standard rigid laparoscope
  • Figure 5: Flexible articulating laparoscope
  • Figure 6: Curved instruments
  • Figure 7: MAGS platform
  • Figure 8: TriPort - Advanced Surgical Concepts
  • Figure 9: SILS Port - Covidien
  • Figure 10: Octoport Dalim Surgnet
  • Figure 11: Gelpoint - Applied Medical
  • Figure 12: X-Cone by Karl Storz
  • Figure 13: ENDOcone by Karl Storz
  • Figure 14: Real Hand High Dexterity Instrument
  • Figure 15: Laparo-Angle Cambridge Endo
  • Figure 16: EndoGrab - Visual Ports Ltd
  • Figure 17: TransPort Multi-Lumen Operating System - USGI
  • Figure 18: In vivo imaging robot
  • Figure 19: Millennium Research Group - Projections for SPA revenue
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