Endoscopy 2010; 42(12): 1096-1103
DOI: 10.1055/s-0030-1255824
Original article

© Georg Thieme Verlag KG Stuttgart · New York

The role of a computed tomography-based image registered navigation system for natural orifice transluminal endoscopic surgery: a comparative study in a porcine model

G.  Fernández-Esparrach1 , R.  San José Estépar2 , C.  Guarner-Argente1 , G.  Martínez-Pallí3 , R.  Navarro3 , C.  Rodríguez de Miguel1 , H.  Córdova1 , C.  C.  Thompson4 , A.  M.  Lacy5 , L.  Donoso6 , J.  R.  Ayuso-Colella6 , A.  Ginès1 , M.  Pellisé1 , J.  Llach1 , K.  G.  Vosburgh2 , 7
  • 1Endoscopy Unit, Department of Gastroenterology, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
  • 2Department of Radiology, Brigham and Women’s Hospital, Boston, USA
  • 3Anesthesiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
  • 4Division of Gastroenterology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  • 5Department of Surgery, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
  • 6Department of Radiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
  • 7Center for Integration of Medicine and Innovative Technology, USA
Further Information

Publication History

submitted 24 December 2010

accepted after revision 19 July 2010

Publication Date:
19 October 2010 (online)

Background and study aims: Most natural orifice transluminal endoscopic surgery (NOTES) procedures have been performed in animal models through the anterior stomach wall, but this approach does not provide efficient access to all anatomic areas of interest. Moreover, injury of the adjacent structures has been reported when using a blind access. The aim of the current study was to assess the utility of a CT-based (CT: computed tomography) image registered navigation system in identifying safe gastrointestinal access sites for NOTES and identifying intraperitoneal structures.

Methods: A total of 30 access procedures were performed in 30 pigs: anterior gastric wall (n = 10), posterior gastric wall (n = 10), and anterior rectal wall (n = 10). Of these, 15 procedures used image registered guidance (IR-NOTES) and 15 procedures used a blind access (NOTES only). Timed abdominal exploration was performed with identification of 11 organs. The location of the endoscopic tip was tracked using an electromagnetic tracking system and was recorded for each case. Necropsy was performed immediately after the procedure. The primary outcome was the rate of complications; secondary outcome variables were number of organs identified and kinematic measurements.

Results: A total of 30 animals weighting a mean (± SD) of 30.2 ± 6.8 kg were included in the study. The incision point was correctly placed in 11 out of 15 animals in each group (73.3 %). The mean peritoneoscopy time and the number of properly identified organs were equivalent in the two groups. There were eight minor complications (26.7 %), two (13.3 %) in the IR-NOTES group and six (40.0 %) in the NOTES only group (P = n. s.). Characteristics of the endoscope tip path showed a statistically significant improvement in trajectory smoothness of motion for all organs in the IR-NOTES group.

Conclusion: The image registered system appears to be feasible in NOTES procedures and results from this study suggest that image registered guidance might be useful for supporting navigation with an increased smoothness of motion.

References

  • 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
  • 2 Kantsevoy S V, Jagannath S B, Niiyama H. et al . Endoscopic gastrojejunostomy with survival in a porcine model.  Gastrointest Endosc. 2005;  62 287-292
  • 3 Park P O, Bergstrom M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis.  Gastrointest Endosc. 2005;  61 601-606
  • 4 Wagh M S, Merrifield B F, Thompson C C. Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model.  Clin Gastroenterol Hepatol. 2005;  3 892-896
  • 5 Wagh M S, Merrifield B F, Thompson C C. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model.  Gastrointest Endosc. 2006;  63 473-478
  • 6 Pai R D, Fong D G, Bundga M E. et al . Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video).  Gastrointest Endosc. 2006;  64 428-434
  • 7 Fong D G, Pai R D, Thompson C C. Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model.  Gastrointest Endosc. 2007;  65 312-318
  • 8 Lacy A M, Delgado S, Rojas O A. et al . Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient.  Surg Endosc. 2009;  23 1130-1137
  • 9 Lacy A M, Delgado S, Rojas O A. et al . MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human.  Surg Endosc. 2008;  22 1717-1723
  • 10 Dallemagne B, Perretta S, Allemann P. et al . Transgastric hybrid cholecystectomy.  Br J Surg. 2009;  96 1162-1166
  • 11 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery . White Paper October 2005.  Surg Endosc. 2006;  20 329-333
  • 12 Voermans R P, van Berge Henegouwen M I, Bemelman W A. et al . Feasibility of transgastric and transcolonic natural orifice transluminal endoscopic surgery peritoneoscopy combined with intraperitoneal EUS.  Gastrointest Endosc. 2009;  69 e61-67
  • 13 Wilhelm D, Meining A, Delius S von. et al . An innovative, safe and sterile sigmoid access (ISSA) for NOTES.  Endoscopy. 2007;  39 401-406
  • 14 Fritscher-Ravens A, Patel K, Ghanbari A. et al . Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures.  Endoscopy. 2007;  39 870-875
  • 15 Fritscher-Ravens A, Ghanbari A, Cuming T. et al . Comparative study of NOTES alone vs. EUS-guided NOTES procedures.  Endoscopy. 2008;  40 925-930
  • 16 Elmunzer B J, Schomisch S J, Trunzo J A. et al . EUS in localizing safe alternate access sites for natural orifice transluminal endoscopic surgery: initial experience in a porcine model.  Gastrointest Endosc. 2009;  69 108-114
  • 17 Vosburgh K G, Stylopoulos N, Thompson C C. et al .Novel real time tracking interface improves the use of laparoscopic and endoscopic ultrasound in the abdomen. Computer Assisted Radiology and Surgery (CARS). Presented at: CARS/ISCAS, June 26 – July 3, 2006, Osaka, Japan. 
  • 18 Vosburgh K G, Stylopoulos N, San José Estépar R. et al . EUS with CT improves efficiency and structure identification over conventional EUS.  Gastrointest Endosc. 2007;  65 866-870
  • 19 San José Estépar R, Stylopoulos N, Ellis R E. et al . Towards scarless surgery: an endoscopic-ultrasound navigation system for transgastric access procedures.  Comput Aided Surg. 2007;  12 311-324
  • 20 Vosburgh K G, San José Estépar R. Natural orifice transluminal endoscopic surgery (NOTES): an opportunity for augmented reality guidance.  Stud Health Technol Inform. 2007;  125 485-490
  • 21 Besl P J, McKay H D. A method for registration of 3-D shapes.  IEEE Transactions on pattern analysis and machine intelligence. 1992;  12 239-256
  • 22 Stylopoulos N, Vosburgh K G. Assessing technical skill in surgery and endoscopy: a set of metrics and an algorithm (C-PASS) to assess skills in surgical and endoscopic procedures.  Surg Innov. 2007;  14 113-121
  • 23 Ellsmere J, Stoll J, Wells 3rd W. et al . A new visualization technique for laparoscopic ultrasonography.  Surgery. 2004;  136 84-92
  • 24 San Jose Estepar R, Stylopoulos N, Ellis R E. et al . Towards scarless surgery: an endoscopic ultrasound navigation system for transgastric access procedures.  Med Image Comput Assist Interv. 2006;  9 (Pt 1) 445-453
  • 25 Voermans R P, Sheppard B, van Berge Henegouwen M I. et al . Comparison of transgastric NOTES and laparoscopic peritoneoscopy for detection of peritoneal metastases.  Ann Surg. 2009;  250 255-259
  • 26 Delius S von, Feussner H, Wilhelm D. et al . Transgastric in vivo histology in the peritoneal cavity using miniprobe-based confocal fluorescence microscopy in an acute porcine model.  Endoscopy. 2007;  39 407-411
  • 27 Feretis C, Kalantzopoulos D, Koulouris P. et al . Endoscopic transgastric procedures in anesthetized pigs: technical challenges, complications, and survival.  Endoscopy. 2007;  39 394-400
  • 28 San José Estépar R, Westin C F, Vosburgh K G. Towards real time 2D to 3D registration for ultrasound-guided endoscopic and laparoscopic procedures.  Int J Comput Assist Radiol Surg. 2009;  4 549-560
  • 29 McGee M F, Schomisch S J, Marks J M. et al . Late phase TNF-alpha depression in natural orifice translumenal endoscopic surgery (NOTES) peritoneoscopy.  Surgery. 2008;  143 318-328
  • 30 Delgado S, Lacy A M, Filella X. et al . Acute phase response in laparoscopic and open colectomy in colon cancer: randomized study.  Dis Colon Rectum. 2001;  44 638-646

G. Fernández-EsparrachMD, PhD 

Endoscopy Unit
Gastroenterology Department
Hospital Clinic

Villarroel 170
08026 Barcelona
Spain

Fax: +34-93-2279850

Email: mgfernan@clinic.ub.es