R. ZORRON Current clinical experience with NOTES: a worldwide report

it's a pleasure antonello thank you for inviting me for this uh great meeting uh i would love to

to share our experience on transvaginal and transcolonic notes that we started in early 2007

and this is a more about also the the revision also of all uh what's happening around the world

So, next slide, please. I think the idea, these are my disclosures. Next, please. The idea is to have an operation that avoids the scar that Marilyn Monroe got for her cholecystectomy. We advanced this for truly laparoscopy, and now we are looking more to single-part surgery, but our aim is to have no scar surgery and for the better of the patients.

Next, please.

We want also to thank all the pioneers in this operation.

So it's sure that Dr. Tzin advanced very much this field

doing transvaginal cholecystectomy after hysterectomy

and also all the pioneers on notes, Kalou, Cantavoy, and Reddy,

and also Dr. Buis, which started notes many years ago

doing trans and endoscopic microsurgery next so this is a this is a view of what we have in

publications now uh in transvaginal uh surgery this is a lot of publications coming out and this

is very good to see that uh our other countries so like brazil and europe and uh started this

these procedures. And now we have a large clinical experience. We have now two large

multi-center studies and we have consistent data to see what's happening with nodes.

Next please. And this is also the transgastric and other procedures that are starting now.

Now the sum of these publications now are 1,169 cases around the world published in expert magazines.

So we are also proud to say that we are starting also the transcolonic nodes to do the colorectal surgery.

I will tell this next.

Next, please.

So we have two great publications now that shares a lot of data.

One is our EMTN multicenter study that Dr. Forgione and Dr. Pugliese also participated on with European and Brazilian and South American cases.

And the other, the German group also published their 551 cases with very good results.

Next, please.

But if you want to try notes, it's very difficult, so there are other things happening.

and so we are glad to see that, can you play the video please, that we can try single port

access surgery and this is a splenectomy of a huge spleen done by the umbilicus in our

clinic here and we can see that this operation can be easily performed with few difficulties

and so to have less scars, to have less problems with the patient so the scar is like this

and so maybe this is better than notes we don't know but it's truly it's easier

to do because it's using our laparoscopic knowledge next please but

surely the importance to have the art of invisibility it can be achieved by notes

either by notes by mini laparoscopy or by less single part surgery so the

importance that the patient has benefits from this evolution of the techniques

techniques. Next. What we tell about notes is still have very good cosmetic benefit.

Every one surgeon that operates notes patient as you, Antonello, knows that it's a less

painful procedure and it can be immediately applied by transvaginal access. It is not

anymore an experimental procedure. We have a standard procedure. We can do this in our

clinic you can avoid hernia other is an obstruction and maybe in the future the

preferred access for colorectal disease the trans colonic approach next so we

have this at the beginning the institutional review board approval in

Brazil and now we started with these two publications into early 2007 next so and

our requirements were a multidisciplinary team because we were

We're working with flexible endoscopy, and this is not usual for Brazilian surgeons,

flexible endoscopic experience, ethical mission approval,

so also animal lab experience, and so 30 days follow-up of this patient,

and each group was sending every three months assessing our registry.

Next, please.

Our first meeting was in Brazil in 2007,

And we got many good people from John Hopkins and Mayo Clinic and Miami and other countries.

And we have this very successful meeting in notes in Rio.

Next, please.

We count now in South America 649 cases, for which most are coming from Brazil, 454 cases, and with very few complications.

Next.

So at the beginning we had this early experience with notes. Can you put the

video please? Yes, thank you. With two endoscopes inserted in the vagina so it

was truly notes, totally notes without laparoscopic assistance using only two

endoscopes, one for retraction and insufflation and the other was for

performing the surgery. Next. We have also developed new

new instruments on transvaginal nodes they are produced by starch now and we

have bounded equipment that helps a lot in doing this very long distance

operation from the vaginas it's around 60 centimeters instruments and I'll show

you next so can you put the video please thank you so we start with an open

procedure inside the vagina is a direct view. So we insert the port. This port allows for

three insertion of the camera and two instruments. And so we can see here the entry at the vagina.

And the instruments are bounded, so we can easily dissect the cystic duct and have a

nice view. If we need, we can put also other trochars for laparoscopic assistance in more

more difficult cases, but we see it's a very standard operation that we can do, performing

clipping transvaginal, using transvaginal clips, very long clipators.

Sometimes this operation is impossible because of the promontory of the patient that makes

a very angulated angle, and so we cannot operate some patients.

So about 5% are not suitable for this operation.

But here we can see that we can clip the cystic duct.

You see the very angled hook that works very fine.

It's very similar what we do with laparoscopy.

And so we have some degree of triangulation.

We have this triangulation.

It's very interesting.

We have also aspiration.

We can wash the surgery.

surgery, and so the extraction site is transvaginal. It's also very easy to extract because of

the large of the organ and also easy to close. So this is a standard operation that we can

perform and now this equipment will be available this year in Europe. Next please. So the results

of the EMT and multicenter study with many countries including Italy. Next please. So

So we can see that transgastric access, transgastric surgery has a longer operative time

and also have more grade 3 and 4 complications, which is very bad compared to transvaginal surgery.

It makes sense because to do transgastric surgery, we need a hybrid procedure.

We need endoscopic instruments, flexible instruments that turns everything more difficult.

and so this is a very, it's more dangerous than transvaginal surgery. Next, please. We can also

see here biliary leakage that happened in some cases here, and no case went to bad result as

death of any patients in any publication of knowledge. Next, please. We had also in one case

transgastric perforation of the esophagus, and this patient stayed 16 days in intensive

care and was operated laparoscopically for mid-asthenitis.

So this is very too much for gallbladder operation, so I think we have to think about transgastric

surgery.

I think it's not the time to do that.

Next.

We have also complications during the operation.

This is a flexible dissection of the gallbladder, very inflamated.

And you see the bleeding here from a posterior artery.

So this case are often, sometimes we can control this by notes,

but often we have to put some trocars and convert the procedure to a formal laparoscopic operation.

So it's not always easy to deal with this using the flexible instruments.

This is a more advanced procedure and laparoscopically is an easy, simple procedure.

Next, please.

We can see also some advantages from notes.

This is a zero analgesia in some patients.

We can see a percent of 23% to 25% of patients receiving no analgesia in the postoperative period.

Next, please.

So, can you, yeah, thank you.

We have options to do this operation, transgastric, transvaginal, transcolonic, and transurethral,

But we really think that transvaginal and transcolonic, transvaginal is already established,

and transcolonic maybe will be the future of colonic surgery.

Next, please.

We are investing a lot now in transcolonic surgery.

We know that Dr. Buis started this concept in 1980s doing transanal endoscopic microsurgery,

and many studies shown in cadavers and experimental fields.

so better, very good results with the transrectal, transcolonic access.

And we started this experience in 2009.

And also Dr. Silla and Dr. Lassi from Barcelona started also their experience

with transrectal extraction of rectal cancer.

Next.

So our first technique employed was with flexible endoscopy.

we perform the dissection using the endoscope and doing the total mesorectal resection,

starting from the line of the anastomosis, the desired anastomosis.

Next, please.

The second technique is a down-to-up transgenal node TME

performed by a single-port device inserted inside the rectum.

So, we start the operation where we desire the line of the anastomosis.

Next, please.

Can you put the video, please?

So this insertion of the device, we have some angle instruments to work inside the rectum.

We use a normal laparoscopic camera and insufflation of the colon.

In the last cases, we are closing the rectum to avoid contamination,

but we can choose the line of our resection and restart with the dissection of the mesorectal

and then progressing up.

And sure, all these cases need laparoscopic assistance

and laparoscopic release of the flexure.

Here we are freeing from the vagina anteriorly,

freeing the rectum and mesorectal envelope.

And later we help with laparoscopy to do high gligation of the mesenteric artery.

artery, and so the specimen is extracted trans-anally, and we can perform either a stapled anastomosis

in a 3 or 4 cm stump, or we can do this like this, with or without the valve, colo-anal

anastomosis in this case.

We have for now 11 cases.

This case, I already published it in 2010.

Next, please. We have here eight case here documented, so with good results. Two with

flexible endoscopy and the others with single port transanally inserted. And you see case

eight here, which was a very obese woman. She had anastomotic late due to necrosis

of the stump. So this is the only complication we had. And case three, we have an impossibility

to do this by notes or laparoscopically, and then it was a bulky tumor, very bad indication,

and then we converted to open surgery. Next, please. What is about the future of surgery?

We can see that we can now think about transoral tridectomy. We can think about transoral

treatment of achalasia and many also bariatric surgery and also less invasive

procedure as radiofrequency ablation of the adrenals so we have these

possibilities to advance in the future and maybe this is better than notes next

please what was notes in 2007 it was very difficult to work we had the

problems with to start this procedure because of lack of materials next please

what is now today we have 169 cases published it so we can see what paths to

follow and which way we can go next please so we see from our what we

explained it today that nose has not proven yet to be better than any

standard methods for any indication yet but transvaginal surgery transvaginal

notes no longer an experimental procedure next well I'm glad to also

with the help of our colleagues from from Brazil of our Brazilian notes

research group next please can you play the video so and here is what how we do

notes in developing countries this is possible to perform safely these

these procedures in Africa, in Brazil and other countries, we don't have the money,

but we can perform very good and safe operations with few resources.

I want to thank you very much for this possibility to show our results, and thanks Antonello

and I'm ready for any doubts you have.

Thank you very much.

Thank you very much, Riccardo. It's a wonderful presentation and a wonderful experience.

As far as I know, you have really been working on this field very, very much. And I have a question

now related especially to the transvaginal approach of which you are an absolute pioneer.

And the question is, are you proposing to all your patients this approach as a standard one,

or are you still selecting the patient?

Which is your attitude?

Yes, this is a very good question.

So this is not a standard that we can say this is better than laparoscopy.

So we let the patient choose.

We have still the study going on,

and so we want to have some patients going to the study.

So we always offer the transvaginal approach.

If they refuse, naturally we do this laparoscopically.

And the thing is that we cannot show that it's better than laparoscopy yet, and so maybe we'll never will.

So I think, but the results are very good, and patients have less pain than laparoscopy.

So they can choose, and we have very difficult operations here because many patients in our public hospital

and university hospital have to wait one year, two years to be operated sometimes.

times and so these gallbladders are really tough and so that is hard to select good cases so we

we are getting the bad cases too yeah i understand uh but according to your experience

do you see any change in the attitude of the patient i mean there is a word that is passing

through the population that this approach could be as safe as the standard one or give better

cosmetic result which is your impression or is going you know still in the hands

of very few people yes I can we can brought the the experience to other

patients so the patients are willing some patients are willing to have this

operation from the experience of the other patients so also in Germany we

have three centers doing very a lot of transvaginal surgery and in some centers

more than laparoscopic surgery so it's it's getting to be standard for some surgeons but

it still requires skill skills and and also equipment so maybe it will take more time but

many patients in brazil knows about this and knows that the risk is is the same as laparoscopy

and are designed to have this operation this is happening now that's very interesting and

And one more point is related to the case of mediastinitis that you report very, I think, very honestly about the transgastric approach.

I think that we should make a point about those cases that are reported because there is a risk, of course, a major risk related to the gastrotomy and of this new, completely new approach for peritoneal surgery.

but there is also a limit of indication and I think that the sergeants and people that are

dealing with this new approach sometimes they try to overcome or not respect the limitation

of the approach trying to demonstrate that they can do everything through the notes and for

example the case that you report it was a case of a big stone that was at a certain point impacted

into the esophagus so in my opinion when we report honestly those cases we have also to

to say that this is not probably a limit of the transgastric approach this was a bad indication

in a patient with such a big stone you don't have to propose a transgastric approach that's my

opinion so I think that we have to try to take the maximum of the benefit of each approach and

of a new technology and of course we have always to remember that no matter which way you can

perform a procedure but each procedure has a limit and so in this case I think this is also

a message that we have to give. Yes, Antonello, you are completely right. I think so you may have

indications, good and bad indications, but it's a very young technique and so we have a lot of

research to do yeah i totally agree so ricardo we have to move ahead because as usually we are

running out of time but i'm very very happy to see you and to attend your lecture thanks a lot

for giving us your information and inspiring also because i've seen some new things that

they will try to replicate and i hope to see you very soon somewhere in the world and to welcome

you in Italy very very soon so goodbye thank you and have a good day ciao