The First Human Abdominal Surgery in Prone Position: An Example of How NOTES Can Be Used to Perform Unique Procedures

NOTES has been touted as the next step in minimally invasive surgery. As such, most of the effort to perform NOTES has been focused on reproducing surgical procedures in a manner similar to how they are accomplished laparoscopically. It seems, however, that a potential advantage for NOTES is to allow surgeons to perform operations in ways that have not been possible before. One example is the ability to access the abdominal cavity with the patient in prone position. Such positioning allows for the use of gravity retraction in a unique way to expose retroperitoneal and pelvic organs better than that seen in traditional supine surgery. This type of exposure may be particularly beneficial for NOTES given the current limitations of retraction while using flexible endoscopic tools.

This video demonstrates the results of our experiments in multiple cadaver models using NOTES to gain exposure of abdominal organs while the patient is in prone position. Both transgastric and transvaginal approaches are used to gain access to intraabdominal and retroperitoneal structures. The exposure of the gallbladder, spleen, pancreas, kidney, rectum, bladder, uterus, and ovaries is far superior to that seen in supine position. By elevating the patient off the table and allowing the abdomen to “hang” additional working space is gained. Included in this demonstration is use of a novel NOTES endoscope with two working channels equipped with elevators, and a retraction device that allows for vigorous manipulation of structures during NOTES procedures.

Given the current state of technology in NOTES, it is unclear yet if this approach is an improvement over laparoscopy. However, if natural orifice access can allow surgeons to accomplish procedures in a manner that is not possible with traditional laparoscopic surgery, then this may be the true advantage of NOTES. Performing abdominal surgery with a patient in prone position is an example of such an advantage.

Session: Podium Presentation

Program Number: V007

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