Klinik für Viszeral-, Gefäss und Thoraxchirurgie, Markus-Krankenhaus, Frankfurter Diakonie Kliniken, Wilhelm Epstein-Str 4, 60431 Frankfurt am Main, Germany.
Surg Endosc. 2010 Mar;24(3):601-9. doi: 10.1007/s00464-009-0587-z. Epub 2009 Aug 18.
The transgastric approach to the abdominal cavity has been under experimental investigation in recent years as a method of natural orifice transluminal endoscopic surgery (NOTES). In this study our team, consisting of surgeons and gastroenterologists, focused on training techniques with currently available instruments to perform transgastric procedures. The purpose of this paper is to evaluate the learning process during the establishment of a training program for NOTES. Therefore several procedures were tested in terms of training issues such as the applicability of instruments and techniques for both gastroenterologists and surgeons.
After initial testing of the basic steps, a defined training program was initialized in an animal facility of a medical company. Permission for animal training was applied for and granted by the local government. Ten training sessions were performed on a porcine model using animals with a median weight of 65 kg (40-85 kg). General anesthesia was performed in all cases. Transgastric tube resection (TTR), cholecystectomy (TCE), cardiomyotomy (TMY), and small bowel segmental resection (TSBR) were performed. The learning process was evaluated, including handling issues for flexible instruments, access, closure problems, and special technical issues. Procedure duration, as a marker of the learning curve effect, was evaluated.
Intra-esophageal friction, lack of platform stability, lack of precision in tissue retraction, and lack of independence of endoscopic vision were the most difficult technical problems encountered. The operative time range was 25-85 min for TTR, 75-185 min for TCE, 95-220 min for TMY, and 100-260 min for TSBR.
A learning curve was demonstrated for each investigated technique. These results are promising in terms of the ability of surgeons and gastroenterologists to develop these procedures into a clinical applicable version. Technical limitations were more important than differences in medical education, providing that there is a certain level of experience in both flexible endoscopy and laparoscopy, as well as a team approach.
近年来，经胃入腹的方法已作为经自然腔道内镜外科手术（NOTES）的一种方法进行了实验研究。在这项研究中，我们的外科医生和胃肠病学家团队专注于使用当前可用的器械来开发经胃手术技术。本文旨在评估NOTES 培训计划建立过程中的学习过程。因此，我们根据器械的适用性以及外科医生和胃肠病学家的适用性，对几种手术方法进行了测试。
在对基本步骤进行初步测试后，我们在一家医疗公司的动物设施中启动了一个明确的培训计划。我们申请并获得了当地政府的动物培训许可。使用体重中位数为 65 公斤（40-85 公斤）的动物在猪模型上进行了 10 次培训。所有病例均采用全身麻醉。进行了经胃管切除术（TTR）、胆囊切除术（TCE）、心肌切开术（TMY）和小肠节段切除术（TSBR）。评估了学习过程，包括对柔性器械的处理问题、入路、闭合问题和特殊技术问题。评估了作为学习曲线效应标志物的手术时间。
食管内摩擦、平台稳定性不足、组织回缩精度不足和内镜视野缺乏独立性是遇到的最困难的技术问题。TTR 的手术时间范围为 25-85 分钟，TCE 为 75-185 分钟，TMY 为 95-220 分钟，TSBR 为 100-260 分钟。
每种研究技术都表现出学习曲线。这些结果令人鼓舞，因为外科医生和胃肠病学家有能力将这些手术发展为临床适用的版本。技术限制比医学教育差异更为重要，前提是在柔性内镜和腹腔镜方面都具有一定水平的经验，并且采用团队方法。
