Natural Orifice Transluminal Endoscopic Surgery (NOTES): An Opportunity for Augmented Reality Guidance

Kirby G. Vosburgh, R. San Jose Estepar
Studies in Health Technology and Informatics
Volume 125, Pages 485-490
2007

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Abstract

Laparoscopic techniques have gained wide acceptance because they offer a safe and less invasive alternative to open surgery. To further reduce the invasiveness of peritoneal access, the next logical step is to eliminate the incision through the abdominal wall using natural orifices as entry points. This Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach has the potential to replace or augment current techniques. Several research groups have cut through the stomach or colon wall (per-oral transgastric or per-anal transcolonic) to perform organ resections in animal models, and some procedures in humans have been reported anecdotally. Widespread use of these techniques will depend on providing the physician with adequate visual feedback, clear indicators of instrument location and orientation, and support in the recognition of anatomic structures. Compared with laparoscopy, successful endoscopy must accommodate several additional complexities: (1) The flexibility of the endoscope tip complicates the understanding of its distal orientation. Successful navigation inside the stomach and in the abdominal cavity generally requires two years of sub-specialty training. (2) Several surgical targets lie in a retrograde position with respect to an incision in the stomach wall. Efficient and safe access to the pancreas, gall bladder, or the kidneys requires detailed knowledge of the tip placement relative to adjacent anatomic structures. (3) Since there is limited direct access to the abdomen, iatrogenic injuries, such as the accidental cutting of an artery, will be more dangerous and difficult to manage. We present here approaches to resolving these limitations though augmented reality techniques using pre-procedure CT or MRI imaging, real time tracking and reference image registration, and display to the operating physician. As an example, the utility of image registration techniques for orientation for the gastric access puncture is discussed in detail. It is anticipated that such augmentation will make intra-cavitary interventional techniques easier to master and use in practice, and thus more likely to be widely adopted.

anisotropy creases with tractography
View of the vasculature anatomy of the stomach of a porcine model. The right image is an exterior view of the right part of the specimen. The right gastrodoudenal artery (white arrow) can be seen lying on top of the stomach wall. The left image is an endoscopic view of the same site from the inside of the stomach towards the right-anterior part. The vessel structure has been overlaid with the semi-transparent model of the stomach wall but it will not be visible in a standard endoscopic view.

Reference

Vosburgh KG, San Jose Estepar R. Natural orifice transluminal endoscopic surgery (notes): An opportunity for augmented reality guidance. Studies in Health Technology and Informatics 2007;125:485-490.

Bibtex entry

@Article{vosburgh07-b,
  author         = {Kirby G. Vosburgh and Raul {San Jose Estepar}},            
  title          = {Natural Orifice Transluminal Endoscopic Surgery (NOTES): An
                   Opportunity for Augmented Reality Guidance},                
  journal        = {Studies in Health Technology and Informatics},             
  year           = {2007},                                                     
  volume         = {125},                                                      
  pages          = {485--490}
}

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