On the suitability of Thiel cadavers for natural orifice transluminal endoscopic surgery (NOTES): surgical training, feasibility studies, and anatomical education
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Surgical training in virtual, animal and cadaver models is essential for minimally invasive surgery. Thiel cadavers are suitable for laparoscopy, but there are few data about the use of embalmed (Tutsch method) and slightly embalmed (Thiel method) cadavers in procedures of Natural Orifice Transluminal Endoscopic Surgery (NOTES), which are usually developed and learned on swine models and fresh frozen cadavers. The aim of this study was thus to assess the use of these cadavers for NOTES approaches.
The following surgical procedures were evaluated: transanal total mesorectal excision (four cadavers: one Tutsch, two Thiel, one fresh frozen), transanal ileorectal bypass (five cadavers: one Tutsch, three Thiel, one fresh frozen), and transvaginal appendectomy (two Tutsch cadaver).
The Thiel method ensured tissue flexibility and consistency suitable for performing the above surgical procedures with good results and without complications, with only a small increase in rigidity with respect to fresh specimens. Cadavers embalmed with higher formalin concentrations (Tutsch method) were more difficult to use, due to high tissue rigidity and resistance of the abdominal wall to pneumoperitoneum, although NOTES accesses were possible.
Thiel cadavers are suitable for transanal/transrectal and transvaginal NOTES approaches, for training surgical residents/specialists and also for surgical research. In minimally invasive surgery (and particularly in NOTES), integration between cadaver (fresh frozen and/or Thiel) and animal models would represent the gold standard, allowing guaranteed knowledge of and respect for human surgical anatomy and correct management of surgery on living subjects. NOTES approaches to human cadavers may also be proposed for the anatomical education of medical students.
KeywordsHuman cadaver model Transanal endoscopic microsurgery Thiel method Surgical training Body donation Total mesorectal excision
The authors are grateful to Anna Rambaldo, Gloria Sarasin and Maria Martina Sfriso for skillful technical assistance in the management of cadavers. The authors also acknowledge Matteo Della Pittima and Giulia Andretta for their help in the preparation of the videos.
Andrea Porzionato, Lino Polese, Emanuele Lezoche, Veronica Macchi, Giovanni Lezoche, Gianfranco Da Dalt, Carla Stecco, Lorenzo Norberto, Stefano Merigliano, Raffaele De Caro have no conflicts of interest or financial ties to disclose.
Supplemental Material 1: Video of transanal total mesorectal excision (00:00-00:30) and transanal ileoproctostomy (00:30-01:00) performed in female fresh frozen cadavers for comparison with preserved cadavers. Transanal total mesorectal excision: rectal wall is cut with forceps and scissors; dissection continues posteriorly along the avascular plane. Transanal ileoproctostomy: suture is begun between rectal wall and an ileal loop pulled into rectum. (WMV 22213 kb)
Supplemental Material 2: Video of transanal total mesorectal excision performed in male Thiel cadaver. Rectal wall is cut with forceps and scissors and dissection continues circumferentially (00:00-00:20). On posterior aspect of rectum, dissection continues cranially along avascular plane between parietal presacral fascia and visceral perirectal fascia, including so-called mesorectum in resection (00:20-00:28). Dissection continues along lateral and anterior rectal walls (00:28-00:47). Peritoneum is opened anteriorly to rectum at level of its reflection and abdominal cavity becomes visible (00:47-00:57). In this video, the preservation of realistic colours and consistence of the dissected tissues is appreciable. (WMV 22830 kb)
Supplemental Material 3: Video of ileoproctostomy through transanal route performed in male Thiel cadaver. Anterior rectal wall is cut with scissors cranially to peritoneal reflection (00:00-00:16). Peritoneoscopy is performed through rectal opening in order to identify an ileal loop to be grasped with retrieval forceps and pulled into rectum (00:16-00:29). Note the flexibility and mobility of the ileal loop. Suture is performed between ileum and rectum (00:29-00:48). The preservation characteristics of the tissues provide realistic sensations during the suture. After opening of ileal wall, ileorectal bypass is finally verified passing from rectum to ileal loop (00:48-00:54). (WMV 19674 kb)
Supplemental Material 4: Video of appendectomy through transvaginal route performed in female Tutsch cadaver. Access through the posterior fornix of the vagina is produced with open technique (00:00-00:13). Examination of the abdominal cavity through transvaginal route (00:14-00:56). Intestinal loops show darker and less realistic colours, together with reduced flexibility and mobility. (WMV 14268 kb)
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