Interview Questions for Transgastric Endoscopic Retroperitoneal Surgery (TERS)

Transgastric Endoscopic Retroperitoneal Surgery (TERS) is indicated for accessing and treating retroperitoneal lesions, particularly those challenging to reach via traditional open surgery or laparoscopy. The specific indications are driven by the nature and location of the pathology. Think of it like needing a specialized key to open a difficult lock.

• Tumors: TERS is particularly useful for small to medium-sized tumors in the retroperitoneum, including those arising from the adrenal glands, kidneys, or lymph nodes. For example, a small, well-encapsulated adrenal adenoma might be ideal for a TERS approach.
• Cysts: Retroperitoneal cysts, depending on their size and location, can also be effectively managed with TERS. Imagine a fluid-filled sac pressing on nearby organs – TERS can offer less invasive removal.
• Biopsies: Obtaining tissue samples for diagnosis from hard-to-reach retroperitoneal areas can be safely and efficiently performed with TERS.
• Hematoma evacuation: In cases of retroperitoneal hematomas that are causing significant symptoms, TERS might offer a minimally invasive solution to drain the accumulated blood.

The decision to use TERS is always made on a case-by-case basis, considering the patient’s overall health, the size and location of the lesion, and the expertise of the surgical team.

Contraindications for TERS are primarily related to factors that would increase the risk of complications or compromise the successful completion of the procedure. Essentially, it’s about identifying situations where the benefits don’t outweigh the risks.

• Large or Invasive Tumors: TERS isn’t suitable for large or extensively invasive tumors that require extensive resection or would be difficult to completely remove through the transgastric approach. Imagine trying to fit a large object through a small opening – it just wouldn’t work.
• Severe Obesity: Significant obesity can make visualization and access to the retroperitoneum difficult, increasing the risk of complications.
• Severe Co-morbidities: Patients with severe cardiovascular, pulmonary, or other systemic diseases may not tolerate the procedure.
• Extensive Adhesions: Pre-existing extensive abdominal adhesions (scar tissue) can impede access and increase the difficulty of the procedure.
• Active Gastritis or Gastric Ulcers: Any significant gastric pathology might compromise the integrity of the gastric wall, making the transgastric approach unsafe.
• Inability to Tolerate General Anesthesia: The procedure requires general anesthesia, making it unsuitable for patients unable to tolerate it.

A thorough pre-operative assessment is crucial to ensure that TERS is the appropriate and safest approach for each individual patient.

The TERS procedure is a complex multi-step process that requires specialized endoscopic equipment and expertise. It’s like a carefully choreographed dance requiring precision and skill. Here’s an outline:

1. Gastroscopy and Gastric Wall Puncture: The procedure begins with a standard gastroscopy to visualize the stomach and identify the optimal site for gastric wall puncture.
2. Creation of a Retroperitoneal Access Tract: A small incision is made in the gastric wall, and a specialized instrument is advanced into the retroperitoneum, carefully creating a pathway.
3. Dissection and Exploration of the Retroperitoneum: Using specialized endoscopic instruments, the surgeon dissects the retroperitoneal tissue to identify and access the target lesion.
4. Lesion Removal or Biopsy: Depending on the indication, the lesion is either removed entirely or a biopsy is taken. This might involve the use of specialized grasping forceps, scissors, or other instruments.
5. Closure of the Gastric Wall Puncture Site: Once the procedure is complete, the gastric puncture site is carefully closed using endoscopic clips or sutures.
6. Post-operative Management: Post-operative care includes monitoring for potential complications, pain management, and appropriate dietary adjustments.

Each step requires meticulous attention to detail and precision to minimize complications. The entire process is guided by real-time imaging, typically fluoroscopy and endoscopy.

Like any surgical procedure, TERS carries potential complications, although the minimally invasive nature aims to reduce them. However, being prepared for potential issues is crucial.

• Bleeding: Bleeding from the puncture site or during dissection is a possibility.
• Perforation: Accidental perforation of the gastric wall, a retroperitoneal organ, or blood vessel is a risk.
• Infection: Infection at the puncture site or within the retroperitoneum can occur.
• Leakage: Leakage of gastric contents from the puncture site can occur.
• Injury to Adjacent Organs: Damage to adjacent organs, such as the spleen, kidney, or pancreas, is a potential but rare complication.
• Pancreatitis (rare): Inflammation of the pancreas can occur, particularly if the procedure involves structures close to the pancreas.
• Post-operative Pain: Patients can experience post-operative pain that requires management.

Careful pre-operative planning, precise technique, and thorough post-operative monitoring are crucial for minimizing these risks.

Managing complications during a TERS procedure requires quick thinking and decisive action. The approach varies depending on the specific complication.

• Bleeding: Control of bleeding may involve the use of endoscopic hemostatic clips, thermal energy devices, or, in rare cases, conversion to open surgery.
• Perforation: Gastric perforation can necessitate immediate repair using endoscopic techniques or conversion to open surgery.
• Infection: Antibiotic therapy is crucial for managing infection.
• Leakage: Gastric leakage might require drainage procedures or even surgery.
• Organ Injury: Injury to adjacent organs requires immediate assessment and tailored management, often involving specialists.

The surgical team must be prepared to address these contingencies, including having readily available resources for managing severe complications. Having a clear plan and adapting based on the situation is critical.

TERS offers significant advantages over open retroperitoneal surgery, making it a preferable option in many cases. Think of it as a keyhole surgery compared to a large incision.

• Minimally Invasive: Smaller incisions result in less trauma, reduced pain, shorter hospital stays, and faster recovery.
• Reduced Scarring: Minimally invasive nature leads to less visible scarring.
• Lower Risk of Infection: Smaller incision size reduces the risk of postoperative infection.
• Less Postoperative Pain: Reduced tissue trauma results in significantly less post-operative pain.
• Faster Recovery: Patients can typically resume normal activities much faster than after open surgery.

These advantages translate to improved patient outcomes, reduced healthcare costs, and enhanced patient satisfaction.

Despite its advantages, TERS has limitations that need to be considered before selecting this approach.

• Limited Applicability: TERS is not suitable for all retroperitoneal conditions. Large or invasive tumors, extensive adhesions, or certain anatomical configurations may preclude its use.
• Steeper Learning Curve: The procedure requires specialized training and expertise, limiting its availability.
• Potential for Complications: Although less frequent than with open surgery, complications like bleeding, perforation, and infection can still occur.
• Need for Specialized Equipment: The procedure requires specific endoscopic equipment, increasing the costs.
• Difficult to Master: The technique can be complex and requires considerable skill and experience to perform safely and effectively.

A thorough assessment of the patient and the lesion is crucial to determine if TERS is the appropriate approach. Open communication between the patient and the surgical team is essential to ensure informed decision-making.

TERS utilizes a variety of specialized endoscopic instruments, carefully selected based on the specific surgical task and patient anatomy. These instruments can be broadly categorized into those for visualization, dissection, and hemostasis.

• Visualization: High-definition endoscopes with advanced features like narrow-band imaging (NBI) provide excellent visualization of the retroperitoneum. These endoscopes allow for better differentiation of tissues and identification of vascular structures, reducing the risk of unintended injury.
• Dissection: This includes instruments like various types of graspers (e.g., atraumatic grasping forceps), dissectors (e.g., bipolar forceps, hook electrosurgical devices), and scissors. These are designed for precise tissue manipulation and dissection, minimizing collateral damage to surrounding structures. The choice of dissector depends on the tissue type; for example, we might prefer bipolar forceps for delicate dissection near vessels, while a hook electrode can be used for more robust tissue division.
• Hemostasis: Control of bleeding is crucial. Instruments like bipolar forceps, argon plasma coagulation (APC) devices, and clips are essential for achieving hemostasis. Bipolar forceps provide precise coagulation, while APC is useful for larger areas of bleeding. Clips are used to secure vessels or tissues, preventing bleeding.

The choice of instrument is also influenced by the specific surgical task. For example, a small, delicate dissector is preferred for intricate procedures near vital organs, while a larger, more robust instrument is appropriate for more extensive dissection.

Instrument selection in TERS is a crucial step that significantly impacts the outcome of the procedure. It’s a personalized decision based on several factors:

• Patient anatomy: The size and location of the target lesion, as well as the presence of any anatomical variations, influence instrument choice. A smaller patient might require smaller instruments to avoid excessive trauma.
• Surgical goal: The intended procedure dictates the necessary instruments. For example, a biopsy requires a smaller, less invasive approach compared to a more extensive resection.
• Surgeon experience and preference: Experienced surgeons often have preferences for certain types of instruments based on their individual surgical technique and comfort level. However, a surgeon should always prioritize patient safety and choose the most appropriate instrument regardless of personal preference.
• Intraoperative findings: During the procedure, the surgeon might need to adjust the instrument selection based on unexpected anatomical variations or complications.

For example, if I’m performing a TERS biopsy of a small adrenal lesion, I would choose smaller-caliber instruments like a needle-knife and forceps to minimize trauma and bleeding. If undertaking a larger resection, I would use a broader range of instruments including graspers, bipolar forceps, and possibly an APC device.

Imaging plays a vital role in TERS, guiding the entire process from pre-operative planning to intraoperative navigation and post-operative assessment. It allows for precise localization of the target lesion, minimizes invasiveness, and improves surgical accuracy. Essentially, it acts as a roadmap for the surgeon, ensuring they can safely and effectively reach the target area within the retroperitoneum.

Pre-operatively, imaging helps define the location, size, and characteristics of the lesion. This information is crucial for choosing the appropriate surgical approach and instruments. Intraoperatively, real-time imaging ensures accurate instrument placement and helps avoid injury to surrounding structures. Post-operatively, imaging confirms successful completion of the procedure and assesses any potential complications.

Several imaging modalities are commonly utilized in TERS, each with its own advantages and limitations:

• Fluoroscopy: Provides real-time imaging of the instruments and tissues during the procedure. This is particularly useful for guiding instrument placement and assessing the extent of the dissection.
• Ultrasound: Endoscopic ultrasound (EUS) is frequently integrated into TERS. It offers excellent visualization of the retroperitoneal structures and helps identify the target lesion accurately, providing high-resolution images of layers and tissues during the operation.
• Computed Tomography (CT) and Magnetic Resonance Imaging (MRI): These are primarily used in the pre-operative planning phase to accurately determine the lesion’s location, size, and relationship to adjacent structures. They provide detailed anatomical information which helps determine the feasibility of the procedure and plan the optimal surgical approach.

Often, a combination of these modalities is used to optimize the accuracy and safety of the TERS procedure. For example, we might use pre-operative CT to plan the procedure, intraoperative fluoroscopy to guide instrument placement, and intraoperative EUS to visualize the target lesion and surrounding structures in detail.

My experience encompasses both transgastric and transduodenal approaches to TERS. The transgastric approach is commonly used for lesions in the left retroperitoneum, while the transduodenal approach provides access to the right retroperitoneum. The choice depends on the location of the target lesion and surgeon expertise.

The transgastric approach involves creating a small incision in the gastric wall, advancing the endoscope into the retroperitoneum, and performing the procedure. This approach is generally associated with a shorter operative time and reduced post-operative pain. However, gastric perforation is a possible complication.

In contrast, the transduodenal approach utilizes a similar technique but accesses the retroperitoneum through the duodenum. It’s typically preferred for lesions located closer to the duodenum. This approach can sometimes be technically more challenging due to the anatomical complexity of the duodenum and the potential for damage to the common bile duct or pancreatic duct.

In either approach, meticulous technique, precise instrumentation, and careful attention to anatomical landmarks are paramount to minimizing complications and maximizing the success rate.

Bleeding management in TERS is critical. Several strategies are employed to control bleeding, depending on the source and severity of the bleeding. Early identification and prompt management are key.

• Bipolar coagulation: This is often the first-line approach for controlling small vessel bleeding. Its precision minimizes tissue damage and thermal injury.
• Argon plasma coagulation (APC): Used for larger areas of bleeding, offering a non-contact method of coagulation.
• Hemostatic clips: For larger vessels that require more robust hemostasis, clips can be applied to securely occlude the bleeding vessel.
• Vascular embolization: In cases of uncontrollable bleeding, vascular embolization might be considered post-operatively. This involves injecting a material into the bleeding vessel to block blood flow.
• Surgical repair: If endoscopic techniques fail to control bleeding, open surgery might be required as a salvage procedure.

In practice, a combination of these techniques might be utilized. For instance, bipolar coagulation might be used to initially control bleeding, followed by APC for larger areas. Clips might be used as a secondary measure to secure bleeding vessels.

Assessing the success of a TERS procedure involves evaluating several parameters both during and after the procedure.

• Intraoperative assessment: This includes complete removal or biopsy of the target lesion, effective control of bleeding, and no evidence of major complications.
• Immediate post-operative assessment: The patient’s vital signs are closely monitored, looking for any signs of bleeding, infection, or perforation. A repeat EUS or CT scan can be conducted to assess the surgical site.
• Long-term follow-up: This is crucial to monitor for any recurrence of the lesion and evaluate the long-term effects of the procedure. Regular imaging studies and clinical examinations are performed to assess the success of the treatment and address any complications. For example, if the goal was complete resection of a tumor, follow up scans would confirm its absence. If the goal was a biopsy, then pathological examination of the specimen would complete the assessment.

Ultimately, the success of a TERS procedure is defined by achieving the intended surgical goal while minimizing complications and ensuring a favorable patient outcome.

Postoperative care for TERS patients is crucial for a successful recovery and minimizing complications. It’s a multi-faceted approach focusing on pain management, infection prevention, and monitoring for potential issues.

• Pain Management: We utilize a multimodal analgesic approach, combining intravenous opioids initially, transitioning to oral analgesics as tolerated. This minimizes opioid-related side effects. Regular pain assessments are vital. For example, we might use a numeric rating scale (NRS) to track pain levels.

• Infection Prevention: Prophylactic antibiotics are administered pre-operatively and continued post-operatively, depending on the surgical findings and individual patient risk factors. Meticulous wound care is essential, and we carefully monitor for signs of infection, such as fever, redness, swelling, or drainage.

• Monitoring for Complications: Close monitoring of vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, is critical in the immediate postoperative period. We also monitor for bleeding, bowel function, and potential leaks at the surgical site. Regular blood tests are performed to assess for infection or organ dysfunction.

• Nutritional Support: Early mobilization and initiation of a clear liquid diet followed by a gradual advancement to a regular diet are encouraged. Nutritional support may be provided intravenously if necessary. We pay close attention to potential gastrointestinal issues due to the surgical approach.

• Discharge Planning: Thorough discharge instructions are provided to the patient and caregiver, including details on pain medication, wound care, dietary restrictions, and follow-up appointments. We often coordinate with physical and occupational therapists to ensure a smooth transition back home.

Patient selection for TERS is critical to ensure procedural success and minimize risk. We meticulously assess each patient to determine if they’re a suitable candidate.

• Disease Assessment: We evaluate the nature, location, and extent of the retroperitoneal pathology. TERS is best suited for lesions that are accessible via the transgastric approach and are not excessively large or invasive.

• Patient Assessment: We assess the patient’s overall health, including their cardiac, respiratory, and renal function. Patients with significant comorbidities or significant medical instability are generally not ideal candidates.

• Surgical Skill and Infrastructure: The availability of experienced surgeons with expertise in both laparoscopy and endoscopy is crucial. Appropriate infrastructure, including advanced imaging and surgical equipment, is also necessary.

• Example: A patient with a small, localized retroperitoneal tumor easily accessible transgastrically and in good overall health would be an ideal candidate. Conversely, a patient with a large, invasive tumor extending beyond the reach of TERS or with severe underlying medical conditions might not be.

Counseling patients about TERS involves a transparent discussion of both its benefits and potential risks. This ensures informed consent and manages patient expectations.

• Benefits: I emphasize the minimally invasive nature of the procedure, which typically leads to less pain, shorter hospital stays, faster recovery times, and smaller scars compared to open surgery. I explain how it can offer a potential cure or significant improvement in quality of life for suitable conditions.

• Risks: I discuss the potential risks, such as bleeding, infection, perforation of organs, leakage at the surgical site, and the rare possibility of needing conversion to open surgery. I also explain potential complications specific to the transgastric approach, such as injury to the stomach or adjacent structures.

• Shared Decision Making: The discussion is not one-sided. I aim to make it a collaborative process, allowing the patient to ask questions, express concerns, and make informed decisions about their care.

• Example: I would explain to a patient that while TERS offers a less invasive approach with a quicker recovery, there is a small but real chance of bleeding that might require further intervention.

Long-term outcomes of TERS are generally favorable for appropriately selected patients. Follow-up assessments are crucial to monitor for recurrence of the disease or any late complications.

• Recurrence Rates: These depend heavily on the type and nature of the treated pathology. Regular follow-up imaging, such as CT scans or MRI, is employed to detect any recurrence.

• Quality of Life: Most patients experience a significant improvement in their quality of life post-TERS, with reduced pain and improved functional capacity. We often use validated questionnaires to measure this objectively.

• Long-Term Complications: Long-term complications are rare but can include persistent pain, bowel obstruction, or adhesions. However, these are less frequent than with open surgery.

• Ongoing Research: Ongoing research continues to refine our understanding of long-term outcomes and improve patient selection criteria to further optimize success rates.

Addressing patient anxiety before a TERS procedure is a critical part of the pre-operative process. It involves empathy, open communication, and education.

• Empathetic Approach: I acknowledge the patient’s anxiety, validating their feelings. This creates a safe space for them to express their concerns.

• Detailed Explanation: I provide a clear and comprehensive explanation of the procedure, addressing any misconceptions. I use simple language, avoiding complex medical jargon. Visual aids like diagrams or videos can be very helpful.

• Realistic Expectations: I set realistic expectations about the procedure, recovery process, and potential risks. Overly optimistic or overly pessimistic approaches are avoided.

• Pain Management Discussion: I discuss the pain management plan in detail, reassuring the patient that their pain will be managed effectively post-operation.

• Preoperative Visit: I offer a pre-operative visit to answer questions and provide reassurance, which can significantly alleviate anxiety. The opportunity to meet the surgical team also helps build trust.

Current research trends in TERS are focused on improving its efficacy, safety, and expanding its applications.

• Minimally Invasive Techniques: Research is ongoing to further refine the minimally invasive nature of the procedure, exploring even smaller incisions and less invasive access routes.

• Robotic Assistance: The integration of robotic technology is actively explored to enhance precision and dexterity during the procedure (as discussed further in the next question).

• Improved Imaging: Advanced imaging techniques, such as intraoperative ultrasound and fluorescence imaging, are being explored to enhance visualization and improve the accuracy of tumor resection.

• Expanded Indications: Studies are investigating the potential of TERS for a wider range of retroperitoneal pathologies.

• Long-Term Outcomes Studies: Larger, long-term outcome studies are being conducted to further clarify the long-term benefits and risks associated with TERS.

My experience with robotic-assisted TERS has been very positive. It offers significant advantages over conventional laparoscopic TERS.

• Enhanced Precision: Robotic arms provide superior dexterity and precision compared to traditional laparoscopic instruments, allowing for more precise dissection and resection of retroperitoneal lesions.

• Improved Visualization: The high-definition 3D visualization provided by the robotic system allows for a better understanding of the surgical anatomy, facilitating more accurate and safe surgery.

• Ergonomics: The ergonomic design of the robotic console reduces surgeon fatigue during long procedures, potentially improving surgical precision and minimizing errors.

• Minimally Invasive Approach: The robotic approach maintains the minimally invasive nature of TERS, preserving the benefits of smaller incisions, less pain, and faster recovery.

• Example: In a complex case involving a retroperitoneal tumor adjacent to major vessels, the robotic system’s dexterity allowed for precise dissection and removal of the tumor without compromising the integrity of the adjacent structures.

Managing unexpected findings during a TERS procedure requires a calm, systematic approach. Our primary strategy is meticulous preoperative planning, including detailed imaging review (CT, MRI) to anticipate potential challenges. However, surprises are inherent in surgery. If we encounter an unexpected anatomical variation, such as unusual vascularity or adhesion formation, we immediately reassess the surgical plan. This might involve adapting the approach, employing additional visualization techniques (e.g., intraoperative ultrasound), or even converting to a more open procedure if necessary. For example, if we discover a larger-than-anticipated tumor invading critical structures, we might need to adjust our resection strategy to ensure complete removal while minimizing damage to adjacent organs. Communication with the anesthesiology team is crucial to ensure patient safety and stability during any adjustments to the procedure. Careful documentation of all findings and decisions is paramount for learning and improving future cases.

TERS involves a complex interplay of anatomical structures. The procedure accesses the retroperitoneum – the space behind the abdominal cavity – through a transgastric approach. This means we’re working through the stomach wall. Key structures we encounter include the stomach itself, the greater curvature, the lesser omentum, the pancreas, the great vessels (aorta, vena cava), the kidneys, the ureters, and various lymphatic chains. A thorough understanding of their location, relationships, and variations is essential to avoid injury. We utilize meticulous dissection techniques, employing advanced endoscopic instruments and visualization, including endoscopes with narrow-angle views and advanced magnification capabilities, to navigate these delicate anatomical regions. For instance, meticulous identification of the renal vessels and ureters is crucial to prevent iatrogenic injuries during tumor resection. A comprehensive understanding of the vascular anatomy ensures safe and efficient hemostasis (control of bleeding) during the procedure.

My experience encompasses a wide spectrum of retroperitoneal tumors, including benign and malignant lesions. I’ve managed cases involving adrenal tumors (both pheochromocytomas and adenomas), sarcomas (such as liposarcomas and leiomyosarcomas), lymphomas, and metastatic disease. Each tumor type presents unique challenges. For instance, pheochromocytomas require careful preoperative alpha- and beta-blocker management to control potential hypertensive crises. Sarcomas often present with significant vascularity requiring meticulous dissection and hemostasis. The surgical approach and extent of resection are tailored to the specific tumor type, size, location, and patient’s overall health. For example, a small, encapsulated adrenal adenoma might require a minimally invasive resection, while a large, locally advanced sarcoma could necessitate a more extensive approach, potentially involving resection of adjacent structures.

TERS differentiates itself from other minimally invasive techniques through its unique access point. While laparoscopic and robotic surgery access the retroperitoneum through abdominal incisions, TERS utilizes the stomach as a portal. This offers specific advantages, particularly for tumors located in the upper retroperitoneum, where access through traditional laparoscopic approaches can be challenging. The transgastric approach allows for a less invasive route with reduced abdominal wall trauma and smaller incisions. However, it also has inherent limitations, such as the need for advanced endoscopic skills and potential risks associated with gastric wall perforation. We meticulously weigh the benefits and risks for each patient before choosing the optimal surgical approach. Ultimately, the best technique depends on individual factors such as tumor location, size, patient’s body habitus, and surgeon’s expertise.

Preventing complications in TERS is a top priority. Our strategies focus on meticulous preoperative planning, including a thorough assessment of the patient’s overall health and the tumor characteristics. This includes advanced imaging studies and sometimes even invasive procedures like biopsies. During the procedure, meticulous technique is paramount. We use advanced endoscopic instruments, including those with enhanced visualization and energy delivery systems (e.g., ultrasonic shears, LigaSure devices), to minimize damage to surrounding structures. Careful attention is given to hemostasis to prevent bleeding. Postoperatively, close monitoring for potential complications like bleeding, infection, and gastric leakage is critical. Early detection and prompt management of these complications is vital for optimizing patient outcomes. For example, we routinely use prophylactic antibiotics and closely monitor vital signs for any indication of sepsis.

Our approach to quality improvement in TERS involves continuous monitoring of our outcomes and a commitment to learning from every case. We meticulously document all procedures, including details of the surgical technique, findings, and complications, creating a database for analysis. We regularly review these data to identify areas where improvements can be made. This includes evaluating factors such as operative time, blood loss, length of hospital stay, and postoperative complications. We actively participate in continuing medical education, attend conferences, and stay updated on the latest surgical techniques and technologies. We also participate in multidisciplinary tumor boards to discuss challenging cases and ensure optimal patient management. Furthermore, we regularly participate in audits and peer reviews to analyze our performance against established benchmarks.

Staying current with advancements in TERS is an ongoing process. I regularly attend national and international conferences dedicated to minimally invasive and advanced surgical techniques, specifically those focused on retroperitoneal surgery. I actively participate in professional societies such as the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and regularly review peer-reviewed publications in high-impact journals, focusing on the latest research and innovations in TERS, including new instruments, techniques, and treatment modalities. I also collaborate with other specialists in related fields, such as radiology and oncology, to ensure I’m aware of the newest advances in imaging techniques and cancer treatment protocols that might inform my surgical decision-making. Continuous learning and adaptation are essential in this rapidly evolving field.