Techniques for Transgastric Access to the Peritoneal Cavity
Section snippets
Animal selection and preparation
Given anatomic similarities to humans, accessibility, and the economy of the model, the pig has become the most popular animal model for training and research in laparoscopic surgery. For the same reasons, the porcine model is being used to evaluate the technical feasibility of NOTES. Domestic pigs 20 to 50 kg have a functional size to the peritoneal cavity. The stomach may generally be considered empty after 8 to 12 hours of fasting, but larger animals may require as long as 48 hours, which
Gastrotomy techniques
Despite advances in laparoscopic instruments and increasing laparoscopic surgical experiences, complications associated with peritoneal access are relatively common and involve a range of intra-abdominal organ injuries [14], [15], [16], [17], [18], [19], [20], [21], [22]. This technical challenge of the first procedural step for any intraperitoneal surgery might be more challenging in NOTES, especially in the absence of specialized instrumentation, such as the Veress needle and the optical
Transgastric access to target organs
The organs in the lower half of the peritoneal cavity are easily accessible by a transgastric approach. Various surgical manipulations have already been successfully attempted, including gynecologic procedures, such as hysterectomy, oophorectomy, ligation, and resection of the uterine horn (Fig. 3) [8], [11]. In anticipation of early NOTES surgery drawing from the advantages of a straight scope position and direct acces from an anterior gastrotomy, we created an in vivo animal model of early
Gastrotomy closure
Simple mucosal apposition with commercially available hemoclips has been used for gastrotomy closure after NOTES. It is technically challenging, however, to approximate thickened (edema and hemorrhage) gastric mucosa at a gastrotomy site after a lengthy surgical procedure. The closure of a large gastrotomy created with a sphincterotome can be even more challenging, as mentioned above.
Several endoscopic tissue apposition devices (tissue anchors) have been developed to establish a robust
Summary
The preliminary experiences in the porcine models have been encouraging for transgastric access to the peritoneal cavity. Creating optimally designed devices for flexible endoscopic NOTES is challenging. Simple diagnostic procedures, such as peritoneoscopy, may be acceptable for human trial in the near future. In general, the number of animals used in studies is uniformly small. The porcine model, which is the animal model used for NOTES study thus far, can withstand peritoneal soiling, and may
References (30)
- et al.
Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model
Gastrointest Endosc
(2006) - et al.
Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video)
Gastrointest Endosc
(2007) - et al.
Pilot study of the porcine uterine horn as an in vivo appendicitis model for development of endoscopic transgastric appendectomy
Gastrointest Endosc
(2006) - et al.
Peroral transgastric organ resection: a feasibility study in pigs
Gastrointest Endosc
(2006) - et al.
Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance
Gastrointest Endosc
(2006) - et al.
Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model
Clin Gastroenterol Hepatol
(2005) - et al.
Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos)
Gastrointest Endosc
(2005) - et al.
Endoscopic gastrojejunostomy with survival in a porcine model
Gastrointest Endosc
(2005) - et al.
Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model
Gastrointest Endosc
(2005) - et al.
Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity
Gastrointest Endosc
(2004)
Novel multi-bending endoscope with new forceps elevating and swinging knife functions facilitates endoscopic submucosal dissection for early gastric cancer
Gastrointest Endosc
Bowel injury in open technique laparoscopic cannula placement
Urology
Optical access trocar injuries in urological laparoscopic surgery
J Urol
Complications of laparoscopic surgery: How to avoid them and how to repair them
J Minim Invasive Gynecol
Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors
Gastrointest Endosc
Cited by (20)
Emerging Intramural and Transmural Endoscopy
2011, Clinical Gastrointestinal Endoscopy, Second EditionGastric wall healing after NOTES procedures: Closure with endoscopic clips provides superior histological outcome compared with threaded tags closure
2010, Gastrointestinal EndoscopyCitation Excerpt :Gastric wall closure with endoscopic clips can be technically challenging. Both Sumiyama et al11 and Merrifield et al10 reported failures to pull the incision edges together and close the gastrotomy by using clips, with more difficulties when edema and hemorrhage were present.16 In our study, Resolution clips (Boston Scientific Microvasive) were chosen because of their large size (facilitating application and tissue approximation) and longest duration of retention at the site of deployment compared with other available endoscopic clips.30
Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans
2010, Gastrointestinal EndoscopyThe future of gastrointestinal therapeutic endoscopy: NOTES
2009, Gastroenterologie Clinique et BiologiqueNatural Orifice Translumenal Endoscopic Surgery
2008, Surgical Clinics of North AmericaCitation Excerpt :Alternatively, a sphicterotome over a guidewire may be used to incise the gastric wall over several centimeters [1]. The former technique may be superior in that the dilation may be less traumatic then a sphicterotome incision, and because the muscle fibers spring back together following endoscope withdrawal, closure may be simplified [26]. Other peritoneal access techniques include PEG-like percutaneous puncture and guidewire insertion into the stomach before gastrotomy creation [27].