Techniques for Transgastric Access to the Peritoneal Cavity

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Natural orifice translumenal endoscopic surgery (NOTES) is a unique emerging surgical concept expanding flexible endoscopy beyond the gut wall. The methods and technology growing from this concept may minimize trauma from surgical access to the peritoneal cavity by completely eliminating body surface incisions. So far, NOTES surgeries have been reported by modifying laparoscopic surgery. The peroral transgastric route was chosen to access the peritoneal cavity in initial trials because of a potentially lower risk for surrounding organ injury using the anterior wall percutaneous endoscopic gastrostomy–style gastrotomy. This article reviews and describes techniques of transgastric access to the peritoneal cavity used in published animal studies.

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)

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    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].

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