Scar-Less Surgery by Abhay Rane Jeffrey A. Cadeddu Mihir M. Desai & Inderbir S. Gill

Author:Abhay Rane, Jeffrey A. Cadeddu, Mihir M. Desai & Inderbir S. Gill
Language: eng
Format: epub
Publisher: Springer London, London

Transgastric NOTES

A transgastric approach introduces the risk of intraperitoneal contamination and infection due to exposure to gastric and bowel contents. In addition, maintaining the spatial orientation is difficult, and all instruments pass through working channels on the endoscope, with the light source and camera in line. With this approach, some maneuvers require working off-axis, further increasing the difficulty of complex procedures. Nevertheless, the transgastric route has garnered significant interest as a NOTES portal for a variety of surgical procedures.

Kalloo et al. was the first to describe the application of transgastric NOTES in an animal model in 2004 [23]. In 50-kg pigs, access to the peritoneal cavity was obtained perorally through an endoscope by needle-knife (Olympus, Center Valley, PA) puncture followed by either an extension of the incision with a sphincterotome or balloon dilation over a guidewire. Transgastric peritoneoscopy and liver biopsy were subsequently performed without complication in either acute or long-term survival animals, and the gastrotomy was closed with clips (EndoClips™; Olympus Optical Co., Tokyo, Japan).

Although the safety and feasibility of the transgastric approach were demonstrated in this initial study, subsequent attempts at organ resection via this portal exposed its limitations. Wagh et al. reported an inability to visualize the gallbladder in four of nine pigs and a difficulty identifying retroperitoneal structures; however, they did successfully perform oophorectomy and partial hysterectomy in some animals [24]. They also noted that the scope stability is limited when attempting to access upper abdominal organs in retroflexion. In another experiment, Merrifield et al. encountered a 40 % complication rate (two of five pigs) following transgastric partial hysterectomy, as one pig suffered peritonitis secondary to incomplete closure of the gastric incision and another was found to have a gastric abscess at the incision site [25]. Thus, full-thickness, watertight closure of the gastric incision site is crucial, and the development of improved closure techniques ensued. Currently, a plethora of NOTES gastrotomy closure devices exist, ranging from clips and staplers to threaded tags/anchors and endoscopic suturing tools, and further research and development are ongoing.

The development of a platform specific to flexible endoscopic procedures was investigated by Swanstrom et al. [26]. Following prototype testing in inanimate models, dogs and pigs were subsequently used in nonsurvival experiments, including transgastric liver biopsy, bowel retraction and manipulation, and cholecystectomy. Their novel instrumentation utilized the ShapeLock® technology (USGI Medical, San Clemente, CA), which allows a scope to be advanced, positioned, and then locked into place for stability. With larger working channels, a prototype 4-mm Pentax flexible scope, and independently movable arms, they were able to successfully perform the procedures with improved optics and triangulation. However, of concern was that despite gastrotomy closure in five animals, only one was found to have a watertight closure on explant testing.

Indeed, an efficient, reliable, and reproducible gastric closure technique is absolutely requisite to the acceptance of this NOTES approach. Moreover, the size of specimens extracted from a gastrotomy site is limited. Accordingly, these issues must be addressed in further ex vivo and animal models prior to routine application in humans.

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