Natural orifice translumenal endoscopic surgery (NOTES): creation of a gastric valve for safe and effective transgastric surgery in humans

Minimally Invasive Surgery Program, Legacy Health System, Suite 560, Portland, OR 97210, USA.
Surgical Endoscopy (Impact Factor: 3.26). 07/2009; 24(1):220. DOI: 10.1007/s00464-009-0547-7
Source: PubMed


NOTES has become a clinical reality. There remain, however, many challenges that need to be addressed in order to refine the technique. One of the most feared potential complications of transgastric surgery is a leak from the port of entry into the peritoneum. When withdrawing the endoscope into the gastric lumen it is difficult to make a secure closure due to the loss of pneumogastrium. We present a novel and safe technique for creating a gastrotomy developed in our animal laboratory and applied in all of our human NOTES cholecystectomies.
Using an aggressive grasping and needle-delivery device, full-thickness bites create an imbricated ridge of tissue that acts as a valve, allowing visualization while maintaining pneumogastrium when the endoscope is withdrawn from the peritoneum into the lumen. At closure, full-thickness serosa-to-serosa approximation is easily achieved due to excellent visualization.
With this technique we have been able to accomplish consistent results in ten pig models. In our series of five patients who have undergone NOTES transgastric cholecystectomy, there have been no leaks to date using the same technique. Video footage presents this technique performed on humans.
Creation of a gastric valve during transgastric surgery has proved to be a safe approach. This technique allows maintenance of insufflation and visualization during the procedure and provides a feasible and safe means of closure at the end of the procedure.

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    ABSTRACT: To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated. To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity. Prospective pilot study in humans. Single tertiary-care center. This study involved 31 patients referred for laparoscopic cholecystectomy. Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area. To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems. The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (> or = 3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1% of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients. This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict. Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.
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    ABSTRACT: Natural orifice translumenal endoscopic surgery (NOTES) is an emerging innovative approach to performing minimally invasive surgical procedures. In its full potential, the concept of incisionless surgery will have mass appeal to patients. However, the barriers to adopting NOTES will have to be overcome before widespread acceptance of these techniques can occur. These potential barriers include infection, visceral leakage, difficulties in tissue manipulation, and increased cost. The history of surgical innovation has continuously overcome similar problems in other settings, and all of these potential obstacles are likely solvable. Training surgeons will be an additional barrier that will need to be overcome, but this obstacle will need to be approached differently than when laparoscopy was introduced, as standards are higher today for privileging and credentialing in most hospitals than 20 years ago. Alternative technologies that were not adopted prior to the introduction of NOTES may now appear more viable making the competitive environment more complex. Increased funding for comparative effectiveness studies and training for competency in innovation will also need original solutions, but are clearly in our patients' best interest.
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    ABSTRACT: Since natural orifice transluminal endoscopic surgery (NOTES) was first described by Anthony Kalloo, it has attracted tremendous interest from surgeons and gastroenterologist all around the world. This special issue of the World Journal of Gastrointestinal Surgery explores the current possibilities and future potential of the most disruptive revolution in the field of surgery represented by the NOTES approach. In the future, new technologies developed for this approach and deeper insight into several gastrointestinal diseases will lead to the design of completely new interventional procedures and change the way we will operate, bringing us to the previously unimaginable goal of "no scar surgery".
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