Directed Submucosal Tunneling for Transgastric NOTES Procedures

Background: Prior natural orifice translumenal endoscopic surgery (NOTES) work has shown the feasibility and the advantages of obtaining peritoneal access by using a tunneled translumenal approach. Objective: We evaluated the feasibility of creating directed transgastric submucosal tunnels with the goal of positioning the endoscope in an in-line position with target abdominal locations.

Methods: We obtained transgastric peritoneal access in 7 swine (mean 30 kg) utilizing our previously described self-approximating translumenal access technique (STAT). As highlighted in our video, target intra-abdominal locations included the right upper quadrant, left upper quadrant, the pelvis and the lesser sac. Briefly, the mucosa was elevated by saline injection and submucosal access was obtained via needle-knife incision. Animals were euthanized after a two week survival period.

Results: Directed submucosal tunneling was feasible and allowed the endoscope to be in an in-line position with the defined target locations. Tunnels were started 1.7 ± 1.4 cm distal to the GE junction. Tunnel formation required 38.4 ± 32.2 minutes. Peritoneoscopy was performed for 33.6 ±14.2 minutes. There were 3 small mucosal tears. Animals thrived in the post-operative period, gaining 5.1 ± 1.4 kg. Necropsy revealed well-healed mucosal and seromuscular incisions and no intra-abdominal or intra-mural infections. Average tunnel length was 7.9 ± 2.7 cm. One animal had minor abdominal adhesions.

Conclusion: Directed transgastric submucosal tunneling is technically feasible in a survival porcine model. This technique allowed in-line positioning of the endoscope with target abdominal locations and permitted reliable gastrotomy closure. Larger numbers of animals are required to determine the reliability of this method, but we remain optimistic that directed submucosal tunneling may prove beneficial for transgastric NOTES procedures.

Session: Podium Presentation

Program Number: V016

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