Introduction: Despite potential advantages of hybrid-NOTES Roux-en-Y gastric bypass (RYGBP), previous research demonstrated its limitation in human cadavers and the strong need for laparoscopic assistance during NOTES for advanced procedures. We assumed that the combination of further knowledge, new instruments and techniques would offer opportunities to perform advanced laparoscopic surgery applying single incision and natural orifice translumenal endoscopic surgery concominantly. The combination of these two techniques might result in a potentially less invasive and cosmetically superior approach when compared to conventional laparoscopy. We have tested this hypothesis in a porcine model performing gastric bypass.
Methods: Gastric pouch creation, measuring of bowel and the formation of gastro-jejunal anastomsis, the major elements of a gastric bypass, were performed in 13 female pigs with a combination of NOTES techniques and single incision laparoscopy. Pouch creation was achieved by a combination of flexible and rigid instruments through a single incision in the abdomen, endoscopic assistance through the vagina and intra-gastric retraction. Enteral measuring was performed with single incision laparoscopy. A magnet pressure anastamosis was utilized for the gastro-jejunal anastomoses. The magnets were placed in the stomach endoscopically and the opposing magnet in the corresponding part of small bowel through an open enterotomy through the incision previously used for single incision laparoscopy.
Results: Gastric pouch formation was found to be challenging as pigs do not have a retrogastric space. Significant single incision laparoscopic assistance was necessary, but sufficient in most animals during this part of the surgery. Additional trocars had to be added for further assistance in 4 animals during gastric pouch formation. Enteral measuring was feasible with single incision laparoscopy in all pigs. Magnetic anastomosis was successfully formed in less than 30 minutes all targeted pigs.
Conclusions: The combination of single incision laparoscopy and NOTES appears to be an effective approach for advanced procedures such as gastric bypass. The number of instruments can be significantly increased when needed to facilitate difficult surgical maneuvers compared to a pure NOTES approach. However, gastric pouch creation in pigs is anatomically extremely challenging. This led to a high rate of conversions in our study and may not be comparable in human patients. Formation of magnetic anastomoses appears reliable, reproducible, and applicable in a hybrid NOTES approach using only one transabdominal incision that was previously used for laparoscopic assistance. A combination of NOTES and single incision surgery appears promising to improve cosmesis and reduce the operative trauma during advanced surgery. Still, further changes in instrument design are required to improve complex hybrid endosurgical procedures and to strictly limit transabdominal assistance to only one incision.
Program Number: P270