Introduction: We previously reported successful transvaginal NOTES cholecystectomy in porcine models but experienced difficulty with pneumoperitoneum gas leakage when Magnetic Anchoring and Guidance System (MAGS) and endoscopic instruments were used in conjunction with conventional trocar seals. The purpose of this study was to evaluate the utility of a novel access port for this procedure.
Methods: Non-survival experiments were performed in pigs (n=3, 30-35kg). Through a vaginotomy created under direct vision, a rigid access port (24mm inner diameter, 28mm outer diameter, 45cm long) was inserted into the peritoneal cavity. The prototype port was equipped with an Air Seal (SurgiQuest), which allowed simultaneous passage of multiple instruments through the single lumen by creating a steady-state of gas (air) flow into and out of the sealing chamber in a vortex-like fashion. Cholecystectomy was performed using a combination of deployable MAGS instruments (graspers, cautery dissector), a gastroscope (visualization, clipping), and articulating rigid graspers (60-70cm long, 5mm diameter, Novare).
Results: An excellent seal (no appreciable gas leakage) was uniformly maintained during simultaneous use of the tethered (mechanical, electrical, pneumatic) MAGS instruments, gastroscope, and articulating rigid graspers. Cholecystectomy was performed in all cases with relatively short mean operative time (2.6 hrs) compared to historical controls (3.75 hrs), due to the distinct ease of passing MAGS instruments directly and rapidly through the Air Seal without backloading tethers or disconnecting equipment. The major limitation was our inability to achieve a pneumoperitoneum pressure above 7mmHg due to the air pump’s capacity. Because of limited intrabdominal working space, a break in the cautery insulation caused a gastric burn and inadequate gallbladder retraction using MAGS graspers required the use of rigid graspers for assistance in 2 cases. No port related problems occurred in cases 1-2, but a significant injury to the vagina was noted at autopsy on the final case in a relatively small pig (30kg).
Conclusions: The Air Seal access port may be very useful for NOTES procedures, as this technology prevents gas leakage when a wide variety of instrument configurations are used. Additional investigations are warranted to further improve pneumoperitoneum pressure and other procedural aspects.
Program Number: P222