Hybrid Transvaginal NOTES Sleeve Gastrectomy in a Pocine Model Using a Magnetically Anchored Camera and Novel Instrumentation

Introduction: The purpose of this study was to determine the feasibility of transvaginal NOTES sleeve gastrectomy using novel instrumentation in a porcine model.
Methods: Anesthetized pigs (non-survival (n=7), 14-day survival (n=1)) underwent sleeve gastrectomy procedures. Under endoscopic visualization, a 25mm x 40cm access port was inserted through a vaginotomy into the peritoneal cavity using blunt dissection (n=5) or a rigid optical obturator (n=3). A Magnetic Anchoring and Guidance System (MAGS) video camera was deployed intra-abdominally and used for subsequent visualization. A long 5mm rigid grasper inserted transvaginally outside of the access port and a 3 mm laparoscopic grasper inserted through a transabdominal left flank trocar were used for tissue manipulation. Percutaneous T-tags were placed at the gastric fundus for retraction. A transorally placed gastroscope was used for gastric tube calibration. Prototype long (61-82cm) transvaginal staplers were used for stomach and vascular division. Alternatively, an endoscopic bipolar sealing device was used for vascular division (n=3). Values are mean ± s.d.
Results: Operative time was 169 ± 46 minutes and blood loss was 156 ± 109 cc. The entire procedure was completed in 4 of 8 cases. Incomplete procedures were due to stapler malfunction (3 cases) and esophageal transection (1 case). Gastric division was completed in 5 of 8 cases; in 4 cases, acceptable tube geometry and volume (165 ± 34 cc) were achieved with no staple line leaks detected in 3 cases. Stapled short gastric vascular division was completed in 7 of 8 cases; bipolar vascular sealing was ineffective in 3 of 3 attempted cases. The MAGS camera was used for 100% of the procedure in 8 of 8 cases but required flexible endoscopic assistance for illumination in 2 cases when the onboard LED’s failed; significant fogging was encountered in 2 cases. At autopsy, there were 2 rectal injuries due to instrument insertion outside of the access port, 1 bladder injury due to optical obturator insertion, and 1 splenic vessel injury due to T-tag penetration. The survival animal thrived post-operatively and had no complications.
Discussion: Transvaginal sleeve gastrectomy appears to be feasible in a porcine model but complications may occur when instruments are inserted without appropriate visualization or protection within a transvaginal access port. Additional device development may yield improved outcomes.

Session: Poster

Program Number: P280

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