INTRODUCTION: Numerous experimental studies have been conducted to evaluate, explore, and develop Natural Orifice Transluminal Endoscopic Surgery (NOTES). The results have been varied ranging from mediocre to excellent. The most common challenge and perhaps the main limiting factor for the progress of NOTES has been the issue of adequate and effective gastrotomy closure. We describe a technique that provides complete closure of NOTES gastrotomy and comparing it with traditional clips.
METHODS: A total of 8 pigs (female, 30-40kg, 5-7 months old) underwent various NOTES procedures (peritoneoscopy, liver biopsy, oophorectomy, tubal ligation) via the transgastric approach. Closure of gastrotomy was done using endoclips (HX-610-090L, Olympus, Japan) in 4 pigs and endoloops (MAJ-254, Olympus, Japan) in the other 4 pigs. Assessment of closure adequacy was done via laparoscopy and at necroscopy after 2 weeks.
RESULTS: In the first 4 pigs, closure was only possible at the lateral edges of the gastrotomy. The central edges were noted to be edematous and the endoclips were unable to catch them securely enough to close the gastrotomy. A mean of 7 clips per animal (3-13) were fired in the attempted total endoclip closure. 3 out of 4 gastrotomies were subsequently closed via laparoscopic suturing. Mean endoscopic closure time was 26.6 minutes (20-35 mins) prior to conversion. Air and fluid leaks were seen on laparoscopy.
In the 4 other animals, adequate and secure closure was achieved using endoloops. A mean of 2 endoloops (1-3 endoloops) were required in each pig. Average closure time was 23.3 minutes (17-28 mins) and there were no air or fluid leaks as confirmed via laparoscopy. No laparoscopic suturing was required in the endoloop group.
CONCLUSION: In our experience, endoloop closure of gastrotomies in experimental NOTES is feasible, effective, and more secure compared to endoclip closure. The animal experience in NOTES may also serve as a platform for potential use in human gastric perforations secondary to a variety of causes.
Program Number: P197