NOTES-Inspired Sleeve Gastrectomy

Elie CHOUILLARD, MD, Abe Fingerhut, MD FACS. On behalf of the Intercontinental Society of Natural Orifice, Endoscopic, and Laparoscopic Surgery (i-NOELS), Poissy, FRANCE

Aim: Miniaturization of the access into the abdominal cavity is, nowadays, gaining popularity. Theoretical advantages include reduced abdominal wall complications, less postoperative pain, reduced genesis of adhesions, shorter hospital stay, faster return to activity and productivity, and preserved cosmesis. Due to the still unresolved technical hurdles, the so-called “hybrid” NOTES approach was developed. Obese patients may theoretically benefit most from these techniques due to a would-be lower abdominal wall-related morbidity. We undertook a pilot study evaluating the Sleeve Gastrectomy under these novel techniques emphasizing feasibility, safety, limitations, and nomenclature problems of these procedures.
Patients and Methods: In January 2008, we started a prospective evaluation of NOTES-related techniques including Bariatrics. Sleeve Gastrectomy could be performed according to three techniques:
– A standardized, vaginal “Hybrid” NOTES technique (i.e., two vaginal ports and one umbilical assistance port), called the v-Sleeve
– Single Incision access Sleeve Gastrectomy (SIS) using one umbilical incision solely
– Single Incision Access Sleeve Gastrectomy with vaginal assistance (i.e., Two abdominal ports with vaginal assistance through one port) (v-SIS)
– Needlescopic Sleeve Gastrectomy with gastric extraction of the operative specimen (n-Sleeve).
Results : 56 patients were considered elligible for the study. The conversion rate (i.e., any additional port insertion) was 21.4 % (11 patients). No major operative incident was encountered. Mortality was 0 %. No patient was transfused. Mean operative duration was 108 minutes (60-280 minutes). Oral diet was resumed on POD 1 (1-4). The postoperative morbidity rate was 3.6 %. No leak was observed. The median duration of hospital stay was 3 days (1-7).
The mean postoperative follow-up was 13 months (3-29). No major mid-term complication was found. One patient had important acid reflux and was successfully treated by StomaphyX fundoplication 14 months after surgery.
Conclusions: Sleeve Gastrectomy by NOTES-inspired techniques is feasible without any compromise either regarding the principles of the operation or the safety of the patient. However, further evaluation and standardization are still needed.

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