Small Bowel Resection and Anastomosis Using “notes”: Lessons Learned in a Survival Model

INTRODUCTION: Natural orifice translumenal endoscopic surgery (NOTES) has been used for a number of technically straightforward surgical procedures. However, to date, no one has reported using NOTES technique for small bowel resection and anastomosis in a survival model.
METHODS AND PROCEDURES: All studies were conducted in accordance with Institutional Animal Care and Use Committee (IACUC) protocols. Five female swine (20-40 kg) under general anesthesia underwent resection of 10 cm of small bowel with stapled side-to-side anastomosis using a dual-endoscopic approach. Only commercially available staplers and instruments were used. Visualization and manipulation were achieved via a trans-gastric endoscope, while transvaginal access into the rectovesical recess permitted introduction of staplers and endoscopic instruments into the peritoneal cavity. Resected specimens were retrieved through the transvaginal port. Recovery was achieved up to 5 days postoperatively.
RESULTS: Using standard endoscopic equipment and commercially available bowel stapling devices, the procedure was extraordinarily challenging. Resection of a segment of small bowel was achieved in each case. However, two out of five attempts (40%) completely failed to achieve re-anastomosis of the divided ends of bowel (after prolonged attempts using all available equipment to achieve the result via the NOTES method), requiring premature sacrifice of those two animals. The remaining three studies resulted in bowel obstruction at the anastomosis (two cases), and peritonitis on the third postoperative day (one case, possibly due to an anastomotic leak).
CONCLUSION: Although complex surgical procedures such as bowel anastomosis can be achieved via NOTES, the technical failure rate using current instrumentation is unacceptably high. Clearly bowel resection and anastomosis reaches a greater level of difficulty than other procedures previously achieved successfully with NOTES. Bowel resection and anastomosis should not be attempted in human patients via NOTES until it has been clearly demonstrated to be not only feasible, but also safe and reproducible, in a relevant survival animal model, in which post-operative complications may be discovered. Use of the survival model also unmasks potential issues which may not be discovered in non-survival models. Potential areas for improvement in technology have been identified, and include the need for greater intraperitoneal mobility and manipulation of tissue.

Session: Podium Presentation

Program Number: S124