Totally stapled gastrojejunal anastomosis using hybrid NOTES ? single 12 mm trocar approach

Lino Polese, MD, PhD, Stefano Merigliano, MD, Gianfranco Da Dalt, MD, Roberto Luisetto, BD, Lorenzo Norberto, MD

Department of Surgery, Oncology and Gastroenterology, Padova University, Italy

Objective of the technology or device
To perform a totally stapled gastrojejunal anastomosis using hybrid NOTES –single 12-mm trans-abdominal trocar approach.

Description of the technology and method of its use or application
A 12 mm Hasson trocar is positioned in the left hypocondrium and a gastroscope is introduced for the following maneuvers. By puncturing under vision the stomach from outside in two different places, two wires are passed through the anterior and posterior gastric wall, pulled and tied out of the mouth. After a jejunal loop is chosen, pulled out (after enlarging the trocar abdominal incision) and a 21 mm stapler anvil is introduced in it and closed with purse string on the loop antimesenteric site, the external part of the anvil is connected with a “cutting system” and then to the wire coming from the posterior gastric wall. By pulling the other wire from the outside, the cutting system reaches and passes through the posterior gastric wall, dragging the external part of the anvil into the stomach, while the internal part and the jejunal loop remain close to the posterior gastric wall. After removal of the cutting system through a small gastrotomy, a stapler is introduced, connected to the anvil and fired performing a circular stapled latero-lateral anastomosis between the posterior gastric wall and the jejunal loop. The gastrotomy is closed with a linear stapler.

Preliminary results if available
The procedure was carried out on 8 domestic pigs of 45 kg using a NOTES hybrid technique with a gastroscope and a 12-mm Hasson trocar, positioned in the left hypocondrium. In all cases the procedure was completed through a single 3 cm abdominal incision, without intraoperative complications. The mean operation time was 2 hours, and endoscopic investigation showed that the anastomoses were intact, patent and airtight. In survival models no complications were found during follow-up and anastomoses were regular and well-functioning at control.

Conclusions/Future directions Totally stapled gastrojejunal anastomosis using a hybrid NOTES –single 12 mm trocar approach is a simple and safe procedure in the porcine model. Further studies are warranted to evaluate the functional and metabolic results of this procedure. The cutting system connected with the anvil was required to perform the procedure.

Session: Poster Presentation

Program Number: ETP045