Transgastric Uterine Horn Resection Using a Novel NOTES Toolbox

Introduction: Natural orifice translumenal endoscopic surgery (NOTES) is a developing area of minimally invasive surgery. In order for NOTES to be performed efficiently and safely, there are several fundamental challenges that need to be addressed. These include a safe method for peritoneal access, maintenance of visualization and spatial orientation, design of instruments that provide articulation for dissection and adequate tissue exposure, specimen retrieval, and reliable access closure methods.

Methods and Procedures: Unilateral uterine horn resection was performed in a live porcine model using the NOTES Toolbox. The Toolbox consists of prototype and newly developed devices used to create the gastrotomy, perform the dissection, retrieve the specimen, and close the gastrotomy. The procedure was performed using only NOTES instruments and video was recorded from the endoscope and an observational laparoscopic camera.

Results: A new access needle was employed that has a shielded needle, integrated dilation balloon, and guidewire that allowed for safer and easier introduction of the operating platform through the gastrotomy. A steerable flexible trocar system provided a rigid operating platform for maintenance of visualization and orientation. Articulating and rotational instruments provided greater freedom of movement, triangulation of instruments for dissection, and improved tissue retraction. A flexible bipolar energy device was used to cauterize tissue with minimal thermal spread. An endoscopic specimen retrieval bag allowed for isolation and removal of the specimen through the trocar. A full-thickness gastrotomy closure was achieved using a T-tag deployment system. The gastrotomy was inspected at necropsy and was found to be intact.

Conclusions: NOTES has several fundamental technical challenges that need to be addressed before it can gain wide acceptance. With the development and use of innovative endoscopic devices such as the ones used in the NOTES Toolbox, NOTES surgery can be more easily achieved.

Session: Podium Video Presentation

Program Number: V026

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