Endoscopy 2007; 39(10): 849-853
DOI: 10.1055/s-2007-966844
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Preliminary pneumoperitoneum facilitates transgastric access into the peritoneal cavity for natural orifice transluminal endoscopic surgery: A pilot study in a live porcine model

C.-W.  Ko1 , E.  J.  Shin2 , J.  M.  Buscaglia2 , J.  O.  Clarke2 , P.  Magno2 , S.  A.  Giday2 , S.  S.  C.  Chung3 , P.  B.  Cotton4 , C.  J.  Gostout5 , R.  H.  Hawes4 , P.  J.  Pasricha6 , A.  N.  Kalloo2 , S.  V.  Kantsevoy2
  • 1Division of Gastroenterology, Taichung Veterans’ General Hospital, Taichung, and Division of Gastroenterology National Yang-Ming University, Taipei, Taiwan
  • 2Division of Gastroenterology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
  • 3Department of Surgery, Chinese University of Hong Kong, Hong Kong
  • 4Medical University of South Carolina, Charleston, South Carolina, USA
  • 5Mayo College of Medicine, Rochester, Minnesota, USA
  • 6University of Texas Medical Branch in Galveston, Galveston, Texas, USA
Further Information

Publication History

submitted 28 March 2007

accepted after revision 30 July 2007

Publication Date:
29 October 2007 (online)

Background and study aims: Safe entrance into the peritoneal cavity through the gastric wall is paramount for the successful clinical introduction of natural orifice transluminal endoscopic surgery (NOTES). The aim of the study was to develop alternative safe transgastric access to the peritoneal cavity.

Patients and methods: We performed 11 survival experiments on 50-kg pigs. In sterile conditions, the abdominal wall was punctured with a Veress needle. The peritoneal cavity was insufflated with 2 L carbon dioxide (CO2). A sterile endoscope was introduced into the stomach through a sterile overtube; the gastric wall was punctured with a needle-knife; after balloon dilation of the puncture site, the endoscope was advanced into the peritoneal cavity. Peritoneoscopy with biopsies from abdominal wall, liver and omentum, was performed. The endoscope was withdrawn into the stomach. The animals were kept alive for 2 weeks and repeat endoscopy was followed by necropsy.

Results: The pneumoperitoneum, easily created with the Veress needle, lifted the abdominal wall and made a CO2-filled space between the stomach and adjacent organs, facilitating gastric wall puncture and advancement of the endoscope into the peritoneal cavity. There were no hemodynamic changes or immediate or delayed complications related to pneumoperitoneum, transgastric access, or intraperitoneal manipulations. Follow-up endoscopy and necropsy revealed no problems or complications inside the stomach or peritoneal cavity.

Conclusions: Creation of a preliminary pneumoperitoneum with a Veress needle facilitates gastric wall puncture and entrance into the peritoneal cavity without injury to adjacent organs, and can improve the safety of NOTES.

References

  • 1 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005.  Surg Endosc. 2006;  20 329-333
  • 2 Kavic M S. Natural orifice translumenal endoscopic surgery: ”NOTES”.  JSLS. 2006;  10 133-134
  • 3 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
  • 4 Jagannath S B, Kantsevoy S V, Vaughn C A. et al . Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model.  Gastrointest Endosc. 2005;  61 449-453
  • 5 Wagh M S, Merrifield B F, Thompson C C. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model.  Gastrointest Endosc. 2006;  63 473-478
  • 6 Kantsevoy S V, Jagannath S B, Niiyama H. et al . Endoscopic gastrojejunostomy with survival in a porcine model.  Gastrointest Endosc. 2005;  62 287-292
  • 7 Kantsevoy S V, Hu B, Jagannath S B. et al . Transgastric endoscopic splenectomy: is it possible?.  Surg Endosc. 2006;  20 522-525
  • 8 Park P O, Bergstrom M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis [videos].  Gastrointest Endosc. 2005;  61 601-606
  • 9 Pai R D, Fong D G, Bundga M E. et al . Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model [with video].  Gastrointest Endosc. 2006;  64 428-434
  • 10 Kantsevoy S V, Jagannath S B, Niiyama H. et al . A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures.  Gastrointest Endosc. 2007;  65 497-500
  • 11 Kalloo A NKS, Singh V K, Magee C A. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastroenterology. 2000;  118 A1039
  • 12 Wilhelm D, Meining A, von Delius S . et al . An innovative, safe and sterile sigmoid access (ISSA) for NOTES.  Endoscopy. 2007;  39 401-406
  • 13 Litynski G S, Paolucci V. Origin of laparoscopy: coincidence or surgical interdisciplinary thought?.  World J Surg. 1998;  22 899-902
  • 14 Inan A, Sen M, Dener C, Bozer M. Comparison of direct trocar and Veress needle insertion in the performance of pneumoperitoneum in laparoscopic cholecystectomy.  Acta Chir Belg. 2005;  105 515-518
  • 15 Rosen D M, Lam A M, Chapman M. et al . Methods of creating pneumoperitoneum: a review of techniques and complications.  Obstet Gynecol Surv. 1998;  53 167-174
  • 16 Cakir T, Tuney D, Esmaeilzadem S, Aktan A O. Safe Veress needle insertion.  J Hepatobiliary Pancreat Surg. 2006;  13 225-227
  • 17 Veress J. A needle for the safe use of pneumoperitoneum.  Gastroenterologia. 1961;  96 150-152
  • 18 Philips P A, Amaral J F. Abdominal access complications in laparoscopic surgery.  J Am Coll Surg. 2001;  192 525-536
  • 19 Agresta F, De Simone P, Ciardo L F, Bedin N. Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized prospective single-center study.  Surg Endosc. 2004;  18 1778-1781
  • 20 Ponsky J L. Complications of laparoscopic cholecystectomy.  Am J Surg. 1991;  161 393-395
  • 21 Neudecker J, Sauerland S, Neugebauer E. et al . The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery.  Surg Endosc. 2002;  16 1121-1143
  • 22 Jansen F W, Kolkman W, Bakkum E A. et al . Complications of laparoscopy: an inquiry about closed- versus open-entry technique.  Am J Obstet Gynecol. 2004;  190 634-638

S. V. Kantsevoy , MD PhD

Johns Hopkins Hospital

Division of Gastroenterology

1830 East Monument Street, Room 423

Baltimore, MD 21205

USA

Fax: +1-410-614-2490

Email: svkan@jhmi.edu

    >