Since the first publication on Natural Orifice Transluminal Endoscopic Surgery (NOTES)
in 2004 research interest has grown steadily [1]
[2]. It seems feasible that endoscopic surgery might be performed via a transgastric,
transvaginal, or transcolonic route of access to the peritoneal cavity [2]
[3]
[4]. There is consensus on the criticality of a secure closure following NOTES procedures
[2]
[3]
[4]. By means of endoscopic full-thickness plication (Plicator®, NDO Surgical, USA),
expeditious and easy placement of transmural sutures can be facilitated [5].
To evaluate the feasibility for gastric wall suturing, a standard nonmodified Plicator
device and 4-mm sutures ([Fig. 1]) were used in two domestic swine following NOTES cholecystectomy.
Fig. 1 Plicator device distal end. a The Plicator is retroflexed and suturing under visualization through a low profile
gastroscope (< 6 mm) is possible. b Schematic illustration of the endoscopic full-thickness suturing of the NOTES access
site to the peritoneal cavity and the Plicator sutures.
Due to the long snout and neck, the 60-cm Plicator device failed to gain transoral
access to the gastric lesions and surgically created access to the esophagus was established
([Fig. 2 ]
a). Procedure time for endoscopic placement of two sutures in the first swine was 19
minutes. Following the procedures laparotomy was performed. In the first case, the
NOTES access site was not closed properly mainly due to gastric debris and poor visibility
of the NOTES access site to the peritoneal cavity. Therefore, in the second swine
extended gastric lavage was carried out, and complete occlusion was achieved within
17 minutes utilizing two sutures. Peritoneal serosa was found to be incorporated into
the suture in the first case during laparotomy ([Fig. 2 ]
b – c). No damage to adjacent organs was found in either case.
Incorporated peritoneal serosa or damage to adjacent organs might represent a peril
of transmural suturing but a more reliable suture might be achieved compared with
endoluminal clipping techniques ([Fig. 2 ]
d). Therefore, this technique seems worthy of wider evaluation. A modified thinner
and longer device and the availability of resorbable sutures could further improve
the applicability of the Plicator in combination with NOTES.
Fig. 2 a Surgically created jugular access to the esophagus after euthanization was necessary
to gain access to the gastric wall opening. b Peritoneal serosa was found incorporated into the gastric closure after full-thickness
suturing. c Exoluminal view after gastrectomy of the suturing site with incorporated peritoneal
serosa. d Endoluminal view of the suturing site.
Acknowledgments
Material support (Plicator device and sutures) for this experiment was provided by
NDO Surgical Inc., USA
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