Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

Objective  This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy. Methods  Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope. Results  A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1). Conclusion  This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.     

Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor

Background and objective  Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients. Methods  Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect. Results  LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients. Conclusions  LAEFR may be considered one of the so-called hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.     

A novel flexible endoluminal stapling device for use in NOTES colotomy closure: a feasibility study using an ex vivo porcine model

Background  

With advances in endoscopic diagnosis of early-stage gastrointestinal pathology, the need to offer minimally invasive treatment is attracting significant interest. It is essential that secure and consistent closure of full-thickness colonic resections and colotomy access be provided in natural orifice translumenal surgery (NOTES). This ex vivo porcine study aimed to evaluate a novel prototype flexible endoscopic stapler device for use in closure of full-thickness colonic defects.     

Evaluation of a modified circular stapler for use as a viscerotomy formation and closure device in natural orifice surgery

Background  

The most challenging of the many hurdles surgeons must overcome to perform natural orifice translumenal endoscopic surgery (NOTES) safely is viscerotomy closure. The perfect device must be easy to deploy, suitable for use on any viscera, and able to create a rapid, reliable, and durable closure. The authors developed a novel device based on an existing circular stapler platform to create and then subsequently close a viscerotomy. The device was tested initially on an ex vivo porcine stomach model, then used on a survival canine model to confirm adequacy of gastric closure and rapidity of deployment.     

Transvaginal endoscopic partial gastrectomy in porcine models: the role of an extra endoscope for gastric control

Background  Transvaginal natural orifice translumenal endoscopic surgery (NOTES) gastrectomy is technically challenging, because wide perigastric dissection under appropriate tissue triangulation is unfeasible with current endoscopic instruments alone. The aim of this study was to investigate the feasibility of transvaginal NOTES gastrectomy with the use of an extra endoscope as a retracting device of the stomach. Methods  This acute in vivo feasibility study was performed under the approval of the Institutional Animal Care and Use Committee (IACUC). Four female 40-kg pigs received general anesthesia and underwent transvaginal endoscopic partial gastrectomy. Under laparoscopic guidance, the uterus was fixed anteriorly and transvaginal access was established in a standard fashion. The perigastric ligaments were dissected with needle knife/insulation-tipped electrosurgical knife (IT) via transvaginally placed double-channel endoscope. This step was assisted with the second, CO₂-insufflating endoscope advanced in the stomach (i.e., so-called endoscopic gastric control). A linear stapling device with a flexible shaft was then passed transvaginally, and the anterior gastric wall was partially resected. The specimen was isolated and retrieved through the vagina. Concluding endoscopy was carried out to confirm the absence of mucosal damage due to endoscopic gastric control. This was further confirmed at necropsy immediately after sacrifice. Results  All animals underwent successful transvaginal NOTES gastrectomy. Endoscopic gastric control greatly facilitated perigastric dissection by providing appropriate tissue countertraction on the ligaments. Use of transabdominal (laparoscopic) graspers was thus minimized. There were no intraoperative complications directly related to use of the primary (transvaginal) endoscope or the additional (gastric) endoscope. Distention of downstream bowel after gastric insufflation was minimal with CO₂. No major injuries were noted on gastric mucosa at postmortem investigations. Conclusions  Transvaginal NOTES partial gastrectomy is feasible in porcine models. Use of an extra endoscope to retract the stomach is effective to minimize transabdominal assistance. Further studies on human subjects are necessary to establish this as a safe and attractive ancillary technique in NOTES.     

Natural orifice translumenal endoscopic surgery (NOTES) applied totally to sigmoidectomy: an original technique with survival in a porcine model

Background  Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investigated the feasibility and outcome of performing localized sigmoidectomy in its entirety via NOTES. Methods  A survival study of five male minipigs (mean weight, 30 kg) was conducted. After anesthesia, a gastrotomy was created by a per os double-channel endoscope, and full peritoneoscopy was performed. A Berci needle then was inserted transparietally to allow maintenance and monitoring of the pneumoperitoneum. Using a transanal probe to facilitate intestinal retraction, the mesentery was dissected with instruments worked through the channels of the transgastric endoscope. The anvil of a circular stapler then was passed per anum into the colon above the point of intended transection. A penetrating transrectal trocar was placed to allow entry of a linear stapler into the peritoneum through a colotomy, and the sigmoid was cross-stapled proximally. The strut of the anvil then was snugged into a colotomy made at this staple line. The specimen was delivered via the anus by a “pull-through” technique. The distal sigmoidal margin was cross-stapled extracorporeally, ensuring that the colotomy was included within the specimen. Retrograde passage of the circular stapler head per anus allowed colocolonic reanastomosis by its mating with the anvil already in situ. The gastrotomy was closed with a previously validated prosthesis. Postoperatively, all the animals were recovered and monitored for well-being during convalescence. Endoscopy (gastroscopy and sigmoidoscopy), laparoscopy, and laparotomy were performed on postoperative day 14 as follow-up measures. Results  Each operation was satisfactorily completed. The mean operative time was 76 min (range, 44–95 min). All the animals prospered postoperatively. Follow-up examination showed full healing of all anastomoses and gastrotomy sites. There was no evidence of luminal stricturing, peritonitis, or intraabdominal sepsis in any animal. Conclusions  Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format. Presented at S032 NOTES Sigmoid Resection at SAGES, April 9–12, 2008.     

Dual-lumen natural orifice translumenal endoscopic surgery (NOTES): a new method for performing a safe anastomosis

Background Bowel anastomosis is one of the most challenging and difficult tasks to perform during natural orifice translumenal endoscopic surgery (NOTES). The difficulty is mainly due to the technical limitations of the endoscopic instruments available. Currently, endoscopic clips, T-bar sutures, or cumbersome suturing devices are used. A dual-lumen NOTES approach can facilitate bowel resection in a pig model by allowing the use of laparoscopic staplers through the rectum. Methods Acute studies were performed on four 40-kg pig models. The dual-lumen NOTES approach was used to perform small bowel resection and anastomosis. An endoscope was passed into the stomach and pushed through the stomach wall into the peritoneal cavity (first lumen), and a 12-mm trocar was placed through the anterior rectal wall, allowing access to the peritoneum (second lumen). Handling of the bowel, resection, and anastomosis were performed using endoscopic instruments through the gastric lumen and laparoscopic instruments through the rectal lumen. The resected small bowel then was removed through the rectum. Results Small bowel resection and anastomosis was successfully completed in all four animals using the dual-lumen NOTES approach. The laparoscopic stapler was used one more time to close the gastrotomy through the rectal port. At autopsy, intact suture lines were noted at the bowel anastomosis and at the stomach, with no evidence of leak from either site. Conclusions Performing a sutured anastomosis in NOTES is complex and time consuming. The use of stapling devices designed for laparoscopic procedures greatly facilitates gastrointestinal tract operations in NOTES. Using both the upper and lower gastrointestinal tract as entry sites for NOTES eliminates some of the current technical limitations of these procedures. Presented at the 2007 society of American Gastrointestinal Endoscopic Surgeons (SAGES) Meeting.     

Hybrid natural orifice translumenal surgery (NOTES) sleeve gastrectomy: a feasibility study using an animal model

Background  The indications for natural orifice translumenal surgery (NOTES) are yet to be determined. Morbidly obese patients may be one population that would benefit from this approach due to the elimination of wound complications and possibly a faster recovery. As a bariatric restrictive procedure, sleeve gastrectomy could be one indication for NOTES. To test the feasibility of this procedure with a NOTES approach, a pig model was used. Methods  Acute studies investigated five 40-kg farm pigs. The rectum was used as the port of entry to the peritoneal cavity, and the stomach was manipulated endoluminally using a gastroscope. Vision was acquired through a 5-mm laparoscope introduced transabdominally (i.e. via the hybrid technique). A 10-mm incision was made on the anterior wall of the rectum and dilated to accommodate a 12-mm trocar introduced through the rectal wall into the peritoneal cavity. The greater curvature of the stomach then was divided and detached, starting from the antrum and proceeding to the esophagogastric junction using a laparoscopic stapler. The sleeve gastrectomy was completed by dividing the short gastric vessels with an ultrasonic scalpel. The gastric pouch then was removed through the rectal incision. Results  A NOTES gastric sleeve resection was successfully performed in all five pigs. The technique was developed, and feasibility was determined. After resection, the gastric remnant was inflated, with no evidence of leakage. At autopsy, intact suture lines were noted. Closure of the rectal incision was not attempted. Conclusion  A NOTES sleeve gastrectomy is feasible in porcine animal models. The rectal port of entry allows rigid laparoscopic instruments to be introduced into the peritoneal cavity and enables performance of gastrointestinal procedures the same as in standard laparoscopic surgery. Extra-long instruments are necessary for dissection and division of the stomach at the esophagogastric junction and for accessing the short gastric vessels.     

Complete Endoscopic Closure of Gastrotomy After Natural Orifice Translumenal Endoscopic Surgery Using the NDO Plicator

Background The NDO Plicator is a device developed for endoscopic treatment of gastroesophageal reflux disease (GERD) by approximation of tissues together with a double-pledgeted U-stitch. It was theorized that this device may facilitate transgastric natural orifice translumenal endoscopic surgery (NOTES) because closure of the transgastric defect remains a key component for advancement of this new technology. Methods A standardized 12-mm gastrotomy was created endoscopically in four pigs using a combination of needle-knife cautery and balloon dilation. As the endoscope was removed, a Savary soft-tipped wire was introduced into the stomach, and the NDO Plicator was subsequently advanced over the wire. Each defect was identified, and the device was positioned. If necessary, the Plicator’s tissue grasper was used to hold the superior aspect of the gastrotomy and bring the opposed borders of the defect within the jaws of the device. The device was fired three times, leaving three pledgeted suture bundles to close the gastric defect. After closure, each animal was explored, and the integrity of the closure was assessed. The animals underwent in vivo contrast fluoroscopy and ex vivo burst pressure testing studies for assessment of leakage at the closure site. Results The first animal was used to test feasibility, refine techniques, and develop a standard procedure. All of the next three animals studied showed complete sealing of the gastrotomy site without evidence of contrast extravasation on multiplanar fluoroscopic imaging. Each stomach was excised, submerged in water, and subjected to a pressurized air leak test. No leaks were noted until pressures exceeded 55 mmHg. Conclusion This study supports the use of the NDO Plicator for closure of standardized gastric defects in a porcine model. In addition to closing NOTES gastrotomies, the NDO Plicator may be a particularly useful tool for obtaining complete closure of gastric perforations and anastomotic leaks, and for performing stomal reduction after gastric bypass procedures. The mechanical properties of a closure are not the only factor determining whether a leak will develop. Tissue opposition, ischemia, and tension are important factors that are not easily or reliably measured. The physiologic relevance of gastric bursting pressure is not known. Therefore, corollary animal studies with longer-term evaluation are necessary before research proceeds to clinical trials. This article was presented at the 2007 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Annual Meeting in April 2007 in Las Vegas, Nevada.     

NOTES: a review of the technical problems encountered and their solutions

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is currently investigated and developed worldwide. In the past few years, multiple groups have confronted this challenge. Many technical problems are encountered in this technique due to the currently available tools for this approach. Some of the unique technical problems in NOTES include: blindly performed primary incisions; uncontrolled pneumoperitoneal pressure; no support for the endoscope in the abdominal cavity; inadequate vision; insufficient illumination; limited retraction and exposure; and the complexity of suturing and performing a safe anastomosis. In this paper, we review the problems encountered in NOTES and provide possible temporary solutions. METHODS: Acute and survival studies were performed on 15 farm pigs. The hybrid technique approach (i.e., endoscopic surgery with the aid of laparoscopic vision) was performed in all cases. Procedures performed included liver biopsies, bilateral tubal ligation, oophprectomy, cholecystectomy, splenectomy and small bowel resection, and anastomosis. RESULTS: All attempted procedures were successfully performed. New methods and techniques were developed to overcome the technical problems. Closure of the gastrotomy was achieved by T-bar sutures and by stapler closure of the stomach incision. Small bowel anastomosis was achieved by the dual-lumen NOTES technique. CONCLUSIONS: The hybrid technique serves as a temporary approach to aid in developing the NOTES technique. A rectal or vaginal port of entry enables and facilitates gastrointestinal NOTES by using available laparoscopic instruments. The common operations performed today in the laparoscopic fashion could be probably performed in the NOTES approach. The safety of these procedures, however, is yet to be determined.     

Endoscopic full-thickness resection of the stomach

Background Endoluminal endoscopic resections of the gastrointestinal (GI) tract have had increasing significance in recent years. Except for the extraperitoneal part of the rectum, endoscopic resections are restricted to the mucosal and submucosal layer to preserve the integrity of the GI tract wall. Methods The SurgAssist is the first flexible stapling device consisting of a 2,000-mm-long flexible shaft and a stapling magazine that can be positioned intraluminally and used with a remote control. To prove the principle, we investigated the endoluminal application of an endoscopically assisted and intraluminally visualized full-thickness resection of the gastric wall in a pilot study of three pigs and a series of three human exenterates. Results Full-thickness resection of the gastric wall in pigs can be performed with the SurgAssist flexible stapling device from an endoluminal access. However, due to the small lumen of the esophagus, the simultaneous transesophageal introduction of the stapler shaft and gastroscope is not possible in pigs. The same procedure in three human exenterates showed that the simultaneous introduction of the flexible stapler and a standard gastroscope could be achieved without damaging the esophageal wall. Full-thickness resections of up to 4 × 4 cm were carried out with the use of two or three stapler magazines. The resulting sutures were found to be airtight upon endoscopic inflation of the stomach. Conclusion The clinical use of the SurgAssist intraluminal stapling device for endoscopic full-thickness resection of the gastric wall seems applicable for lesions in suitable locations of the stomach. Gastrointestinal stroma tumors and T1 tumors of the lower gastric corpus and antrum region are possible indications.     

Partial gastrectomy using natural orifice translumenal endoscopic surgery (NOTES) for gastric submucosal tumors: early experience in humans

Background

Transvaginal endoscopic gastric surgery is one of the cutting edge procedures in the field of natural orifice translumenal endoscopic surgery (NOTES). Its feasibility has been shown sporadically in bariatric cases but not in oncologic conditions. The authors report their early experience with hybrid transvaginal NOTES gastrectomy for gastric submucosal tumors (SMTs).

Methods

Two female patients with SMTs in the distal stomach participated in this institutional review board (IRB)-approved study. Surgical indication was determined according to the National Comprehensive Cancer Network (NCCN) sarcoma guidelines, and the study adhered to the following oncologic principles: no direct handling of the lesion, full-thickness resection, and reasonable surgical margins. The study protocol required a minimum of two laparoscopic ports to ensure procedural safety and aforementioned oncologic appropriateness. Under laparoscopic guidance, a transvaginal route was created and secured with a 50-cm flexible overtube. A gastrointestinal endoscope was introduced, and the perigastric dissection was performed using an insulation-tipped diathermy knife (IT knife) and needle knife. This process was assisted with two laparoscopic graspers. After perigastric mobilization, the transvaginal endoscope was replaced with a digital stapling device, and partial gastrectomy was accomplished. The resected specimen was isolated and delivered through the vagina, and the vaginal wound was closed under direct vision. Outcomes measurements included surgical results, pain scoring, and clinical outcomes.

Results

Both operations were completed successfully in compliance with the aforementioned oncologic principles. The operating time was 365 and 170 min, respectively. The estimated blood loss was negligible. A minilaparotomy for specimen delivery was successfully avoided in both cases. A minimal vaginal incision was added for one patient at retrieval. Postoperatively, both patients reported no pain and recovered rapidly. The final diagnosis was hemorrhagic lipoma and gastrointestinal stromal tumor (GIST), respectively.

Conclusion

Our initial experience with human transvaginal NOTES gastrectomy showed it to be feasible and safe for gastric SMTs. It is a complex but promising surgical alternative for female oncologic patients undergoing partial gastric resection.     

NOTES: approach to the liver and spleen

Background  Minimally invasive abdominal surgery means minimal trauma to the abdominal wall, thus reducing postoperative pain and wound complications, and facilitating earlier mobilization and shorter hospitalization in comparison with conventional surgery. Natural orifice translumenal endoscopic surgery (NOTES) has the potential to further reduce the invasiveness of surgery in human patients. Here we report an experimental study of NOTES to access the liver and spleen, discuss its current status, and review the related literature. Methods  The utility of transgastric peritoneoscopy was evaluated using one 15-kg pig and four 8-kg dogs on the basis of acute experiments. Under general anesthesia with endotracheal intubation, a forward-viewing, double-channel endoscope was advanced into the peritoneal cavity through a gastric hole. Liver biopsy from the edge of the liver was performed using routine biopsy forceps. Splenectomy was performed using a laparoscopically assisted procedure, and then the spleen was pulled into the stomach using an endoscopic polypectomy snare after enlargement of the gastric orifice. The animals were then sacrificed and necropsy was performed. Results  There were no complications during incision of the gastric wall and entry into the peritoneal cavity. Peritoneoscopy gave satisfactory visualization of the abdominal cavity in all directions. Liver biopsy was performed successfully without any bleeding and adequate samples were obtained in all cases. Splenectomies were also accomplished uneventfully, except for injury of the splenic parenchyma due to excessive force during pulling into the stomach. Necropsy revealed no particular damage to other intraperitoneal organs related to this transgastric procedure. Conclusion  Although NOTES is a feasible procedure and offers several advantages to patients, surgeons and endoscopists need to resolve several key issues before its clinical introduction for routine surgical work and to establish a training system for NOTES in order to avoid critical complications.     

Natural orifice translumenal endoscopic surgery (NOTES): creation of a gastric valve for safe and effective transgastric surgery in humans

Introduction  

NOTES has become a clinical reality. There remain, however, many challenges that need to be addressed in order to refine the technique. One of the most feared potential complications of transgastric surgery is a leak from the port of entry into the peritoneum. When withdrawing the endoscope into the gastric lumen it is difficult to make a secure closure due to the loss of pneumogastrium. We present a novel and safe technique for creating a gastrotomy developed in our animal laboratory and applied in all of our human NOTES cholecystectomies.     

Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis

Background

Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described.

Methods

After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique.

Results

Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series.

Conclusions

The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).     

Can Gastric Irrigation Prevent Infection During NOTES Mesh Placement?

Background  Natural orifice transluminal endoscopic surgery (NOTES) ventral hernia repair could avoid abdominal wall incisions. The infectious risk for mesh placement is of concern. We compared NOTES with laparoscopic mesh placement. Methods  Thirty-seven swine were randomized to abdominal wall polypropylene mesh placement via NOTES or laparoscopy or NOTES control. All animals received antibiotics and gastric irrigation; the laparoscopy group also received preoperative acid suppression. In the NOTES mesh group, the 2-cm² polypropylene mesh was placed using a transgastric transportation device and clipped to the anterior abdominal wall. The control animals underwent endoscopy (no gastrotomy) followed by laparoscopic mesh placement or NOTES only without mesh placement. Necropsy was performed at 14 days. Results  One NOTES mesh placement was incomplete (endoscope failure). All mesh animals survived to 14 days. At necropsy, significantly more mesh infections were noted in the NOTES mesh versus laparoscopy group (4:11 vs 0:14; p = 0.03). Gastric irrigation reduced the bacterial load significantly in all groups (p < 0.001). Infection was independent of gastric bacterial load. No difference between acid suppressed and non-suppressed animals was seen. Conclusion  The mesh placement via NOTES is technically feasible but has a high infection rate despite irrigation. Sterile conduits are needed to enable NOTES-type hernia repair with mesh. Presented at the 49th annual meeting of the Society for Surgery of the Alimentary Tract, May 21, 2008, San Diego, CA.     

Transoral Technique for Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass (LRYGBP) Can Accelerate Learning Curve and Reduce Cost

Background  

The stapled gastrojejunostomy of the laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be created by linear and circular stapling techniques. In the circular-stapled technique, the anvil of the stapler can be introduced into the gastric pouch transabdominally or pulled down the esophagus (transorally) by attachment to a modified gastric tube. The purpose of this study is to determine if the transoral technique to introduce the anvil will reduce operative time and cost compared with the transabdominal technique, which requires creating a new gastrotomy to insert the anvil and followed by its closure.     

NOTES: cadaveric rendezvous hybrid small bowel resection

Background  Natural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques [1–4]. Before NOTES gains widespread popularity, it must be proven to be a safe and efficacious technique [5]. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation. Methods  Currently, most investigational NOTES procedures are performed using a single transgastric, transcolonic, or transvaginal access point to the abdomen. In order to provide greater range of motion and freedom of movement, a rendezvous procedure using simultaneous transgastric and transcolonic approaches was used to perform a small bowel resection. This video demonstrates a successful NOTES hybrid small bowel resection with the use of two laparoscopic ports in a cadaveric model. A powered stapling device attached to a flexible shaft is introduced transcolonically and facilitates division and re-anastamosis of the small bowel. A dual-channel operating endoscope introduced transgastrically allows for precise dissection and creation of enterotomies necessary for the small bowel resection. Conclusions  While technically challenging, NOTES hybrid small bowel resection can be accomplished with specially designed instrumentation utilizing the rendezvous technique. There are several technical limitations preventing this procedure from being completed in a pure NOTES fashion. A safe method of creating blind enterotomies will be needed to eliminate laparoscopic visualization of the enterotomy sites. Adequate endoscopic exposure and retraction of tissue is still difficult and currently requires percutaneous adjuncts. New closure devices will be needed for safe and reliable NOTES enterotomy closure. With the development of such instruments, this, as well as other NOTES procedures, will become more technically feasible. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Resection and stapling technique for wide-based giant bullae in video-assisted thoracic surgery using a new end-stapler

In video-assisted thoracic surgery (VATS), stapling resection for wide-based giant bullae requires a large-volume reduction of normal lung parenchyma and is technically difficult because of the lack of holding and stapling ability of the end stapler for the thick lung parenchyma. A new end-stapler device, the Echelon 60 Endopath stapler (60-mm stapling), has a long, strong anvil and a wide jaw aperture and is able to easily hold thick lung parenchyma. This device is able to divide with precise stapling over a long incision. In VATS management for two recent cases of broad-based giant bullae, this new device was used instead of suture closure and easily achieved stapled closure after excision of the bulla wall. This method prevents large-volume reduction of normal lung and enables an easy, fast, and reliable suture along a precise stapling line.     

Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)

Background  

Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting in-line endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access.