腹腔镜联合经自然孔道内镜外科技术动物研究

目的 初步探讨腹腔镜联合经自然孔道内镜外科(NOTES)技术的操作方法、可行性及安全性.方法 采用雌性小型猪模型4头.先常规腹腔镜检查,腹腔镜监视下选择经胃壁切口的位置,经内镜用针状刀在胃前壁打孔,扩张球囊扩大切口后将内镜送入腹腔.腹腔镜和内镜配合下进行腹腔脏器探查、输卵管结扎、卵巢切除、胆囊切除及关闭胃壁切口,根据术中情况选择是否放置腹腔引流管.术后常规应用抗生素3 d,半流食饲养.2周后内镜检查胃壁切口腔内闭合情况,处死模型进行解剖,观察胃壁切口脏面闭合情况和手术部位改变.结果 两镜联合顺完成了腹腔脏器探查、输卯管结扎2次、卵巢切除2次、胆囊切除2次和胃壁切口闭合术.2头猪术后放置腹腔引流管.4头模型猪术后均存活至2周,体重增加;解剖后见胃壁切口愈合良好,脏面可见切口处少许组织粘连.手术部位无大出血及粘连,临近脏器无损伤,腹腔无脓肿.结论 腹腔镜联合经胃壁切口内镜下的腹腔脏器探查术、输卵管结扎术、卵巢切除术及胆囊切除术是可行的,具有一定的安全性.腹腔镜辅助可降低NOTES的难度.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

经胃、结肠与经胃、阴道双路径猪输卵管切除术和肝脏活检术的比较研究

目的 探讨经胃、经结肠路径联合与经胃、经阴道路径联合的内镜外科学技术(NOTES)切除猪输卵管和肝脏活检的可行性和安全性.方法 将雌性中国农大小型猪4头分为两组,A组2头经胃、经结肠路径联合腹腔内镜探查术及输卵管切除术;B组2头经胃、经阴道联合腹腔内镜探查术及输卵管切除术.术后处死动物并解剖,观察每组发生并发症情况.结果两种联合途径对腹腔内NOTES操作难易程度相仿,均可完成腹腔探查术、输卵管切除术及肝脏活检术.但是当内镜穿过结肠壁进入腹腔时,发生邻近结肠穿孔1例.结论经胃、经结肠路径联合与经胃、经阴道路径联合NOTES猪输卵管切除术和肝脏活检术是可行的,但经阴道路径似乎比经结肠路径更安全.     

Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video)

BACKGROUND: Transgastric cholecystectomy is a natural orifice transluminal endoscopic surgery (NOTES) procedure that has been reported in 2 nonsurvival studies. Both studies detail substantial technical limitations, with only a 33% success rate when limited to 1 gastric incision site, despite the use of a multichannel locking endoscope. OBJECTIVE: The aim of this study was to evaluate the feasibility and technical limitations of transcolonic cholecystectomy in a survival model. DESIGN: Animal feasibility study. INTERVENTIONS: Five pigs, under general anesthesia, were prepared with tap-water enemas, a peranal antibiotic lavage, and a Betadine rinse. A dual-channel endoscope was advanced into the peritoneum through an anterior, transcolonic incision 15 to 20 cm from the anus. After cystic duct and artery ligation, dissection of the gallbladder was achieved by using grasping and cutting instruments. After removing the gallbladder, the colonic incision was closed by using Endoloops and/or endoclips. The animals lived for 2 weeks after the procedure, then they were euthanized, and a necropsy was performed. RESULTS: All 5 gallbladders were successfully resected. Four of the 5 animals flourished in the postoperative period, with appropriate weight gain. In 1 animal, complete closure of the colonic incision was not possible, and it was euthanized at 48 hours for suspected peritonitis. CONCLUSIONS: This study reports the first transcolonic organ resection and demonstrates the first successful NOTES cholecystectomy in a survival model. The transcolonic approach provided improved endoscope stability and biliary exposure compared with the transgastric route, and complete incision closure appeared critical for procedural success.     

Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model

BACKGROUND: Published reports on NOTES (natural orifice transluminal endoscopic surgery) have thus far been limited to the transgastric method. OBJECTIVE: The aim of this study was to assess the transcolonic approach as a means of accessing and systematically exploring the abdominal cavity in a survival study design. DESIGN: Six pigs were placed under general anesthesia and were prepped with multiple tap-water enemas, followed by instillation of a cefazolin suspension and a povidone-iodine lavage. Equipment was prepared with a high-level chemical disinfection, and an aseptic technique was used. An incision was made in the anterior colonic wall, and abdominal exploration was performed by using a double-channel endoscope. The incision was subsequently closed with endoscopic clips, endoloops, or a prototype closure device. PATIENTS: Six female Yorkshire pigs that weighed 25 to 30 kg. RESULTS: Stomach, liver, gallbladder, spleen, small bowel, colon, and peritoneal surfaces were identified in all animals in less than 3 minutes. The lower pelvic organs were not consistently visualized. All animals were alive for 14 days without apparent complications. At necropsy, the colonic incision sites were completely closed and appeared well healed. Microscopic inflammatory changes were seen at the closure site in all animals, including microabscesses. Incision-related adhesions were identified in 4 of 6 animals. CONCLUSIONS: This study demonstrated the use of a novel transcolonic approach to successfully access and explore the abdominal cavity. In contrast to the transgastric method, a transcolonic approach provides more consistent identification of structures in the upper abdomen and provides better en face orientation and scope stability. Therapeutic interventions in the upper abdomen, including organ resection, may be more tenable by using a transcolonic method; however, further studies are needed to address issues of sterility and colonic closure.     

Initial experience from the transgastric endoscopic peritoneoscopy and biopsy: a stepwise approach from the laboratory to clinical application

Background and Aim: Natural‐orifice translumenal endoscopic surgery (NOTES) is a newly minimally invasive technique that gives access to the abdominal cavity via transgastric, transcolonic, transvaginal or transvesical routes. The aim of the present study was to evaluate the safety and feasibility of transgastric endoscopic peritoneoscopy and biopsy from laboratory to clinical application. Methods: With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle‐knife and through‐the‐scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. After 2 weeks, another transgastric endoscopic exploration was performed in a different location of the stomach. The peritoneal cavity was examined before the gastric incision was closed. After 4 weeks of observation, necropsy was performed. In the clinical application, after gastric lavage, the first step was the creation of the gastrotomy under general anesthesia, sometime under direct vision of the laparoscopic scope. Then the endoscope can be maneuvered in the peritoneal cavity. And peritoneoscopy and biopsy were performed. Biopsies can be obtained from any suspicious areas using punch biopsy forceps. The gastrotomy was then closed with clips. The gastroscopy was examined after one week. Results: Twenty‐eight transgastric endoscopic peritoneoscopies and biopsies in pigs and a total of five transgastric human endoscopic peritoneoscopies and biopsies have been performed. All procedures were completed satisfactorily in the pig model and all patients. There were no intraoperative or postoperative complications. Conclusions: The advantages of peritoneoscopy and biopsy appeared to be enhanced by this approach. Patients had minor postoperative pain and minimal scarring. It is safe and feasible for us to use transgastric endoscopic peritoneoscopy and biopsy in humans.     

Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope

BACKGROUND: Transgastric cholecystectomy is thought to technically and anatomically challenge a single entry flexible endoscopic approach. OBJECTIVES: To examine the feasibility of a transgastric-only cholecystectomy, endoscope performance in an upper-abdominal operation, and the usefulness of an offset gastrotomy. STUDY DESIGN: Animal survival study. SETTING: Animal research laboratory. PATIENTS: Six domestic pigs. MAIN OUTCOME MEASUREMENTS: Transgastric access to the gallbladder and technical feasibility of unassisted transgastric cholecystectomy. INTERVENTIONS: A cephalad submucosal tunnel was created in the anterior gastric wall with a high-pressure CO2 injection. An EMR-cap myotomy was performed distally within the submucosal space and created an offset gastrotomy. An endoscope was inserted into the peritoneal cavity through the myotomy. Access to the gallbladder was compared by using a multibending therapeutic endoscope (R-scope), with a standard double-channel endoscope. A cholecystectomy was performed by using both types of endoscopes. The myotomy site was sealed with the overlying mucosal flap. The mucosal entry point was closed with clips or tissue anchors. RESULTS: A standard double-channel endoscope could access the gallbladder in 2 of 4 attempts. A multibending endoscope accessed the gallbladder in all 4 attempts, including 2 pigs in which the standard scope failed to access the gallbladder. In 4 pigs, a cholecystectomy was completed. Two pigs died during surgery, with air embolization observed in 1. Two pigs survived a planned 1-week survival period. CONCLUSIONS: Transgastric cholecystectomy is technically feasible. Transgastric access to the gallbladder may be improved by using submucosal endoscopy with an offset exit gastrotomy by means of the mucosal flap safety-valve technique and a multibending gastroscope.     

A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures

BACKGROUND: We have previously reported the feasibility and safety of per-oral transgastric endoscopic procedures in a porcine model. OBJECTIVE: Our purpose was to evaluate the safety and feasibility of a PEG-like approach to the peritoneal cavity. SETTINGS: Acute experiments on 50-kg pigs under general anesthesia. DESIGN AND INTERVENTIONS: After per-oral intubation, the endoscope was positioned into the body of the stomach, the anterior abdominal wall was transilluminated and punctured with a needle, and a guidewire was inserted into the stomach through the needle. The guidewire was grasped with endoscopic forceps and pulled through the biopsy channel of the endoscope. A sphincterotome was inserted into the gastric wall over the guidewire. Gastric incision was performed and the endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated and endoscopic peritoneoscopy was performed. Then the animal was euthanized and necropsy was performed. MAIN OUTCOME MEASURES: Safety of transgastric entrance to peritoneal cavity. RESULTS: The PEG-like approach was used in 12 pigs. The average procedure time was 11.4 +/- 3.7 minutes. There was only 1 complication related to the access: bleeding from the gastric wall incision was documented when a pure cut (without coagulation) current was used for incision of the gastric wall. There were no complications in the other 11 pigs. The necropsy did not reveal any damage to organs adjacent to the stomach. LIMITATIONS: Gastric wall incision is located on anterior gastric wall. CONCLUSIONS: The PEG-like transgastric approach to the peritoneal cavity appears technically simple and safe.     

Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos)

BACKGROUND: Transgastric flexible endoscopic surgery might offer advantages over open and laparoscopic surgery. The aim of this study was to develop methods for performing transgastric biliary endosurgery. METHODS: Cholecystectomies and biliary anastomoses were performed in 8 anesthetized pigs (27-30 kg) in nonsurvival studies. Two endoscopes passed perorally were inserted through the stomach wall after needle-knife incision. Endoscope-induced pneumoperitoneum allowed viewing and manipulation of the gallbladder with both endoscopes independently. The cystic duct was dissected, clipped, and transected. Cholecystectomy was performed with one of two methods: either by using two endoscopes, or a single endoscope and a 5-mm-diameter grasping instrument inserted transabdominally. Clips and sutures were used to attach the gallbladder to the stomach wall, and an incision was made to form a cholecystogastrostomy. In survival experiments in 8 pigs, transgastric incisions were closed with endoscopic sutures. RESULTS: The gallbladder was successfully removed in 8 pigs (nonsurvival experiments). The time for the procedure ranged from 2.5 hours to 40 minutes and decreased with experience. At postmortem examination, clips placed on the cystic duct and the artery were secure. An anastomosis was successfully formed between gallbladder and stomach in 3 pigs. In 8 pigs, full-thickness incisions in the stomach wall were closed with two to 4 stitches. All 8 pigs survived (median follow-up, 22 days; range 14-28 days). CONCLUSIONS: Transgastric gallbladder surgery, including cholecystectomy and biliary anastomosis, is feasible. Full-thickness gastric incisions were safely closed in survival studies. The efficacy and the safety of transgastric surgery merits further study.     

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 gastrojejunostomy with survival in a porcine model

BACKGROUND: We have previously reported the feasibility and the safety of an endoscopic transgastric approach to the peritoneal cavity in a porcine model. We now report successful performance of endoscopic gastrojejunostomy with survival. METHODS: All procedures were performed on 50-kg pigs, with the pigs under general anesthesia, in aseptic conditions with sterilized endoscopes and accessories. The stomach was irrigated with antibiotic solution, and a gastric incision was performed with a needle-knife and a sphincterotome. A standard upper endoscope was advanced through a sterile overtube into the peritoneal cavity. A loop of jejunum was identified, was retracted into the stomach, and was secured with sutures while using a prototype endoscopic suturing device. An incision was made into the jejunal loop with a needle-knife, and the filet-opened ends of the jejunal wall were secured to the gastric wall with a second line of sutures, completing the gastrojejunostomy. OBSERVATIONS: Two pigs survived for 2 weeks. Endoscopy and a radiographic contrast study performed after gastrojejunostomy revealed a patent anastomosis with normal-appearing gastric and jejunal mucosa. Postmortem examination demonstrated a well-healed anastomosis without infection or adhesions. CONCLUSIONS: The endoscopic transgastric approach to create a gastrojejunostomy is technically feasible and can be performed, with survival, in a porcine model.     

Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model.

BACKGROUND & AIMS: The evolution of flexible endoscopes and endoscopic devices has recently enabled per-oral transgastric abdominal exploration in animal models. This study was undertaken to assess the ability to systematically identify abdominopelvic organs and to determine the feasibility of organ resection via the transgastric route. METHODS: Female Yorkshire pigs were used for the study. Under general anesthesia, a gastroscope was used to place a sterile overtube into the esophagus. After antibacterial lavage, the gastric wall was incised, and a sterile dual-channel endoscope was advanced into the peritoneal cavity. Endoscopic abdominal exploration was then methodically performed in 9 animals with oophorectomy and partial hysterectomy in 6 animals. The gastric incision was closed with endoclips. Of the animals that underwent organ resection, 3 were sacrificed immediately after surgery, and the subsequent 3 survived. RESULTS: The peritoneal cavity was accessed uneventfully, and the stomach, liver, small bowel, colon, urinary bladder, uterus, fallopian tubes, and ovaries were able to be evaluated in all cases. The gallbladder could be visualized in only 5 of the 9 animals, and retroperitoneal structures could not be consistently identified. Oophorectomy with partial hysterectomy was performed in 6 animals. The 3 animals in the survival group did well for 24 hours without sequelae. CONCLUSIONS: This study shows the ability of endoscopic transgastric peritoneal exploration to successfully identify most abdominopelvic organs and demonstrates the technical feasibility of transgastric organ resection.