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

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Abstract
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. 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. 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. Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format.