Transgastric peritoneoscopy and appendectomy: thoughts on our first experience in humans

We present a series of three patients operated on by means of natural-orifice transgastric peritoneoscopy, including one appendectomy. A standard double-lumen gastroscope was used together with standard endoscopic tools. In all patients abdominal access through the gastric wall was smooth using a needle-knife/guide-wire/balloon technique. The whole abdominal cavity could be visualized and the appendix was found in two patients. In one patient the procedure was converted to laparoscopic appendectomy and in one to open surgery. In the third patient transgastric appendectomy was performed. The gastric access site was closed with the T-tag technique. Patients were allowed to drink and eat as soon as they woke up. Postoperatively patients were followed clinically and with standard laboratory tests daily until discharged. One patient (converted to open surgery) had a serious complication (pneumothorax). The transgastric approach to the abdominal cavity was shown to be feasible, but significant technical problems remain to be resolved.

References

• 1 Buess G, Cuschieri A. Raising our heads above the parapet: ES not NOTES.  Surg Endosc. 2007;  21 835-837
• 2 Park P O, Bergström M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos).  Gastrointest Endosc. 2005;  61 601-606
• 3 Bergström M, Ikeda K, Swain P, Park P O. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video).  Gastrointest Endosc. 2006;  63 307-312
• 4 Bergström M, Swain P, Park P O. Early clinical experience with a new flexible endoscopic suturing method for natural orifice transluminal endoscopic surgery and intraluminal endosurgery (with videos).  Gastrointest Endosc. 2008;  67 528-533
• 5 Raju G S, Fritscher-Ravens A, Rothstein R I. et al . Endoscopic closure of colon perforation compared to surgery in a porcine model: a randomized controlled trial (with videos).  Gastrointest Endosc. 2008;  68 324-332
• 6 Auyang E D, Hungness E S, Vaziri K. et al . Human NOTES cholecystectomy: transgastric hybrid technique.  J Gastrointest Surg. 2009;  13 1149-1150
• 7 Hazey J W, Narula V K, Renton D B. et al . Natural-orifice transgastric endoscopic peritoneoscopy in humans: initial clinical trial.  Surg Endosc. 2008;  22 16-20
• 8 Rao G V, Reddy D N, Banerjee R. NOTES: human experience.  Gastrointest Endosc Clin N Am. 2008;  18 361-370; x
• 9 Swanstrom L L, Kozarek R, Pasricha P J. et al . Development of a new access device for transgastric surgery.  J Gastrointest Surg. 2005;  9 1129-1136; discussion 36–37
• 10 Voermans R P, van Berge Henegouwen M I, Bemelman W A, Fockens P. Novel over-the-scope-clip system for gastrotomy closure in natural orifice transluminal endoscopic surgery (NOTES): an ex vivo comparison study.  Endoscopy. 2009;  (in press)
• 11 von Renteln D, Schmidt A, Vassiliou M C. et al . Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study.  Endoscopy. 2009;  41 481-486
• 12 Perretta S, Sereno S, Forgione A. et al . A new method to close the gastrotomy by using a cardiac septal occluder: long-term survival study in a porcine model.  Gastrointest Endosc. 2007;  66 809-813