This experiment was aimed to demonstrate the technical feasibility of NOTES small bowel resection via a combined transgastric-transvaginal approach.
The procedure was performed in a laboratory setting of the Johns Hopkins University School of Medicine. Acute porcine model was used.
A pig was placed on the operating table in the supine position. Pneumoperitoneum was established using a laparoscopic Veress needle. Transvaginal port was established first.
A flexible endoscope and an overtube was used to establish the transvaginal port. Colpotomy was performed through the posterior wall of the vagina by an endoscopic needle-knife.
An endoscope with the overtube was advanced into the peritoneal cavity through the vaginal opening. The overtube was carefully advanced until its distal end was well positioned within the peritoneal cavity.
The transgastric port was established next. The endoscope was advanced into the stomach. Here you can see the light from the endoscope seen through the gastric wall. The gastric opening was created by the balloon dilatation technique. Here you can see the balloon. The gastric view was provided by the endoscope inserted through the vagina. The endoscope was advanced into the peritoneal cavity. Small bowel was identified.
A rigid linear stapler was placed into the peritoneal cavity through the transvaginal port. The loop of the small bowel was placed between the stapler's arms. A small incision was created in the mesentery using the endoscopic needle-knife. The loop of the small bowel was positioned on the stapler's arms using endoscopic graspers. The stapler was then fired creating the cut and stapled the end of the small bowel. The second stapled end of the small bowel was created in the same manner. One more fire of the stapler and use of the laparoscopic scissors trough the transvaginal port completed the separation. The excised segment of the small bowel was extracted through the vagina. Here you can see the resected segment of the small bowel.
An enterotomy was created on the antimesenteric side of the proximal and distal limbs of the bowel using the needle-knife. The bowel limbs were placed on the stapler's arms using endoscopic graspers. When both bowel limbs were properly positioned, the stapler was fired creating a small bowel anastomosis.
The opposing cut edges of the enterotomy were held with the graspers, and the enterotomy was closed by firing the stapler. The anastomosis was inspected. The overtube was then withdrawn. The gastric opening was closed with the t-bars, and the endoscope was withdrawn.
The technique shown in this video has demonstrated the technical feasibility of small bowel resection by NOTES transgastric & transvaginal approach. The procedure, however, is technically demanding, due to the lack of specialized endoscopic tools.
The authors would like to acknowledge the American Society for Gastrointestinal Endoscopy, Division of Gastroenterology of Johns Hopkins University School of Medicine, Division of Gastroenterology of St. Michael's Hospital. Wilson-Cook Medical Inc, Pentax Medical Co for their support.
Elena Dubcenco, MD, Johns Hopkins Medical Center