What devices are needed for accessing digestive or other organs within the gastrointestinal tract and within the peritoneal cavity? What are the complications when instruments are passed into the gastrointestinal tract and out of the stomach for performing diagnostic or therapeutic surgical procedures? What is the early clinical experiencewith flexible endoscopic suturing techniques for transgastric surgery (NOTES)?
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…an innovative technique for suturing was described by European surgeons. On the horizon is the flexible endoscopic access to the peritoneal cavity via the transgastric route and the promise of hybrid endoscopic laparoscopic approaches to complex surgical procedures. The challenge: manage with a flexible endoscope the repair of perforations, leaky anastomoses, and other incisions of the gastrointestinal (GI) wall. With natural orifice transluminal endoscopic surgery (NOTES) full gastric resection, pyloroplasty, and gastrojejunostomy are among the procedures that are being considered in addition to the prospect of repairing leaks from previous surgical anastomoses.
Using a double channel endoscope, a 19-gauge EUS needle, T-fasteners suture tags and thread locks the peritoneal cavity is accessed through transluminal methods. In order to close the gastric wall, a first T fastener is placed through the full thickness of the gastric wall. Another T anchor is deployed endoscopically on the other side of the incision. After the thread locks are advanced to tie the threads of the T fastners together, transmural tissue apposition is accomplished in order to achieve full thickness closure.
Nevertheless, the closure of the GI access site is very challenging and critical. In numerous cases an added challenge is the need to expand the access site for specimen removal like the appendix. The new closure devices therefore need to accommodate for larger puncture than just the access puncture to the peritoneal cavity. The size of the defect that needs closure may be larger due to the instrumentation used or the need of expansion.
In complex procedures intraperitoneal complications such as bleeding, accidental bowel perforation, or injury of the spleen might occur. Also a total endoluminal approach may be preferred, a hybrid single port laparoscopic endoluminal procedure may be more feasible in the near future.