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FIRST NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) EXPERIENCE IN CANADA
E Dubcenco1, T Grantcharov2, CJ Streutker3, OD Rotstein2, NN Baxter2, KN Jeejeebhoy1, JP Baker1
1Division of Gastroenterology; 2Division of General Surgery; 3Department of Histopathology, St Michael’s Hospital, Toronto, Ontario
AIM: To develop a technique for performing transcolonic peritoneoscopy.
METHODS: This is an experimental study performed in pigs. A flexible “R” endoscope (Olympus Optical Co, Ltd, Tokyo, Japan) was inserted through the anus and then through a colonic wall incision (at 15-20 cm from the anal verge) into the peritoneal cavity. Abdominal exploration with identification of the upper and lower abdominal organs was performed. At the completion of the peritoneoscopy, the colonic wall incision was closed with endoclips.
RESULTS: 5 non-survival and 5 survival experiments were performed. The first 2 non-survival experiments were complicated by significant bowel distension due to the air trapped in the colon as well as contamination of the incision area by colonic content. In the rest of the pigs, the experiment was performed with the use of an intracolonic balloon designed by investigators to prevent colonic distension. Specifically, an intraluminal balloon-tipped catheter was inflated above the level of a colonic incision to occlude the colonic lumen. The full thickness colonic incision was then made using an endoscopic needle knife. The endoscope was inserted via the defect into the abdominal cavity and complete evaluation was performed. Occlusion of the colonic lumen facilitated peritoneal exploration by preventing dilatation of the colon. The endoscope was then withdrawn back into the colon and the incision was closed with endoclips. Using this technique, we performed a complete peritoneal exploration and closure of the full thickness incision without complications in the remaining 8 pigs. All 5 pigs in the survival experiment were kept alive for two weeks. They were given food within hours after the surgery. No clinical signs of peritonitis or any distress were noted.
CONCLUSIONS: Transcolonic endoscopic peritoneal exploration is feasible. Excessive bowel distension and fecal contamination due to spillage from proximal bowel may be barriers to performing transcolonic NOTES. Isolation of the operative area by sealing the colonic lumen with the balloon above the colonic incision may overcome these problems, and optimize the technique.
The authors would like to acknowledge Olympus Canada Inc. and AMT Electrosurgery Inc. for providing the study with endoscopic equipment and necessary tools. The study was supported by Divisional grant (GI Division, St. Michael’s Hospital)