Endoscopic Transgastric Abdominal Exploration and Organ Resection: Initial Experience in a Porcine Model

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Background & Aims: The evolution of flexible endoscopes and endoscopic devices has recently enabled per-oral transgastric abdominal exploration in animal models. This study was undertaken to assess the ability to systematically identify abdominopelvic organs and to determine the feasibility of organ resection via the transgastric route. Methods: Female Yorkshire pigs were used for the study. Under general anesthesia, a gastroscope was used to place a sterile overtube into the esophagus. After antibacterial lavage, the gastric wall was incised, and a sterile dual-channel endoscope was advanced into the peritoneal cavity. Endoscopic abdominal exploration was then methodically performed in 9 animals with oophorectomy and partial hysterectomy in 6 animals. The gastric incision was closed with endoclips. Of the animals that underwent organ resection, 3 were sacrificed immediately after surgery, and the subsequent 3 survived. Results: The peritoneal cavity was accessed uneventfully, and the stomach, liver, small bowel, colon, urinary bladder, uterus, fallopian tubes, and ovaries were able to be evaluated in all cases. The gallbladder could be visualized in only 5 of the 9 animals, and retroperitoneal structures could not be consistently identified. Oophorectomy with partial hysterectomy was performed in 6 animals. The 3 animals in the survival group did well for 24 hours without sequelae. Conclusions: This study shows the ability of endoscopic transgastric peritoneal exploration to successfully identify most abdominopelvic organs and demonstrates the technical feasibility of transgastric organ resection.

Section snippets

Animals

Female Yorkshire pigs (Parson’s Farm, Hadley, MA) weighing 25–30 kg were used for the study and were housed at Animal Research at Children’s Hospital, Boston, Massachusetts. The study protocol was approved by the animal research committee at Children’s Hospital.

Endoscopes and Instruments

Single- and double-channel gastroduodenoscopes (GIF Q140 and GIF 2T100; Olympus, Tokyo, Japan) were used. Endoscopes were chemically sterilized with 2.4% glutaraldehyde (Cidex; Johnson and Johnson, Irvine, CA) and air-dried. Reusable

Peritoneal Exploration

The abdomen and pelvis were successfully explored in all 9 animals. Initial experiments for developing the transgastric technique included 1 cadaver and 5 live, anesthetized animals that were killed immediately after surgery. Subsequent survival surgeries were performed in 3 pigs. It was found that the proximal anterior gastric wall provided the most reliable access to the peritoneal cavity with greatest ease. During endoscopic exploration, the stomach, liver, small bowel, colon, urinary

Discussion

Standard approaches for abdominal surgery include open laparotomy and laparoscopic procedures, both of which require incisions in the abdominal wall. Advances in minimally invasive surgery aim to decrease surgical morbidity and mortality and to improve surgical efficiency by using less invasive techniques. Minilaparotomy, minilaparoscopy, and combined laparoscopic procedures are now commonly performed for appendectomy, cholecystectomy, hysterectomy, salpingectomy, and tubal ligations.2, 3

Summary/Conclusion

The transgastric endoscopic route has been suggested as a novel technique for minimally invasive surgery of the abdomen and pelvis. Our study demonstrates that the peritoneal cavity can be systematically explored by using this approach with successful identification of most organs, and that organ resection (oophorectomy and partial hysterectomy) can be performed without early complications. Development of more dexterous endoscopic tools is crucial to the advancement of such endoscopic surgical

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Supported by the Division of Gastroenterology funds, Brigham and Women’s Hospital.

M. S. Wagh and B. F. Merrifield contributed equally to this work.

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