title: Dual-port distal pancreatectomy using a prototype endoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery (NOTES) survival study in a porcine model.
abstract: OBJECTIVE
  Natural orifice transluminal endoscopic surgery (NOTES) is a potentially less invasive alternative to laparoscopic surgery that may be applicable to distal pancreatectomy. We aimed to demonstrate the technical feasibility of a NOTES distal pancreatectomy in an in vivo porcine model via a combined transvaginal-transcolonic approach.
  
  
  METHODS
  The procedure was performed in five female Yorkshire pigs weighing approximately 30 kg each. A prototype endoscope ("R-scope"), advanced into the peritoneal cavity through an anterior colotomy, and a computer-assisted linear stapler, introduced transvaginally, were used in dissection and resection of the distal pancreas. Prone positioning was used to enhance retroperitoneal exposure. Pneumodissection was used for blunt dissection. The colotomies were closed with endoloops. Necropsies were done immediately after the procedure in the first three animals, and after 2 weeks' survival in the final two animals.
  
  
  RESULTS
  Distal pancreatectomy was successful in all five animals. Prone positioning was critically important for proper exposure of retroperitoneal and pelvic structures. Pneumodissection was effective for blunt dissection, and both the linear stapler and R-scope functioned smoothly. Transvaginal and transcolonic access provided similar intraperitoneal views, and the dual-lumen approach enhanced triangulation. Both survival animals thrived postoperatively. Necropsies revealed clean staple lines; closed transcolonic and transvaginal incisions; and absence of infection, hemorrhage, or fluid collections.
  
  
  CONCLUSIONS
  NOTES distal pancreatectomy is technically feasible in the porcine model. The transvaginal approach provides a vantage point very similar to that of the transcolonic route and holds promise as a NOTES access site, either singly or as part of a dual-lumen approach. The endoscopic linear stapler and R-scope both advance NOTES capabilities. The novel concepts of fully prone positioning, pneumodissection, and endoloop colotomy closures are introduced. Considering anatomical differences and that healthy animals were used, transferring this technique to patients with pancreatic disease might be difficult and further modifications would likely be needed.
authors.affiliation: Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
authors.forename: M
authors.initials: M
authors.lastname: Ryou
authors.forename: D G
authors.initials: DG
authors.lastname: Fong
authors.forename: R D
authors.initials: RD
authors.lastname: Pai
authors.forename: A
authors.initials: A
authors.lastname: Tavakkolizadeh
authors.forename: D W
authors.initials: DW
authors.lastname: Rattner
authors.forename: C C
authors.initials: CC
authors.lastname: Thompson
mesh_terms: D000818:Animals; D003106:Colon; D004195:Disease Models, Animal; D019723:Endoscopes; D016145:Endoscopy, Digestive System / Q000379:methods* / Q000401:mortality; D004867:Equipment Design; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D010180:Pancreatectomy / Q000295:instrumentation* / Q000401:mortality; D010182:Pancreatic Diseases / Q000601:surgery*; D013528:Surgical Staplers; D015996:Survival Rate; D013536:Suture Techniques / Q000295:instrumentation*; D013552:Swine; D016896:Treatment Outcome; D014621:Vagina