title: Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video).
abstract: BACKGROUND
  The ability to access the abdominal cavity though a direct (modified-PEG type) gastric incision to perform natural orifice transluminal endoscopic surgery (NOTES) has been demonstrated in the literature. However, the optimal technique to access the abdomen remains unknown.
  
  
  OBJECTIVE
  The aim of this study was to evaluate the safety and feasibility of a transgastric approach to the abdominal cavity through an extended submucosal tunnel.
  
  
  METHODS
  Animal feasibility study.
  
  
  METHODS
  Transgastric endoscopic peritoneoscopy was performed in 7 anesthetized swine, including 2 acute and 5 survival animals. After the creation of a 10-cm to 12-cm tunnel in the gastric submucosal plane, the peritoneal cavity was accessed by needle-knife puncture through the gastric wall near the greater curvature. The peritoneal cavity was examined before the gastric mucosal incision was closed with endoclips. Survival animals were euthanized two weeks after the procedure, and a necropsy was performed.
  
  
  RESULTS
  The abdominal cavity was successfully entered without complication in all 7 animals. The mucosal incisions were able to be closed by endoscopy. In the survival experiments, all animals recovered and gained weight. Two animals experienced clinically unapparent infectious complications.
  
  
  CONCLUSIONS
  Small sample size.
  
  
  CONCLUSIONS
  A peroral transgastric approach to the abdominal cavity through an extended submucosal tunnel is technically feasible and allows safe abdominal access and reliable closure with currently available technology. It has potential benefits as an alternative to direct transgastric access for NOTES procedures.
authors.affiliation: Division of Minimally Invasive and Bariatric Surgery, The Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania 17033, USA.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Pauli
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Moyer
authors.forename: Randy S
authors.initials: RS
authors.lastname: Haluck
authors.forename: Abraham
authors.initials: A
authors.lastname: Mathew
mesh_terms: D034841:Abdominal Cavity / Q000601:surgery*; D000818:Animals; D004195:Disease Models, Animal; D005240:Feasibility Studies; D005260:Female; D007431:Intraoperative Complications / Q000401:mortality* / Q000473:pathology; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods* / Q000401:mortality*; D011028:Pneumoperitoneum, Artificial / Q000379:methods; D013270:Stomach / Q000601:surgery*; D015996:Survival Rate; D013552:Swine; D014741:Video Recording