title: Reliable gastric closure after natural orifice translumenal endoscopic surgery (NOTES) using a novel automated flexible stapling device.
abstract: BACKGROUND
  Reliable closure of the translumenal incision is one of the main challenges facing natural orifice translumenal endoscopic surgery (NOTES). This study aimed to evaluate the use of an automated flexible stapling device (SurgASSIST) for closure of the gastrotomy incision in a porcine model.
  
  
  METHODS
  A double-channel gastroscope was advanced into the stomach. A gastric wall incision was made, and the endoscope was advanced into the peritoneal cavity. After peritoneoscopy, the endoscope was withdrawn into the stomach. The SurgASSIST stapler was advanced orally into the stomach. The gastrotomy edges were positioned between the opened stapler arms using two endoscopic grasping forceps. Stapler loads with and without a cutting blade were used for gastric closure. After firing of the stapler to close the gastric wall incision, x-ray with contrast was performed to assess for gastric leakage. At the end of the procedure, the animals were killed for a study of closure adequacy.
  
  
  RESULTS
  Four acute animal experiments were performed. The delivery and positioning of the stapler were achieved, with technical difficulties mostly due to a short working length (60 cm) of the device. Firing of the staple delivered four rows of staples. Postmortem examination of pig 1 (when a cutting blade was used) demonstrated full-thickness closure of the gastric wall incision, but the cutting blade caused a transmural hole right at the end of the staple line. For this reason, we stopped using stapler loads with a cutting blade. In the three remaining animals (pigs 2-4), we were able to achieve a full-thickness closure of the gastric wall incision without any complications.
  
  
  CONCLUSIONS
  The flexible stapling device may provide a simple and reliable technique for lumenal closure after NOTES procedures. Further survival studies are currently under way to evaluate the long-term efficacy of gastric closure with the stapler after intraperitoneal interventions.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, MD 21287, USA.
authors.forename: O R
authors.initials: OR
authors.lastname: Meireles
authors.forename: S V
authors.initials: SV
authors.lastname: Kantsevoy
authors.forename: L R
authors.initials: LR
authors.lastname: Assumpcao
authors.forename: P
authors.initials: P
authors.lastname: Magno
authors.forename: X
authors.initials: X
authors.lastname: Dray
authors.forename: S A
authors.initials: SA
authors.lastname: Giday
authors.forename: A N
authors.initials: AN
authors.lastname: Kalloo
authors.forename: E J
authors.initials: EJ
authors.lastname: Hanly
authors.forename: M R
authors.initials: MR
authors.lastname: Marohn
mesh_terms: D000818:Animals; D004867:Equipment Design; D005773:Gastroscopy / Q000379:methods*; D005774:Gastrostomy / Q000295:instrumentation*; D017792:Surgical Stapling / Q000379:methods; D013537:Sutures; D013552:Swine