title: Hybrid natural orifice translumenal surgery (NOTES) sleeve gastrectomy: a feasibility study using an animal model.
abstract: BACKGROUND
  The indications for natural orifice translumenal surgery (NOTES) are yet to be determined. Morbidly obese patients may be one population that would benefit from this approach due to the elimination of wound complications and possibly a faster recovery. As a bariatric restrictive procedure, sleeve gastrectomy could be one indication for NOTES. To test the feasibility of this procedure with a NOTES approach, a pig model was used.
  
  
  METHODS
  Acute studies investigated five 40-kg farm pigs. The rectum was used as the port of entry to the peritoneal cavity, and the stomach was manipulated endoluminally using a gastroscope. Vision was acquired through a 5-mm laparoscope introduced transabdominally (i.e. via the hybrid technique). A 10-mm incision was made on the anterior wall of the rectum and dilated to accommodate a 12-mm trocar introduced through the rectal wall into the peritoneal cavity. The greater curvature of the stomach then was divided and detached, starting from the antrum and proceeding to the esophagogastric junction using a laparoscopic stapler. The sleeve gastrectomy was completed by dividing the short gastric vessels with an ultrasonic scalpel. The gastric pouch then was removed through the rectal incision.
  
  
  RESULTS
  A NOTES gastric sleeve resection was successfully performed in all five pigs. The technique was developed, and feasibility was determined. After resection, the gastric remnant was inflated, with no evidence of leakage. At autopsy, intact suture lines were noted. Closure of the rectal incision was not attempted.
  
  
  CONCLUSIONS
  A NOTES sleeve gastrectomy is feasible in porcine animal models. The rectal port of entry allows rigid laparoscopic instruments to be introduced into the peritoneal cavity and enables performance of gastrointestinal procedures the same as in standard laparoscopic surgery. Extra-long instruments are necessary for dissection and division of the stomach at the esophagogastric junction and for accessing the short gastric vessels.
authors.affiliation: Department of Surgery, Minimally Invasive Surgery, University of California-San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA. yoavmintz@yahoo.com
authors.forename: Yoav
authors.initials: Y
authors.lastname: Mintz
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
authors.forename: Michelle K
authors.initials: MK
authors.lastname: Savu
authors.forename: John
authors.initials: J
authors.lastname: Cullen
authors.forename: Alana
authors.initials: A
authors.lastname: Chock
authors.forename: Sonia
authors.initials: S
authors.lastname: Ramamoorthy
authors.forename: David W
authors.initials: DW
authors.lastname: Easter
authors.forename: Mark A
authors.initials: MA
authors.lastname: Talamini
mesh_terms: D000818:Animals; D005240:Feasibility Studies; D005260:Female; D005743:Gastrectomy / Q000295:instrumentation / Q000379:methods*; D018530:Gastric Stump / Q000473:pathology; D005773:Gastroscopy; D010535:Laparoscopy; D012007:Rectum / Q000601:surgery*; D013537:Sutures; D013552:Swine