Transgastric and transperineal natural orifice translumenal endoscopic surgery (NOTES) in an appendectomy test bed.
BACKGROUND
Our purpose was to establish a NOTES appendectomy test bed to evaluate whether the transgastric or transperineal (transvaginal) approach is most efficient.


METHODS
Using the uterine horns of female pigs as a model for appendectomy, 18 NOTES appendectomies were performed in 2 arms: 9 transgastric and 9 transvaginal. The primary outcome was mean total operative time for each technique excluding access closure. Secondary outcomes were peritoneal access and resection times. Means were compared using Student's t-test.


RESULTS
Transgastric cases were faster than transperineal (46.5+/-14.5 vs 60.0+/-20.2 minutes, P=.02). Most of the improvement in transgastric times was due to faster resection (37.9+/-17.4 vs 51.3+/-16.5 minutes, P=.03). Neither approach was faster for peritoneal access (8.2+/-3.4 vs 8.3+/-4.5 minutes, nonsignificant). A significant learning curve was not demonstrated for the transgastric approach (53.0 vs 40.3 minutes, nonsignificant). A significant learning curve was demonstrated for the transperineal approach (76.0 vs 46.7 minutes, P=.02). Transperineal times improved over the study and approached transgastric; however, the last three transgastric cases were still significantly faster than the last three transperineal (40.3 vs 46.7 minutes, P=.02). No complications occurred in either group.


CONCLUSIONS
The transgastric as compared with transperineal approach to NOTES appendectomy resulted in improved operative time in this model. The transperineal approach demonstrated a significant learning curve with operative times between techniques converging over time. This NOTES appendectomy test bed is suitable for evaluating NOTES innovations.
Jayaraman
Shiva
S
Canadian Surgical Technologies & Advanced Robotics, Lawson Health Research Institute, London, Ontario, Canada.
Schlachta
Christopher M
CM
D000818:Animals; D001062:Appendectomy / Q000379:methods*; D005260:Female; D013270:Stomach; D013552:Swine; D014621:Vagina