title: Experience with a training program for transgastric procedures in NOTES.
abstract: BACKGROUND
  The transgastric approach to the abdominal cavity has been under experimental investigation in recent years as a method of natural orifice transluminal endoscopic surgery (NOTES). In this study our team, consisting of surgeons and gastroenterologists, focused on training techniques with currently available instruments to perform transgastric procedures. The purpose of this paper is to evaluate the learning process during the establishment of a training program for NOTES. Therefore several procedures were tested in terms of training issues such as the applicability of instruments and techniques for both gastroenterologists and surgeons.
  
  
  METHODS
  After initial testing of the basic steps, a defined training program was initialized in an animal facility of a medical company. Permission for animal training was applied for and granted by the local government. Ten training sessions were performed on a porcine model using animals with a median weight of 65 kg (40-85 kg). General anesthesia was performed in all cases. Transgastric tube resection (TTR), cholecystectomy (TCE), cardiomyotomy (TMY), and small bowel segmental resection (TSBR) were performed. The learning process was evaluated, including handling issues for flexible instruments, access, closure problems, and special technical issues. Procedure duration, as a marker of the learning curve effect, was evaluated.
  
  
  RESULTS
  Intra-esophageal friction, lack of platform stability, lack of precision in tissue retraction, and lack of independence of endoscopic vision were the most difficult technical problems encountered. The operative time range was 25-85 min for TTR, 75-185 min for TCE, 95-220 min for TMY, and 100-260 min for TSBR.
  
  
  CONCLUSIONS
  A learning curve was demonstrated for each investigated technique. These results are promising in terms of the ability of surgeons and gastroenterologists to develop these procedures into a clinical applicable version. Technical limitations were more important than differences in medical education, providing that there is a certain level of experience in both flexible endoscopy and laparoscopy, as well as a team approach.
authors.affiliation: Klinik für Viszeral-, Gefäss und Thoraxchirurgie, Markus-Krankenhaus, Frankfurter Diakonie Kliniken, Wilhelm Epstein-Str 4, 60431 Frankfurt am Main, Germany. Karl-Hermann.Fuchs@FDK.info
authors.forename: Karl-Hermann
authors.initials: KH
authors.lastname: Fuchs
authors.forename: Wolfram
authors.initials: W
authors.lastname: Breithaupt
authors.forename: Hans-Jürgen
authors.initials: HJ
authors.lastname: Kühl
authors.forename: Thomas
authors.initials: T
authors.lastname: Schulz
authors.forename: Axel
authors.initials: A
authors.lastname: Dignass
mesh_terms: D000818:Animals; D002299:Cardia / Q000601:surgery; D017081:Cholecystectomy, Laparoscopic; D002983:Clinical Competence; D004502:Education, Medical, Continuing; D004521:Educational Measurement; D004724:Endoscopy / Q000193:education*; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005187:Fallopian Tubes / Q000601:surgery; D005260:Female; D005762:Gastroenterology / Q000193:education*; D006801:Humans; D007421:Intestine, Small / Q000601:surgery; D010348:Patient Care Team; D013552:Swine
references.citation: Gastrointest Endosc. 2006 Feb;63(2):302-6
references.pmid: 16427939
references.citation: Surg Endosc. 2007 Mar;21(3):475-9
references.pmid: 17177078
references.citation: Endoscopy. 2007 Oct;39(10):881-7
references.pmid: 17968804
references.citation: Endoscopy. 2007 May;39(5):401-6
references.pmid: 17516345
references.citation: Surg Innov. 2008 Dec;15(4):332-3
references.pmid: 19036737
references.citation: Gastrointest Endosc. 2004 Jul;60(1):114-7
references.pmid: 15229442
references.citation: Arch Surg. 2007 Sep;142(9):823-6; discussion 826-7
references.pmid: 17875836
references.citation: Urology. 2008 Jan;71(1):3-6
references.pmid: 18242353
references.citation: Surg Endosc. 2008 Mar;22(3):600-4
references.pmid: 17973169
references.citation: Gastrointest Endosc. 2005 Aug;62(2):287-92
references.pmid: 16046997
references.citation: Gastrointest Endosc. 2005 Apr;61(4):601-6
references.pmid: 15812420
references.citation: Surg Endosc. 2006 Feb;20(2):329-33
references.pmid: 16402290
references.citation: Ann Surg. 2008 Apr;247(4):583-602
references.pmid: 18362621
references.citation: Surg Endosc. 2008 Jun;22(6):1427-9
references.pmid: 18398645
references.citation: N Engl J Med. 1991 Apr 18;324(16):1073-8
references.pmid: 1826143