title: Transrectal endoscopic retrorectal access (TERA): a novel NOTES approach to the peritoneal cavity.
abstract: BACKGROUND
  As the field of natural orifice translumenal endoscopic surgery (NOTES) expands, new access sites are being investigated. One access site to the peritoneal cavity, which has not been the subject of much investigation, is transrectal access. The aim of this article is to describe a new method to peritoneal access: transrectal endoscopic retrorectal access (TERA).
  
  
  METHODS
  Three pigs were placed in the supine position under general anesthesia, and an umbilical port was placed for the pneumoperitoneum, as well as visualization of the pelvic dissection and access. A rectotomy was made under direct vision above the dentate line posteriorly. The flexible endoscope was introduced into the retrorectal space, balloon dilation was used to open and dissect the retrorectal plane, and the peritoneal cavity was entered with a needle knife. After peritoneal exploration, the endoscope was withdrawn and the rectotomy was closed under direct vision.
  
  
  RESULTS
  Each of the 3 cases was successful with entry into the peritoneal cavity to the right of the sacral promontory. Direct visualization allowed the avoidance of injury to the ureter, vessels, and nervous structures of the pelvis. The flexible endoscope allowed an easy direct visualization of the upper abdominal organs. In addition, retroflexion allowed a view of the pelvic organs. Mean operative time was 40 minutes.
  
  
  CONCLUSIONS
  TERA is a novel access route to the peritoneal cavity that can be performed by using readily available instrumentation. When performed under direct view, injury to the adjacent structures can be avoided while obtaining access. Unresolved issues include sterility of the procedure and reproducibility, and future survival studies will delineate long-term safety.
authors.affiliation: Department of Surgery, University of California-San Diego, San Diego, California, USA.
authors.forename: Sonia L
authors.initials: SL
authors.lastname: Ramamoorthy
authors.forename: Lauren J
authors.initials: LJ
authors.lastname: Fischer
authors.forename: Garth
authors.initials: G
authors.lastname: Jacobsen
authors.forename: Kari
authors.initials: K
authors.lastname: Thompson
authors.forename: Brian
authors.initials: B
authors.lastname: Wong
authors.forename: Adam
authors.initials: A
authors.lastname: Spivack
authors.forename: John
authors.initials: J
authors.lastname: Cullen
authors.forename: Mark A
authors.initials: MA
authors.lastname: Talamini
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
mesh_terms: D000818:Animals; D002404:Catheterization; D004210:Dissection; D004724:Endoscopy / Q000379:methods*; D023421:Models, Animal; D010529:Peritoneal Cavity / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D013552:Swine