title: Safe alternative transgastric peritoneal access in humans: NOTES.
abstract: BACKGROUND
  Diagnostic transgastric endoscopic peritoneoscopy has been used to evaluate the abdomen. We present our experience with transgastric endoscopic peritoneoscopy (TEP) to access the peritoneum, direct trocar placement, and perform adhesiolysis without laparoscopic visualization in patients undergoing laparoscopic Roux-en-Y gastric bypass.
  
  
  METHODS
  Forty patients participated. There are 2 arms to the study. The initial 20 patients underwent pre-insufflation of the abdomen prior to TEP. The second 20 had no pre-insufflation. Ten patients in each arm had no surgical history. The other 10 had previous intra-abdominal procedures. TEP was performed through a gastrotomy created without laparoscopic visualization. Adhesions were visualized and taken down endoscopically prior to trocar placement. Diagnostic findings, operative times, and clinical course were recorded.
  
  
  RESULTS
  Average TEP time was 19 min. Three patients had limited visualization due to intra-abdominal adhesions (2) and omental fat (1). Three of the 20 without and 17 of 20 with a history of intra-abdominal surgery had adhesions visualized endoscopically. Endoscopic adhesiolysis was performed in 1 and 4 patients in these groups respectively. Six occult umbilical hernias, 1 inguinal hernia, and 1 hiatal hernia were noted on endoscopic exploration. There were no complications related to intubation of the stomach, accessing the peritoneum, or endoscopic exploration.
  
  
  CONCLUSIONS
  TEP is a safe and accurate means to access the peritoneum, visualize the abdominal wall, perform adhesiolysis, and direct trocar placement without laparoscopic guidance. Safe and reliable gastric closure remains the sole limitation to its clinical use outside of a protocol necessitating a gastrotomy.
authors.affiliation: The Ohio State University Medical Center, Department of Surgery, Columbus, OH 43210-1228, USA. peter.nau@osumc.edu
authors.forename: Peter
authors.initials: P
authors.lastname: Nau
authors.forename: Joel
authors.initials: J
authors.lastname: Anderson
authors.forename: Lynn
authors.initials: L
authors.lastname: Happel
authors.forename: Benjamin
authors.initials: B
authors.lastname: Yuh
authors.forename: Vimal K
authors.initials: VK
authors.lastname: Narula
authors.forename: Bradley
authors.initials: B
authors.lastname: Needleman
authors.forename: E Christopher
authors.initials: EC
authors.lastname: Ellison
authors.forename: W Scott
authors.initials: WS
authors.lastname: Melvin
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Hazey
mesh_terms: D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D009767:Obesity, Morbid / Q000601:surgery; D011028:Pneumoperitoneum, Artificial; D017751:Safety Management; D013525:Surgical Instruments; D000267:Tissue Adhesions / Q000601:surgery; D016896:Treatment Outcome