title: A NOTES approach for thoracic surgery: transgastric thoracoscopy via a diaphragmatic incision in a survival porcine model.
abstract: OBJECTIVE
  Recently the NOTES approach has been extended to mediastinum by a transesophageal access and to the thorax by a transvescical endoscopic approach. The aim of this study was to assess the feasibility and the safety of transgastric endoscopic approach to the thoracic cavity, with lung biopsy, in a survival porcine model.
  
  
  METHODS
  The study was performed on four 20-30 kg female pigs (Sus scrofus domesticus). Following gastric wall incision, the muscular pars of the left diaphragmatic dome was incised along with the parietal pleura and the endoscope advanced into the thoracic cavity. In all animals, a thoracoscopy was performed as well as peripheral lung biopsy. At the end of the operation the endoscope was withdrawn from the thoracic cavity after pleural sac decompression and the diaphragmatic incision closed by endoscopic clips under maximal expansion of lungs. The gastric incision was finally closed by endoscopic clips. Chest-tube placement was not utilized. Animals were sacrificed by day 15 postoperatively.
  
  
  RESULTS
  The gastroscope was easily introduced into the thoracic cavity that allowed to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. No adverse event occurred during the survival period. The postmortem examination 15 days after surgery revealed a good closure of the diaphragmatic incision. At necropsy, the lung biopsies were completely healed. There were no signs of infection in both thoracic and peritoneal cavities. The length of follow-up and number of animals studied might have not been sufficient.
  
  
  CONCLUSIONS
  This study demonstrates the feasibility of transgastric thoracoscopy in porcine model. Long-term follow-up of much larger series will be necessary for provision of more reliable answers if this approach should be adopted in the future and eventually translated for humans with advantages for patients.
authors.affiliation: Department of Surgery and Advanced Technologies, Center for Technical Innovation in Surgery (ITC), University of Naples Federico IISchool of Medicine, Naples, Italy. giovanni.depalma@unina.it
authors.forename: G D
authors.initials: GD
authors.lastname: De Palma
authors.forename: S
authors.initials: S
authors.lastname: Siciliano
authors.forename: P
authors.initials: P
authors.lastname: Addeo
authors.forename: F
authors.initials: F
authors.lastname: Salvatori
authors.forename: M
authors.initials: M
authors.lastname: Persico
authors.forename: S
authors.initials: S
authors.lastname: Masone
authors.forename: M
authors.initials: M
authors.lastname: Rega
authors.forename: F
authors.initials: F
authors.lastname: Maione
authors.forename: E
authors.initials: E
authors.lastname: Coppola Bottazzi
authors.forename: E
authors.initials: E
authors.lastname: Serrao
authors.forename: M
authors.initials: M
authors.lastname: Adamo
authors.forename: G
authors.initials: G
authors.lastname: Persico
mesh_terms: D000818:Animals; D003964:Diaphragm / Q000601:surgery; D005240:Feasibility Studies; D005260:Female; D023421:Models, Animal; D013270:Stomach; D013552:Swine; D013906:Thoracoscopy / Q000379:methods*