title: Complications during natural orifice translumenal endoscopic surgery: endoscopic management of splenic laceration and hemorrhage.
abstract: BACKGROUND
  Accidental splenic laceration and hemorrhage during natural orifice translumenal endoscopic surgery (NOTES) can lead to life-threatening consequences. The NOTES approach may need to be aborted in these circumstances for a standard laparoscopy or laparotomy.
  
  
  OBJECTIVE
  To determine the feasibility of endoscopically managing intraoperative splenic laceration and hemorrhage during NOTES using standard endoscopic tools.
  
  
  METHODS
  Nine pigs underwent transcolonic endoscopic surgery, and 18 intentional splenic lacerations were made. Animals were treated as follows: (1) control group with no therapy (n = 3), (2) endoscopic tamponade/packing (n = 3), and (3) endoscopic hemostasis with bipolar cautery (n = 12). A blinded second endoscopist performed NOTES exploration and attempted to identify the site and treat the laceration in 3 cases. The colonic incision was closed using endoclips in the survival studies. Necropsy was performed immediately after surgery in acute cases and at the end of 1 week in the survival cases.
  
  
  RESULTS
  Bleeding persisted beyond 10 minutes in all control cases without therapy. In the tamponade group, bleeding persisted beyond 17 minutes in 2 and a large clot formed at 12 minutes in 1 case that precluded further assessment. Bleeding was controlled endoscopically using standard bipolar cautery in all animals (mean time: 12 minutes). All lacerations were identified and managed by the blinded endoscopist. Survival animals had an uncomplicated postoperative course. No bleeding was seen at necropsy.
  
  
  CONCLUSIONS
  We demonstrate the management of intraoperative splenic hemorrhage during NOTES using standard endoscopic tools. The site of splenic bleeding could be correctly identified and treated in a blinded fashion.
authors.affiliation: Division of Gastroenterology, University of Florida, Gainesville, Florida, 32610, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Fyock
authors.forename: Lukasz M
authors.initials: LM
authors.lastname: Kowalczyk
authors.forename: Anand R
authors.initials: AR
authors.lastname: Gupte
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Forsmark
authors.forename: Mihir S
authors.initials: MS
authors.lastname: Wagh
mesh_terms: D000818:Animals; D002425:Cautery; D005260:Female; D006470:Hemorrhage / Q000601:surgery*; D016558:Hemostasis, Endoscopic; D007431:Intraoperative Complications / Q000601:surgery; D022125:Lacerations / Q000601:surgery*; D010535:Laparoscopy; D007813:Laparotomy; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods; D013154:Spleen / Q000293:injuries*; D013158:Splenic Diseases / Q000601:surgery*; D013552:Swine