title: Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model.
abstract: OBJECTIVE
  To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model.
  
  
  METHODS
  The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy.
  
  
  RESULTS
  Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels.
  
  
  CONCLUSIONS
  The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.
authors.affiliation: Institute of Minimally Invasive Medicine, Tongji University, Shanghai 200092, China.
authors.forename: Hong
authors.initials: H
authors.lastname: Shi
authors.forename: Sheng-Jun
authors.initials: SJ
authors.lastname: Jiang
authors.forename: Bin
authors.initials: B
authors.lastname: Li
authors.forename: Deng-Ke
authors.initials: DK
authors.lastname: Fu
authors.forename: Pei
authors.initials: P
authors.lastname: Xin
authors.forename: Yong-Guang
authors.initials: YG
authors.lastname: Wang
mesh_terms: D001003:Anal Canal; D000818:Animals; D004564:Electrocoagulation; D005240:Feasibility Studies; D005260:Female; D006488:Hemostasis, Surgical; D008099:Liver / Q000601:surgery*; D023421:Models, Animal; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D013552:Swine; D014472:Umbilicus; D014621:Vagina; D014867:Water
chemical_list: D014867:Water