title: Comparison of anterior transgastric access techniques for natural orifice translumenal endoscopic surgery.
abstract: BACKGROUND
  The advancement of natural orifice translumenal endoscopic surgery (NOTES) into clinical practice is dependent on its safety, efficacy, and efficiency. Access is the obligatory first step in NOTES and serves as a surrogate to technical difficulties associated with this novel surgical approach. This study aimed to compare endoscopic transgastric access techniques in terms of safety, reproducibility, and efficiency.
  
  
  METHODS
  Seven variations for anterior transgastric NOTES access were evaluated with female domestic swine. After marking of an anterior site, electrocautery was used to create a small gastrotomy, followed by balloon dilation and entry into the peritoneal cavity. Methodologic variations incorporated the use of guidewires, electrocautery and dilation combined within a single device, support tubes, and dilation without electrocautery. Access times were recorded, and tissue injury was evaluated.
  
  
  RESULTS
  In 70 access attempts, the most serious complication was bleeding from the gastroepiploic vessel, controlled with electrocautery. High variability in access times was prevalent with almost all the access techniques.
  
  
  CONCLUSIONS
  This study supports the presumption that an anterior transgastric access technique for NOTES procedures is safe. The use of a wire to mark the site and another wire to retain the gastrotomy provided safe, efficient, and reproducible transgastric access. Comparison with laparoscopy exposed the disparity in technical challenges facing NOTES, suggesting that new technology and further refinement in methodology are required for NOTES to be clinically relevant.
authors.affiliation: Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA. sjs12@case.edu
authors.forename: Steve J
authors.initials: SJ
authors.lastname: Schomisch
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Furlan
authors.forename: Jamie M
authors.initials: JM
authors.lastname: Andrews
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Trunzo
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Ponsky
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Marks
mesh_terms: D000818:Animals; D002404:Catheterization / Q000379:methods; D005260:Female; D005774:Gastrostomy / Q000379:methods*; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation / Q000379:methods*; D013525:Surgical Instruments; D013552:Swine