title: Specialized instrumentation facilitates stable peritoneal access, gastric decompression, and visualization during transgastric endoscopic peritoneoscopy.
abstract: OBJECTIVE
  The lack of high-fidelity instrumentation has impeded the development and implementation of natural orifice transluminal endoscopic surgery (NOTES). A steerable flexible trocar (SFT), a rotary access needle (RAN), and an articulating needle knife were developed as components of a flexible instrument set to facilitate transgastric peritoneal access and transluminal abdominal procedures. This cohort study aimed to assess the safety, feasibility, and efficacy of these devices during transgastric peritoneoscopy.
  
  
  METHODS
  Ten morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Following laparoscopic access, transgastric peritoneal access was established using the SFT and RAN, and transgastric peritoneoscopy performed. NOTES adhesiolysis was performed in 2 patients with significant intra-abdominal adhesions due to prior surgery. Outcome measures included time to enter the peritoneal cavity, ability to visualize each quadrant of the abdomen, ability to perform adhesiolysis, and complications.
  
  
  RESULTS
  Ten patients with a median body mass index as stated in table 1 of 47.5 kg/m(2) were enrolled. Successful transgastric access was achieved in 8 of the 10 patients. One procedure was aborted because of difficulty creating the gastrotomy. Another procedure was aborted because of the difficult passage of the device through the oropharynx. An upper esophageal laceration occurred in one patient. Transgastric peritoneal access required 17.4 ± 5.5 minutes, and peritoneoscopy averaged 24.7 ± 7.6 minutes. The 4 abdominal quadrants were visualized and were accessible with the endoscope in all patients.
  
  
  CONCLUSIONS
  The SFT and RAN facilitate transgastric peritoneal access and visualization of difficult-to-reach areas of the peritoneum. These devices provide advanced instrumentation for transgastric NOTES procedures; however, care must be taken during the transoral insertion to avoid complications.
authors.affiliation: The Ohio State University Medical Center, Columbus, OH, USA.
authors.forename: Kyle A
authors.initials: KA
authors.lastname: Perry
authors.forename: Nilay
authors.initials: N
authors.lastname: Shah
authors.forename: Vanchad
authors.initials: V
authors.lastname: Memark
authors.forename: Peter
authors.initials: P
authors.lastname: Nau
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Needleman
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Hazey
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D020776:Endoscopes, Gastrointestinal; D005260:Female; D015390:Gastric Bypass / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation* / Q000379:methods; D009767:Obesity, Morbid / Q000601:surgery; D010529:Peritoneal Cavity / Q000601:surgery*; D016896:Treatment Outcome