title: Transvesical NOTES: survival study in porcine model.
abstract: OBJECTIVE
  The optimal access route and method for natural orifice transluminal endoscopic surgery (NOTES) has not been established. A transvesical approach, with its low rate of peritoneal contamination, is an effective clean portal of entry, but a safe urinary bladder closure has been a challenge. We developed a new technique for a safe, pure transvesical NOTES approach.
  
  
  METHODS
  Four female piglets were used in the study. With the pigs under anesthesia, a flexible cystoscope (15Fr) was used to make an endoscopic cystotomy; diagnostic peritoneoscopy of the abdominal quadrants was done with biopsies and hemostasis. At the end, a Vicryl loop was pushed to close the bladder incision while the incision edges were pulled inwards. The pigs were euthanized after 2 wk, and necropsies were performed.
  
  
  RESULTS
  No bowel injury was noted in any of the 4 pigs. Satisfactory bladder closure was done in 2 pigs, while a partial closure was achieved in 1 case. In the postoperative period, the pigs showed no signs of pain or distress, voided normally, and had a good appetite. On necropsy, we noted healed cystotomy incisions, no intraabdominal adhesions, and no adhesions at the site.
  
  
  CONCLUSIONS
  Our new technique for endoscopic cystotomy overcomes previously reported risks for bowel injuries. Using this route gives good spatial orientation and access to all quadrants, including the pelvis. Biopsies with good hemostasis can be easily achieved. Lack of intraperitoneal changes postoperatively indicate that this procedure may be safe for humans.
authors.affiliation: Department of Surgery, Providence Hospital and Medical Centers, Southfield, MI, USA. drjsbhullar@gmail.com
authors.forename: Jasneet Singh
authors.initials: JS
authors.lastname: Bhullar
authors.forename: Gokulakkrishna
authors.initials: G
authors.lastname: Subhas
authors.forename: Aditya
authors.initials: A
authors.lastname: Gupta
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Jacobs
authors.forename: Melissa
authors.initials: M
authors.lastname: Decker
authors.forename: Boris
authors.initials: B
authors.lastname: Silberberg
authors.forename: Vijay K
authors.initials: VK
authors.lastname: Mittal
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D005260:Female; D010535:Laparoscopy; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D010537:Peritoneum / Q000601:surgery*; D013552:Swine; D001743:Urinary Bladder / Q000601:surgery*; D001745:Urinary Bladder Diseases / Q000601:surgery*