title: Laparoscopic sleeve gastrectomy with transgastric visualization: another step toward totally NOTES procedures.
abstract: BACKGROUND
  Laparoendoscopic single-site sleeve gastrectomy is gaining acceptance. However, totally natural orifice translumenal endoscopic surgery (NOTES) in morbidly obese patients is still controversial due to safety and technical issues. To this end, we have developed a technique for sleeve gastrectomy in which the surgical field view is achieved through transgastric approach and the operating channel will eventually be through the vagina to form a dual lumen totally NOTES procedure for sleeve gastrectomy. As a step toward this approach, we performed a single abdominal incision in order to simulate the transvaginal route. This study is another step toward combined transvaginal and transgastric totally NOTES sleeve gastrectomy.
  
  
  METHODS
  A combined NOTES and single trocar sleeve gastrectomy was performed on 8 porcine animal models. The endoscope was inserted through the gastric wall and served as the vision source for the procedure. A second endoscope was inserted via the transabdominal trocar together with the surgical instruments.
  
  
  RESULTS
  Sleeve gastrectomy was performed on 8 porcine models. The operative time for the first procedure was 5 hours, but after determining the technique, the time was reduced by half.
  
  
  CONCLUSIONS
  Combined NOTES and single trocar sleeve gastrectomy is feasible in a porcine model. We achieved an excellent view of the surgical field through the transgastric approach. We believe that in the near future, combining the transgastric visualization of the surgical field together with a transvaginal approach may enable performing a total NOTES sleeve gastrectomy procedure. This hypothesis will be studied in further animal experiments before implementation in humans.
authors.affiliation: Hadassah Hebrew University Medical Center, Jerusalem, Israel ramelazary@hadassah.org.il.
authors.forename: Ram
authors.initials: R
authors.lastname: Elazary
authors.affiliation: Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Avraham
authors.initials: A
authors.lastname: Schlager
authors.affiliation: Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Abed
authors.initials: A
authors.lastname: Khalaileh
authors.affiliation: Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Yoav
authors.initials: Y
authors.lastname: Mintz
mesh_terms: D000818:Animals; D005743:Gastrectomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D013270:Stomach / Q000601:surgery; D013552:Swine
keywords: LESS; NOTES; flexible endoscope; laparoendoscopic single site; laparoscopy; morbid obesity; natural orifice translumenal endoscopic surgery; single trocar; sleeve gastrectomy