Natural Orifice Translumenal Endoscopic Surgery for Roux-En-Y Gastric Bypass: An Experimental Surgical Study in a Human Cadaver Model
Monika E. Hagen*1, Francois Pugin1, Oliver J. Wagner2, Paul Swain3, Nicolas C. Buchs1, Margherita Cadeddu4, Priya a. Jamidar5, Jean Fasel6, Philippe Morel1
1Division of Digestive Surgery, University Hospital Geneva, Geneva, Switzerland; 2Department of Visceral and Transplantation Surgery, University of Bern, Bern, Switzerland; 3Imperial College, London, United Kingdom; 4McMaster University, Hamilton, ON, Canada; 5Section of Digestive Diseases, Yale University, New Haven, CT; 6Division of Anatomy, University Geneva, Geneva, Switzerland
Background: Advantages of a NOTES or NOTES hybrid approach to Roux-en-Y gastric bypass (RYGB) might include: easier access to the peritoneal cavity, subtantial reduction in number of ports and port related complications, improved cosmesis and others. NOTES was initially concieved as a procedure for relatively minor intraperitoneal operations. The most common NOTES procedure currently is cholecystectomy which is of moderate complexity. RYGB is a complex surgical procedure of advanced level. The technical feasibility of a NOTES-RYGB and limitations of available flexible and rigid instrumentation for such a procedure is unknown.
Methods: NOTES hybrid RYGB was performed in 4 human cadavers (frozen or preserved) using a combination of flexible and rigid instruments. Pouch creation was achieved by needle knife dissection of a retrogastric window using a flexible gastroscope introduced transvaginally. Articulated linear staplers were placed through a transumbilical port to transect the stomach. Measurements of the bilary and alimenary limbs were accomplished with flexible and rigid graspers. A 21 mm anvil was introduced through a needle-knife incision into the small intestine and connected to the flexible shaft of a flexible transesophageal stapler to form a gastrojejunostomy. A linear stapler was used for the jejuno-jejunal anastomosis.
Results: It was feasible to perform bypass surgery in all cadavers. Dissection and pouch creation was easier than expected using flexible instruments to form the pouch. Ordinary rigid instruments (graspers and staplers) were too short for some transvaginal or transrectal manipulations. Anvil manipulation and docking was difficult using flexible instruments. Combinations of flexible and rigid visualization and manipulation were especially helpful for pouch creation and stapler manipulation. Transabdominal port access number was reduced from 5-7 to 1-3 with 1-2 translumenal access ports.
Conclusions: Roux-enY bypass surgery ís technically feasible in human cadavers using a NOTES hybrid approach. Port numbers can be reduced. A combination of flexible with rigid endoscopic techniques devices offers specific advantages for components of this type of surgery. Changes in instrument design are required to improve complex hybrid endosurgical procedures.
