Original ArticleExperimental EndoscopyTransgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope
Section snippets
Multibending endoscope
The endoscope used (XGIF-2TQ260ZMY, R-scope; Olympus Optical Co, Ltd, Tokyo, Japan) has 2 bending sections: the proximal section can be deflected in a single plane (up–down); the distal section can be deflected in 2 planes (up-down, right-left). There also are 2 actuated instrument channels: 1 allows vertical elevation, the other allows a horizontal “swing” movement (Fig. 1, Table 1).
CO2 tissue separation
For CO2 injection, a commercially available CO2 cylinder (CO2 Duster; American Recorder Technology Inc, Simi
SEMF with CO2 insufflation
A bowl-shaped giant submucosal bleb over 8 cm in diameter was created by several milliseconds (estimated only) of CO2 injection for 5 animals (Fig. 4), completely separating the submucosal layer from the mucosa, thereby forming a true space (Fig. 5). In 1 pig, a complete submucosal dissection failed, despite CO2 injections in 5 different locations. The submucosal space was eventually created with supplemental balloon dissection.
Gallbladder access
Myotomies with the attached serosa could be performed inside the
Discussion
A pure transgastric cholecystectomy is feasible when using a cephalad directional exit from the stomach to allow access to the gallbladder. Although the overall outcomes may not have been ideal, they proved instructional with regard to moving forward with NOTES research and development.
Modifying the anterior gastric exit with the SEMF technique directed cephalad could effectively create a biologic endoscope and instrument guide for the upper abdominal cavity. Furthermore, the R-type endoscope
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2018, Gastrointestinal EndoscopyLessons Learned from Traditional NOTES. A Historical Perspective.
2016, Gastrointestinal Endoscopy Clinics of North AmericaCitation Excerpt :They then went on to conceive that by making an incision through the muscularis propria and serosa at the end of the tunnel; they could accomplish safe entry into the peritoneal cavity as well as safe closure using the mucosal flap. They called this “tunneled offset viscerotomy.”5 Their work on creating a submucosal working space came about from their desire to improve the technique of en bloc resection.
Investigating deeper: Muscularis propria to natural orifice transluminal endoscopic surgery
2014, Gastrointestinal Endoscopy Clinics of North AmericaCitation Excerpt :The submucosal space, or tunnel, in more limited applications of SEMF, requires a 4 to 5 cm length to provide a safety flap valve. In the authors’ experience, a 5 to 10 cm long tunnel is superior; the greater length acts as an added safety measure during NOTES procedures for less risk of extraluminal contamination.6,7 The SEMF procedure is initiated by creation of a submucosal fluid cushion (SFC) to access the submucosa and initiate the anticipated route of the submucosal tunnel.
Historical notes: The road to peroral endoscopic myotomy
2013, Techniques in Gastrointestinal EndoscopyA technical review of flexible endoscopic multitasking platforms
2012, International Journal of SurgeryCitation Excerpt :Later bench top studies of an improved R-scope demonstrated its superiority in performing ESD in the lesser curvature when compared to the DCE.53 Experimentally, it has been used to perform transgastric cholecystectomy and distal pancreatectomy in survival porcine models.54–56 It has also been used to perform transgastric peritoneoscopy.
Third-space endoscopy: The final frontier
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