Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans.

Linke, Georg R; Zerz, Andreas; Kapitza, Florian; Warschkow, Rene; Lange, Jochen; Meyenberger, Christa M; Binek, Janek

BACKGROUND To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated. OBJECTIVE To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity. DESIGN Prospective pilot study in humans. SETTING Single tertiary-care center. PATIENTS This study involved 31 patients referred for laparoscopic cholecystectomy. INTERVENTION Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area. MAIN OUTCOME MEASUREMENTS To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems. RESULTS The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (> or = 3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1% of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients. LIMITATIONS This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict. CONCLUSION Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.