Hagen M E, Wagner O J, Swain P, Pugin F, Buchs N, Caddedu M, Jamidar P, Fasel J, Morel P
Division of Digestive Surgery, University Hospital Geneva, Geneva, Switzerland.
Endoscopy. 2008 Nov;40(11):918-24. doi: 10.1055/s-2008-1077720. Epub 2008 Nov 13.
The advantages of a hybrid natural orifice transluminal endoscopic surgery approach to Roux-en-Y gastric bypass (hNOTES-RYGBP) might include: easier access to the peritoneal cavity, reduced number of ports and related complications, improved cosmesis, and others. However, currently available conventional endoscopic and laparoscopic instruments might be unsuitable for complex surgical procedures using transluminal access. The aim of this study was to investigate the feasibility and limitations of a NOTES RYGBP.
hNOTES-RYGBP was performed in human cadavers. Pouch creation was achieved by needle-knife dissection using a transvaginal, flexible scope. Articulating linear staplers were placed transumbilically to transect the stomach. Measurements of the small bowel were accomplished intraluminally or with flexible and rigid graspers. New methods were tested to create the gastro-jejunal anastomosis. A linear laparoscopic stapler was used to form the jejuno-jejunal anastomosis.
Stapler manipulation and anvil docking, bowel manipulation and measurement, and tissue dissection presented the main obstacles for hNOTES-RYGBP. Conventional instruments were too short for some transvaginal manipulations. The time to complete the procedure was 6 - 9 hours. It was feasible to perform a complete hNOTES-RYGBP in four out of seven cadavers. Two cadavers were unsuitable due to anatomical abnormalities or advanced decay. One procedure was terminated before completion because of time constraints. Combinations of flexible and rigid visualization and manipulation were helpful, especially for dissection and gastric pouch creation.
Several factors made hNOTES-RYGBP very challenging and time-consuming. A lack of proper instrumentation resulting in insufficient tissue traction, countertraction, and instrument manipulation complicated several steps during the procedure. A combination of flexible with rigid endoscopic techniques offers specific advantages for components of this type of surgery. Changes in instrument design are required to improve more complex endosurgical procedures.
杂交式经自然腔道内镜手术途径行Roux-en-Y胃旁路术（hNOTES-RYGBP）的优势可能包括：更容易进入腹腔、减少端口数量及相关并发症、改善美观等。然而，目前现有的传统内镜和腹腔镜器械可能不适用于经腔道入路的复杂手术。本研究的目的是探讨NOTES RYGBP的可行性和局限性。
在人体尸体上进行hNOTES-RYGBP。通过经阴道的柔性内镜用针刀分离来创建胃囊。经脐放置可弯曲线性吻合器横断胃。通过腔内测量或使用柔性和刚性抓钳测量小肠。测试了创建胃肠吻合的新方法。使用线性腹腔镜吻合器形成空肠-空肠吻合。
吻合器操作与钉砧对接、肠管操作与测量以及组织分离是hNOTES-RYGBP的主要障碍。传统器械对于一些经阴道操作来说太短。完成该手术的时间为6至9小时。在七具尸体中有四具可行完整的hNOTES-RYGBP。两具尸体因解剖异常或高度腐败而不适合。由于时间限制，有一台手术在完成前终止。柔性和刚性可视化及操作的结合很有帮助，特别是在分离和胃囊创建方面。
几个因素使得hNOTES-RYGBP极具挑战性且耗时。缺乏合适的器械导致组织牵引、对抗牵引和器械操作不足，使手术过程中的几个步骤变得复杂。柔性与刚性内镜技术的结合为这类手术的各个部分提供了特定优势。需要改进器械设计以完善更复杂的内镜手术。
