Tagaya Nobumi, Kubota Keiichi
Second Department of Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan.
J Hepatobiliary Pancreat Surg. 2009;16(3):283-7. doi: 10.1007/s00534-009-0085-7. Epub 2009 Apr 7.
Minimally invasive abdominal surgery means minimal trauma to the abdominal wall, thus reducing postoperative pain and wound complications, and facilitating earlier mobilization and shorter hospitalization in comparison with conventional surgery. Natural orifice translumenal endoscopic surgery (NOTES) has the potential to further reduce the invasiveness of surgery in human patients. Here we report an experimental study of NOTES to access the liver and spleen, discuss its current status, and review the related literature.
The utility of transgastric peritoneoscopy was evaluated using one 15-kg pig and four 8-kg dogs on the basis of acute experiments. Under general anesthesia with endotracheal intubation, a forward-viewing, double-channel endoscope was advanced into the peritoneal cavity through a gastric hole. Liver biopsy from the edge of the liver was performed using routine biopsy forceps. Splenectomy was performed using a laparoscopically assisted procedure, and then the spleen was pulled into the stomach using an endoscopic polypectomy snare after enlargement of the gastric orifice. The animals were then sacrificed and necropsy was performed.
There were no complications during incision of the gastric wall and entry into the peritoneal cavity. Peritoneoscopy gave satisfactory visualization of the abdominal cavity in all directions. Liver biopsy was performed successfully without any bleeding and adequate samples were obtained in all cases. Splenectomies were also accomplished uneventfully, except for injury of the splenic parenchyma due to excessive force during pulling into the stomach. Necropsy revealed no particular damage to other intraperitoneal organs related to this transgastric procedure.
Although NOTES is a feasible procedure and offers several advantages to patients, surgeons and endoscopists need to resolve several key issues before its clinical introduction for routine surgical work and to establish a training system for NOTES in order to avoid critical complications.
微创腹部手术意味着对腹壁的创伤最小，因此与传统手术相比，可减轻术后疼痛和伤口并发症，并有助于更早活动和缩短住院时间。经自然腔道内镜手术（NOTES）有可能进一步降低人类患者手术的侵入性。在此，我们报告一项关于NOTES进入肝脏和脾脏的实验研究，讨论其现状，并回顾相关文献。
基于急性实验，使用1头15千克的猪和4只8千克的狗评估经胃腹膜腔镜检查的效用。在气管插管全身麻醉下，将前视双通道内镜通过胃孔推进到腹腔。使用常规活检钳从肝边缘进行肝活检。采用腹腔镜辅助手术进行脾切除术，然后在扩大胃孔后，使用内镜息肉切除圈套器将脾脏拉入胃内。然后处死动物并进行尸检。
胃壁切开和进入腹腔过程中无并发症。腹膜腔镜检查在各个方向均能提供满意的腹腔视野。肝活检成功完成，无出血，所有病例均获得足够样本。脾切除术也顺利完成，但在拉入胃内时因用力过大导致脾实质损伤。尸检显示与该经胃手术相关的其他腹腔内器官无特殊损伤。
尽管NOTES是一种可行的手术方法，对患者、外科医生和内镜医生有诸多优势，但在将其引入临床用于常规手术工作之前，外科医生和内镜医生需要解决几个关键问题，并建立NOTES培训系统以避免严重并发症。
