Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
Surg Endosc. 2010 Jun;24(6):1474-81. doi: 10.1007/s00464-009-0760-4. Epub 2009 Dec 24.
Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting in-line endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access.
In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for in-line endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed.
Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 +/- 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 +/- 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 +/- 1.2 kg) in the 2-week survival period.
Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.
黏膜下剥离术被证明是一种可行的技术，可安全获得经口经胃腹膜通道，用于自然腔道内镜外科手术（NOTES）。作者假设他们之前描述的自逼近经腔通道技术（STAT）可用于创建定向胃黏膜下隧道，允许内窥镜以预定的腹部位置直线定位，否则这些位置可能难以进入。
在这项研究中，14 头国内农场猪接受了经口经胃腹膜镜检查。在直接内镜可视化下，通过在胃的黏膜层和肌肉层之间解剖来创建黏膜下隧道。每个隧道均由四个腹腔内位置之一（右上象限、左上象限、小网膜囊和骨盆）作为内窥镜直线定位的最终目标来创建。一旦获得腹膜通道，就评估直线定位并进行腹膜镜检查。使用内镜放置的夹关闭黏膜下隧道。手术后 2 周处死动物，并进行尸检。
在 14 只动物中的 12 只成功地将黏膜下隧道定向到预定的腹腔内目标。创建隧道所需的平均解剖时间为 51+/-32 分钟。所有经胃隧道均成功地用内镜放置的夹（平均 3.2+/-1.1）关闭，在尸检中，没有任何动物的胃切开漏迹象。一只动物发生与经胃隧道无关的十二指肠穿孔，并在术后第 2 天死亡。其余动物在 2 周的存活期内恢复并增加体重（平均 5.5+/-1.2 公斤）。
在猪模型中，定向黏膜下解剖术在技术上是可行的，并允许内窥镜以预定的腹部目标位置直线定位。STAT 方法提供了安全的腹膜通道，允许进行简单可靠的内镜夹闭，并且具有出色的短期存活率。这种获得经胃通道的方法可能是未来NOTES 手术的一种辅助技术。
