Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
J Am Coll Surg. 2010 Apr;210(4):480-90. doi: 10.1016/j.jamcollsurg.2010.01.005.
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a developing, minimally invasive surgical approach whose potential benefits are being investigated. Little is known about secure access site closure and early healing kinetics of transvisceral access.
Transvisceral access incisions were created in the colon (C-NOTES, n = 8) and stomach (G-NOTES, n = 8) for peritoneal exploration. Incisions were closed primarily with endoloops, endoclips, or t-tags. Macroscopic and histologic analyses performed on postoperative day 7 assessed gross appearance, granulation tissue, inflammation, ulceration, and complications.
Macroscopically, incisions appeared closed without intraperitoneal spillage. Incisions closed by endoloop and t-tags showed intense granulation tissue fill of defect despite partial (G-NOTES, n = 3) and transmural ulceration (C-NOTES, n = 8; G-NOTES, n = 3). Of the 30 t-tags applied, 40% broke or deployed into the peritoneal cavity. Endoclip closures (C-NOTES, n = 1; G-NOTES, n = 1) did not show histologic mucosal continuity. Healing complications included transmural necrosis (C-NOTES, n = 1; G-NOTES, n = 1), foreign body material (C-NOTES, n = 3; G-NOTES, n = 2), and microabscesses (G-NOTES, n = 1).
This study provides a reproducible model to assess noninvasive repair of planned visceral perforations. Of investigated technologies, endoloop closure was favored for transcolonic incisions, and t-tags with omental patch for transgastric incisions, although these have significant limitations. Endoclips were inadequate for primary closure, but may be useful as an adjunctive closure modality. Additional studies are needed to examine visceral repair at later time points, as they will help determine the quality and kinetics of repair of a variety of incision closure strategies. This study demonstrates the need for improved technologies to more reliably close visceral transluminal defects.
经自然腔道内镜外科（NOTES）是一种发展中的微创外科方法，其潜在优势正在研究中。关于经内脏入路的安全通道关闭和早期愈合动力学，人们知之甚少。
在结肠（C-NOTES，n=8）和胃（G-NOTES，n=8）中创建经内脏入路切口进行腹膜探查。切口主要用内镜吻合环、内镜夹或 T 型夹闭合。术后第 7 天进行大体观察、肉芽组织、炎症、溃疡和并发症的组织学分析。
大体上，切口外观闭合，无腹腔内渗漏。尽管存在部分（G-NOTES，n=3）和穿透性溃疡（C-NOTES，n=8；G-NOTES，n=3），但内镜吻合环和 T 型夹闭合的切口显示出强烈的肉芽组织填充缺陷。在应用的 30 个 T 型夹中，有 40%断裂或部署到腹腔内。内镜夹闭合（C-NOTES，n=1；G-NOTES，n=1）未显示组织学黏膜连续性。愈合并发症包括穿透性坏死（C-NOTES，n=1；G-NOTES，n=1）、异物材料（C-NOTES，n=3；G-NOTES，n=2）和微脓肿（G-NOTES，n=1）。
本研究提供了一种可重复的模型，用于评估计划的内脏穿孔的非侵入性修复。在所研究的技术中，内镜吻合环闭合适用于经结肠切口，T 型夹加网膜补丁适用于经胃切口，但这些技术有明显的局限性。内镜夹不适合初次闭合，但可能作为辅助闭合方式有用。需要进一步研究以检查内脏修复的后期时间点，因为这将有助于确定各种切口闭合策略的修复质量和动力学。本研究表明需要改进技术，以更可靠地闭合内脏经腔道缺陷。
