Bhullar Jasneet Singh, Subhas Gokulakkrishna, Gupta Aditya, Jacobs Michael J, Decker Melissa, Silberberg Boris, Mittal Vijay K
Department of Surgery, Providence Hospital and Medical Centers, Southfield, MI, USA.
JSLS. 2012 Oct-Dec;16(4):606-11. doi: 10.4293/108680812X13462882737294.
The optimal access route and method for natural orifice transluminal endoscopic surgery (NOTES) has not been established. A transvesical approach, with its low rate of peritoneal contamination, is an effective clean portal of entry, but a safe urinary bladder closure has been a challenge. We developed a new technique for a safe, pure transvesical NOTES approach.
Four female piglets were used in the study. With the pigs under anesthesia, a flexible cystoscope (15Fr) was used to make an endoscopic cystotomy; diagnostic peritoneoscopy of the abdominal quadrants was done with biopsies and hemostasis. At the end, a Vicryl loop was pushed to close the bladder incision while the incision edges were pulled inwards. The pigs were euthanized after 2 wk, and necropsies were performed.
No bowel injury was noted in any of the 4 pigs. Satisfactory bladder closure was done in 2 pigs, while a partial closure was achieved in 1 case. In the postoperative period, the pigs showed no signs of pain or distress, voided normally, and had a good appetite. On necropsy, we noted healed cystotomy incisions, no intraabdominal adhesions, and no adhesions at the site.
Our new technique for endoscopic cystotomy overcomes previously reported risks for bowel injuries. Using this route gives good spatial orientation and access to all quadrants, including the pelvis. Biopsies with good hemostasis can be easily achieved. Lack of intraperitoneal changes postoperatively indicate that this procedure may be safe for humans.
经自然腔道内镜手术（NOTES）的最佳入路和方法尚未确定。经膀胱入路，因其腹膜污染率低，是一种有效的清洁进入途径，但安全的膀胱闭合一直是个挑战。我们开发了一种新的技术用于安全、单纯的经膀胱NOTES入路。
本研究使用了4只雌性仔猪。在猪麻醉状态下，使用一根15Fr的软性膀胱镜进行内镜膀胱切开术；对腹部象限进行诊断性腹腔镜检查并取活检及止血。最后，当切口边缘向内牵拉时，用薇乔线环推进以闭合膀胱切口。2周后对猪实施安乐死并进行尸检。
4只猪中均未发现肠损伤。2只猪实现了满意的膀胱闭合，1例实现了部分闭合。术后，猪未表现出疼痛或痛苦迹象，排尿正常，食欲良好。尸检时，我们注意到膀胱切开术切口愈合，无腹腔内粘连，且该部位无粘连。
我们的内镜膀胱切开新技术克服了先前报道的肠损伤风险。采用该入路可获得良好的空间定位并能进入包括盆腔在内的所有象限。可轻松实现良好止血的活检。术后无腹腔内变化表明该手术对人类可能是安全的。
