Second generation sigmoid access for NOTES using the ISSA-system

Background:

Transluminal surgery offers challenging possibilities for trauma reduction. Current investigations are mainly focused upon optimization of the access routes and its safe closure.

Methods:

We developed a trocar system consisting of a modified TEM (transanal endoscopic microsurgery) device and a specially designed overtube, serving as a stable gate for the endoscope during interventions. The TEM device allows for safe, transsigmoid introduction of the overtube into the abdominal cavity and for reliable closure of the entry site by surgical techniques. By the help of a decontaminating solution which is installed via a Verres needle, the pelvic content is separated during the introduction phase; the solution also reduces the risk of infection. The system was evaluated in a survival animal study in 5 pigs and used in acute interventions in almost 30 animals.

Results:

There were almost no complications by using the ISSA system for transluminal surgery. There were no bleeding events, the access to upper abdominal organs was excellent in all animals. In one case only a laceration of the urinary bladder occurred, but could be handled easily. The closure of the entry site was leak proof in all cases, there were no signs of infection, nor any adhesions in the survival study. The overtube proved to be essential for repeated introduction of the scope.

Conclusion:

The transcolonic approach using the guide tube of the ISSA system is feasible and safe. It offers mentionable advantages compared to alternative techniques and reduces known shortcomings of NOTES. With the help of approved surgical principles for closure of the entry point a reliable solution for this main problem is realized.

Keywords: NOTES, transsigmoid, trocar, guide tube, access