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Techniques and challenges of NOTeS cholecystectomy

and manipulate the instrument, the provision of adequate and stable exposure, and the avoidance of significant trauma or injury.13 Among the three proposed peritoneal access sites, the transvaginal route offers the smallest learning curve due to extensive transvaginal experience in gynecological sur- geries, the ability to use rigid instrumentation with optical correctness and the availability of reliable closure devices to safely close the colpotomy. These factors help explain why the transvaginal route of access currently accounts for 93.5% of all NOTES procedure performed to date.

While gaining peritoneal access through the stomach9 or rectum2,14 is feasible, reliable closure devices are not readily available to the NOTES surgeon. Natural concerns center- ing on risk of postoperative leak and peritoneal contamina- tion via transgastric and transcolonic NOTES approaches has also slowed human experimentation; however several

prototypes for safe access and gastric closure have been developed (see Table 2).15 Many of these devices have pro- duced favorable outcomes in in vivo porcine models; however there has been limited data to support human clinical use. In fact, while each device may have its special advantages and disadvantages, no data comparing the efficiency, safety, or the reliability of these prototypes exists.

Voermans et al evaluated seven different gastrotomy clo- sure devices in an ex vivo model, which involved filling the stomach with air and assessing burst pressures.16 All closures were done manually to guarantee an ideal seal. These authors reported that the burst pressures for the Eagle Claw VIII, the flexible stapler and the flexible Endostitch closures were equivalent to hand-sewn interrupted surgical suture closure with 3.0 polydioxane II (206 mmHg). Purse string modified T tags, purse string suturing devices and the T tags were

Table 2 Gastric and intestinal closure devices currently being tested for transgastric and transcolonic NOTeS16

Closure device


T tags (ethicon endo-Surgery, Cincinnati, Metal “T”-bar and thread loaded

Advantage Strength

Disadvantage Leaks through needle holes, due


onto a 19-gauge hollow needle passed through tissue lateral of defect and anchor is ejected beyond

to excessive apposition force between anchors. Blind punctures through gastric wall.

wall. Another anchor is placed in the same manner on the opposite side of defect and the tissue is approximated by a locking cinch.

Purse string modified T tags (Cook endoscopy, winston- Salem, NC, USA)

Purse string suturing device (LSi Solutions, victor, NY, USA)

Flexible stapler (Power Medical interventions, Langhorne, PA, USA)

Flexible endostitch (Covidien, North Haven, CT, USA)

Resolution clips (Boston Scientific, Natick, MA, USA)

eagle Claw viii (Olympus Corporation,Tokyo, Japan)

A metal ring is added to the midpoint to the tradition T tag device in order to deploy four sutures sequentially, in a square pattern, on the same suture. Creates a vacuum to draw the gastric wall into a chamber in which a 3-mm blade may make an incision. Sutures are deployed and tightened with a titanium knot. Computer-guided cutting and stapling device on a flexible shaft.

Opening and closing of the jaws moves a needle to opposite sides and through the tissue. Barbs keep the suture secure to the tissue without the need to endoscopically tie a knot. Standard endoclips

Attached to the tip of the endoscope, opposing jaws can move simultaneously, one jaw attaches to the tissue, while the other jaw holds a curved needle to deliver a suture through the tissue.The needle tip can detach and lock into the suture device cartridge once jaws are locked.

Allows 4 fasteners to be sequentially deployed on same suture

easy to use, rapid and adequate closure, negates endoscopic knot tying

easy to use, rapid and adequate closure, negates endoscopic knot tying easy to use, rapid and adequate closure, negates endoscopic knot tying

ease of use

ease of use


Tissue tear at clip site

Size and maneuverability in vivo

Size and maneuverability in vivo

incomplete closure (Deep layers may slip from clip) Still in prototype phase

Open Access Surgery 2010:3

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