Clinical and Pathological Outcomes After Endoscopic Transgastric Partial Hysterectomy in a Porcine Model

Abstract

Introduction: Traditionally per-oral endoscopy has been limited to the intestinal lumen. A transgastric approach may allow less invasive means of performing select surgical procedures. This approach could reduce post-operative abdominal wall pain, wound infection, herniation, and adhesions. Methods: Female Yorkshire pigs were kept NPO for 24 hours. Enrofloxacin and Fentanyl were given at surgery. All instruments were sterilized with glutaraldehyde. Animals were intubated, given Isoflourane, and ventilated as needed. A diagnostic gastroscope was used to place the sterile esophageal overtube. The stomach was lavaged with normal saline and Cefazolin solution was instilled into the stomach for 10 minutes. A needle-knife was used to make a sub-centimeter incision through the anterior gastric wall, and a therapeutic gastroscope was pushed through the incision into the peritoneal cavity. An endoscopic grasping forcep was used to pull the uterus into an Olympus Endoloop which was then secured. The uterine horn and portions of the uterine body, broad ligament, and mesosalpinx were resected with a polypectomy snare. The site was inspected for bleeding and damage to adjacent organs. Using the snare, the resected uterus was removed through the mouth via the gastric incision. The gastric incision was closed with Olympus Hemoclip. Post-operative medications included fentanyl, ranitidine, and enterofloxacin. The animals were, given ad libitum food, and monitored twice daily. After two weeks necropsy was performed. Results: Transgastric partial hysterectomy was successfully performed in five pigs without significant bleeding or organ damage. One animal became lethargic and febrile; and a necropsy was performed on post-operative day four. Necropsy revealed an opened gastric incision, and suppurative peritonitis. No complications were encountered in the other four animals during the two-week survival period. These four animals ate and ambulated within one day of surgery. The four animals exhibited no signs of distress, and gained weight during the survival period. Necropsy revealed well-healed gastric incisions in the four animals; no adhesions, hematomas, abscesses, or lacerations, were seen. Conclusion: We demonstrate that endoscopic transgastric partial hysterectomy is technically feasible and short-term survival without clinical or pathologic complications can be achieved. Secure closure of the stomach incision is essential. Introduction: Traditionally per-oral endoscopy has been limited to the intestinal lumen. A transgastric approach may allow less invasive means of performing select surgical procedures. This approach could reduce post-operative abdominal wall pain, wound infection, herniation, and adhesions. Methods: Female Yorkshire pigs were kept NPO for 24 hours. Enrofloxacin and Fentanyl were given at surgery. All instruments were sterilized with glutaraldehyde. Animals were intubated, given Isoflourane, and ventilated as needed. A diagnostic gastroscope was used to place the sterile esophageal overtube. The stomach was lavaged with normal saline and Cefazolin solution was instilled into the stomach for 10 minutes. A needle-knife was used to make a sub-centimeter incision through the anterior gastric wall, and a therapeutic gastroscope was pushed through the incision into the peritoneal cavity. An endoscopic grasping forcep was used to pull the uterus into an Olympus Endoloop which was then secured. The uterine horn and portions of the uterine body, broad ligament, and mesosalpinx were resected with a polypectomy snare. The site was inspected for bleeding and damage to adjacent organs. Using the snare, the resected uterus was removed through the mouth via the gastric incision. The gastric incision was closed with Olympus Hemoclip. Post-operative medications included fentanyl, ranitidine, and enterofloxacin. The animals were, given ad libitum food, and monitored twice daily. After two weeks necropsy was performed. Results: Transgastric partial hysterectomy was successfully performed in five pigs without significant bleeding or organ damage. One animal became lethargic and febrile; and a necropsy was performed on post-operative day four. Necropsy revealed an opened gastric incision, and suppurative peritonitis. No complications were encountered in the other four animals during the two-week survival period. These four animals ate and ambulated within one day of surgery. The four animals exhibited no signs of distress, and gained weight during the survival period. Necropsy revealed well-healed gastric incisions in the four animals; no adhesions, hematomas, abscesses, or lacerations, were seen. Conclusion: We demonstrate that endoscopic transgastric partial hysterectomy is technically feasible and short-term survival without clinical or pathologic complications can be achieved. Secure closure of the stomach incision is essential.