Deconstructing the Endoscope: Intragastric, Transgastric and Laparoscopic Wireless Endosurgery Using Manipulable Attached and Free Capsule Imagers

Abstract

Introduction: Wireless capsule endoscopy (WCE) might be usefully deployed to aid endosurgery. Spacial separation of the imager and the axis of the tools of endosurgery in flexible endoscopy might offer improved views of less accessible targets and free precious intra-esophageal space for the passage of mechanical devices. The use of extra cameras during laparoscopy or transgastric surgery might allow new angles of view improving efficacy and safety. Methods: Studies using GivenImaging capsules (SB and Eso) and a real-time imager (Sony U70) were made in 9 pigs weighing 28-45 Kg during flexible endoscopic, transgastric and laparoscopic endosurgical procedures. Methods of attachment of WCE to the stomach (submucosal and full thickness) were tested using new endoscopic sewing methods. Capsules were also placed with a PEG-like method allowing the capsule to be raised, lowered and rotated and angled to examine a specific site in the stomach or small intestine. WCE were passed through and beyond esophageal overtubes to allow manipulable imaging leaving the total overtube inner diameter available for endosurgical device passage. Capsule endoscopes were placed in the peritoneal cavity at laparoscopy to allow continuous wireless views of target structures including gallbladder, diaphragm and liver with simultaneous laparoscopic imaging using a Storz laparoscopic system. Transabdominal and peritoneal attachment was used for stabilization and remote manipulation. Results: Intragastric: WCE sewn to the stomach wall or held by thread passed through the abdominal wall were able to capture multiple images of specific targets for endotherapy including lower esophageal junction, ulcers and biliary orifice. Some simple methods of remote articulation of attached and free capsule were tested. WCE attached to, or freely observing, the end of esophageal overtubes were able to view instruments manipulating the cardia without retroflexion. Transgastric: Capsules passed through transgastric incisions allowed simultaneous views of both sides of the gastric incision during suturing maneuvers. Laparoscopic: wireless imaging allowed imaging of biliary manipulations, and liver biopsy with or without the use of the conventional laparoscope image and imaging of subhepatic structures inaccessible to laparoscopy. Conclusions: Wireless endosopy with and without attachment and manipulation capacities allowed spatial separation of imaging and therapeutic functions of flexible endoscopy. Multiple simultaneous views of structures during transgastric and laparoscopic surgery using wireless and conventional endoscopes gave useful views which could not be obtained with conventional endoscopes.