ENDOSCOPIC PARTIAL HYSTERECTOMY IN A PORCINE MODEL USING A NOVEL PER-ORAL TRANSGASTRIC APPROACH

Abstract

Purpose: Traditionally per-oral endoscopy has been limited to the intestinal lumen. Previous studies have reported transgastric endoscopy howeverthere are no published reports of organ resection using this method. By avoiding abdominal incisions this approach may reduce post-operative abdominal wall pain, wound infection, herniation, and adhesions. We sought to demonstrate the feasibility of performing a per-oral transgastric partial hysterectomy. Methods: Four-month old female domestic pigs had food withheld for 24 hours and were given antibiotics prior to surgery. After induction of anesthesia, the esophagus was intubated, a sterile overtube placed, and an antibacterial gastric lavage performed. Both written and video logs were kept. A sterile therapeutic endoscope was passed through the overtube into the stomach. Before incising the gastric wall an endoscopic ultrasound was performed to avoid blood vessels and intra-abdominal organs. Using a needle-knife, a 1cm incision was made in the gastric wall and the opening was dilated to 15 mm using a Microvasive CRE balloon. The gastroduodenoscope was pushed through the gastric wall and into the peritoneal cavity. The fallopian tubes, uterus, and ovaries were identified. Forceps were used to pull the uterus and portions of the fallopian tubes through an Olympus Endo-Loop. The loop was then tightly closed and secured. Subsequently, a snare was positioned just distal to the Endo-Loop and cautery was used to resect the uterus and portions of the fallopian tubes. The specimen was removed through the mouth via the gastric incision and was sent for pathology. The gastric incision was closed using endoscopically placed clips. Results: Gastric incisions were performed without significant bleeding. The small intestine, fallopian tubes, uterus, and ovaries were readily identified and could be repositioned with standard endoscopic equipment. We were able to perform the partial hysterectomy without visible bleeding. The animals remained stable throughout the procedure and no immediate postoperative complications were encountered. Necropsy confirmed partial hysterectomy with bilateral partial tubectomy. There was no evidence of intra-abdominal or gastric bleeding, hematoma, infection, or organ damage. Conclusions: This study demonstrates the feasibility of per-oral transgastric organ resection, specifically partial hysterectomy. Although in early development this approach may represent a less invasive alternative to traditional surgery.