Transvaginal Single Access “Pure” NOTES Sleeve Gastrectomy Using a Deployable Magnetically Anchored Video Camera

Abstract

Introduction: Laparoscopic sleeve gastrectomy is a new operation for morbid obesity that involves a vertical gastric resection, leaving a narrow tube (150-200 cc) along the lesser curve. This operation avoids anastomoses required for gastric bypass and has resulted in effective weight loss. The goal of this study was to determine the feasibility of transvaginal NOTES sleeve gastrectomy without laparoscopic assistance. Methods: Non-survival procedures were conducted in pigs (n = 2, 34-35 kg). Through a vaginotomy created under direct vision, a rigid access tube (23 mm inner diameter, 40 cm long) with dual instrument seals (used to maintain a CO2 pneumoperitoneum) was inserted into the peritoneal cavity. A single or dual channel gastroscope was used for initial visualization and a deployable magnetically anchored video camera (onboard light source) was used for visualization during subsequent portions of the procedure. The stomach was retracted using flexible endoscopic graspers, a new long (70 cm) articulating rigid grasper (5 mm diameter), magnetically anchored maneuverable graspers, T-tag fasteners, and traction sutures placed with prototype articulating flexible and rigid suturing devices (9 mm diameter). An articulating rigid linear stapler (13 mm diameter) with an elongated shaft (70 cm) was used for stomach and vascular division. Results: No laparoscopic assistance was used. During the first procedure, only a single gastric stapler application was achieved due to retraction difficulties despite the use of several grasper strategies and 3 percutaneous T-tags. In the second procedure, only a single percutaneous T-tag was used; traction sutures passed through the access port and held externally facilitated adequate retraction and complete gastric division using a total of 6 stapler cartridges (60mm length). Two vascular cartridges (45 mm length) were used for short gastric vessel division. The deployable video camera provided superior imaging of the operative field compared to the flexible endoscope. Blood loss was minimal (<30 cc) and no intraabdominal injuries were detected at autopsy. Ex-vivo evaluation revealed an intact vertical staple line with no leaks or compromise of the esophagus or gastric outlet and a remnant volume of 500 cc.Conclusions: This is the first study to document the feasibility of a transvaginal sleeve gastrectomy using a single access “pure” NOTES approach. The deployable video camera improved visualization and allowed maximal use of the limited access space for therapeutic instruments. Further refinements in instrumentation and techniques are expected to provide greater accuracy in achieving the desired degree of gastric resection.