Balloon Dissection Research Articles

Traditional polypropylene and lightweight meshes in totally extraperitoneal inguinal herniorrhaphy

Background Placement of a prosthetic mesh is integral to successful totally extraperitoneal (TEP) herniorrhaphy. Available meshes have supported the surgical efforts well but search for an ideal mesh continues. Post-herniorrhaphy pain is an index of patient reported outcomes (PRO). The pain is attributable to balloon dissection, cautery, sutures, tackers and prosthesis. Reducing polypropylene content of the mesh is associated with attenuated inflammatory response by the host and improved compliance and comfort. We report the difference in PROs in TEP herniorrhaphy with either heavy polypropylene (PPM) or light weight mesh (LWM) being used for the repair. Patients and methods From June 2004 to December 2005, consecutive candidates for TEP herniorrhaphy were enrolled for this prospective study with an informed consent and compliance to Ethics guidelines. They were operated under general anesthesia (GA) on a day care basis using either PPM or LWM meshes as per the patient's choice. Operative and postoperative PRO were statistically analyzed by an independent doctor using the Microsoft Office Excel 2003. Results One hundred fourteen (84 PPMs and 30 LWMs) TEP herniorrhaphies were performed under GA on 57 male patients without any exclusion, on a day care basis. There was no technical difficulty, operative complications, conversion or prolonged hospital stay in either group. Patients of LWM reported better outcome in regards to pain, NSAID usage, seroma and recurrence. All patients of LWM reported an earlier return to activity. Conclusion Light weight meshes result in comparatively better “patient reported outcomes” in TEP inguinal herniorrhaphy as compared to heavy polypropylene meshes.

A new balloon dissector for totally extraperitoeneal hernia repair

BACKGROUND:Balloon dissectors (BD) find their use in totally extraperitoneal (TEP) and retroperitoneoscopic procedures. Commercial BD is prohibitively expensive. The author uses an indigenously assembled BD and describes the same.MATERIAL AND METHODS:The author assembles the BD by tying glove-fingers on an NG tube and then tying this assembly in the concavity of a Kelly's clamp, premounted with peanut gauze (KC-BD).RESULTS:The author has used it in the last 75 cases of TEP. A large working space is created, without any iatrogenic injuries or balloon rupture. This cheap indigenous BD can be assembled easily and in no time at all.CONCLUSIONS:KC-BD offers several advantages because of its unique design. It is effective, totally nontraumatic, inexpensive, and easy to assemble.

Is Retroperitoneal Approach Feasible for Robotic Dismembered Pyeloplasty: Initial Experience and Long-Term Results

To present our initial series of robotic-assisted retroperitoneal dismembered pyeloplasty in adults patients using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). Ten adult patients with unilateral ureteropelvic junction (UPJ) obstruction underwent robotic-assisted retroperitoneoscopic Anderson-Hynes dismembered pyeloplasty between February 2004 and March 2005. UPJ obstruction was primary in six patients and secondary in four patients after failed endopyelotomy. Dismembered pyeloplasty was performed utilizing a retroperitoneal approach (developed by balloon dissection). Three retroperitoneal laparoscopic ports were placed for the robot, and a fourth port was used by the assistant. Robotic-assisted laparoscopic technique was utilized to perform the entire procedure in all cases. All cases (seven right, three left) were successfully completed using the robot without conversion to conventional laparoscopic or open technique. Median surgical time was 175 minutes (95% confidence interval [CI] 128-185), median estimated blood loss was 50 mL (95% CI, 26-62), and the median hospital stay was 48 hours (95% CI, 27-65). No complications occurred. At a mean follow-up of 30 months (range 24-36), clinical symptomatic assessment with a numeric pain scale, health-related quality of life evaluation with the Short Form 36 health survey, and functional assessment with Tc-99m-mercaptoacetyltriglycine, diuretic renography, and intravenous urogram demonstrated a successful outcome in all cases. Robotic-assisted dismembered pyeloplasty can be performed efficiently by the retroperitoneal laparoscopic technique. Our surgical outcomes are comparable to previously published laparoscopic and transperitoneal robotic-assisted dismembered pyeloplasty series in adults with excellent clinical and radiologic success rates.

Pilot Study of Transesophageal Endoscopic Surgery: NOTES Esophagomyotomy, Vagotomy, Lymphadenectomy

The aim of this study was to evaluate the technical feasibility of endosonographically-assisted transesophageal access for vagotomy, esophagomyotomy, and lymphadenectomy in a nonsurvival study with six porcine models in an animal laboratory with general anesthesia. Saline/hydroxypropylmethylcellulose (HPMC) was injected into the submucosa with a subsequent biliary balloon dissection, creating a substantial submucosal space for a cap-fitted endoscope. A distal esophageal myotomy was performed after access into the thoracic cavity. Over the course of 6 pigs, esophagomyotomy (simulating a Heller myotomy), vagotomy, and lymphadenectomy were performed. The esophageal insertion/access site was sealed by the flap of mucosa. Using a midesophageal entrance point, successful thoracic access and therapeutic interventions involving the esophagus and periesophageal structures were performed in 6 pigs. The submucosal saline/HPMC tunneling technique allowed for successful access to the upper mediastinum through the esophagus with feasible therapeutic interventions.

Retroperitoneal Laparoscopic Partial Nephrectomy: Surgical Experience and Outcomes

We present outcomes in 110 consecutive patients who underwent retroperitoneal laparoscopic partial nephrectomy performed in a 72-month period by a single surgeon (MG). Patients were placed in the flank position and the retroperitoneal space was developed using a balloon dissector. Hilar control was achieved with bulldog clamps. Tumor depth and extent were evaluated using intraoperative sonography. Perioperative data were assessed and outcomes were retrospectively analyzed at a mean followup of 23 months. Mean patient age was 62 years. Mean operative time was 199.7 minutes and mean postoperative stay was 2.6 days. Mean blood loss was 260.0 ml and mean tumor size was 2.4 cm. Final pathological evaluation revealed negative positive margins in these cases. Of all tumors 63.7% were pathologically confirmed renal cell carcinoma. In 57 patients mean preoperative and postoperative creatinine was 1.1 and 1.3 mg/dl, respectively, at a mean of 20.6 months. In 47 patients with renal cell carcinoma who underwent computerized tomography or magnetic resonance imaging during the mean 23-month followup there was 1 incidence of local recurrence at 1 year. Conversion to open surgery occurred in 2 cases and laparoscopic radical nephrectomy was performed in 4. The rate of major complications was 4.5%. Although it is technically challenging, the retroperitoneal approach to laparoscopic partial nephrectomy can be performed in a safe and timely manner with perioperative outcomes comparable to those reported for open and transperitoneal approaches. Furthermore, this approach allows the containment of blood and urine outside the peritoneal cavity. Our intermediate term results revealed excellent cancer control and preserved renal function.

An Alternative Access Technique Under Direct Vision for Preperitoneoscopic Pelvic Surgery: Easier for the Beginners

We present an alternative access technique to facilitate preperitoneoscopic (extraperitoneal laparoscopic) approach for radical prostatectomy, herniorrhaphy, and other pelvic procedures. A 0 degrees telescope was mounted into a Visiport Optical Trocar (Visiport), and via a periumbilical incision it was advanced under direct vision at first vertically through different layers of the anterior abdominal wall. Immediately before the posterior rectus sheath, it was redirected caudally and horizontally toward the symphysis pubis. The Visiport was withdrawn and replaced by a dissection balloon that was inflated for developing the working space, then it was substituted with a 12-mm trocar to begin the pneumo-extraperitoneum. The surgical procedures are detailed in the attached video. This technique was used in 168 of 179 patients undergoing preperitoneoscopic surgery (97 radical prostatectomies, 80 totally extraperitoneal herniorrhaphies, and 2 urinary bladder diverticulectomies). Operative parameters were compared with 11 preceding patients approached with the open Hasson technique. All of the procedures to create the preperitoneoscopic space were successfully with no complications. For radical prostatectomy, there was a significantly faster access to the preperitoneal space (38 +/- 12 vs 540 +/- 69 seconds) and a faster setup of the whole operative space (15 +/- 5 vs 29 +/- 9 minutes, both P < .05) with the new technique. Less pericannular CO(2) leakage was experienced during the preperitoneoscopy with our technique. This alternative technique offers a simple, safe, quick, and effective access for creating a preperitonescopic working space.

Endoscopic perineal approach to the presacral space: a feasibility study

Currently, pathologies from the presacral space are explored primarily by using transabdominal approaches. Major complications may occur, including bowel and rectal perforation, or bleeding. To avoid and reduce these potentially severe risks, a new surgical approach to the presacral space, which permits exploration through the perineum with minimal invasive techniques, had already been developed and is now further elaborated in a cadaver and clinical study. A prospective study was performed using four cadavers with no history of pelvic or perineal disease. A minimally invasive exploration of the presacral retroperitoneum was performed to examine a potential new anatomical surgical space. After positioning the patients in the prone or supine position, a 1-cm vertical median incision was made in the ano-coccygeal ligament. Entry to the presacral space was first established through blunt-finger and balloon dissection. A 30 degrees 10-mm laparoscope was inserted through a 12-mm trocar, and two additional 5-mm trocars were inserted to avoid injury to the sciatic nerve. A clinical pilot study was performed on three patients using this technique. Under direct vision, a wide dissected cavity was observed, with the rectum and mesorectum retracted ventrally. Access and manipulation of posterior pelvic organs were simplified. Placing cadavers in the jack-knife position provided superior accessibility to the presacral space when compared with a supine position. Clear exposure of the sacrum, mesorectum, ureters and bladder, prostate region, iliac vessels (with its branches), and lymph nodes was achieved. Endoscopic perineal approach to the presacral space was considered.

Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study

Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon. Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection. There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001). Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.

Chemically assisted endoscopic mechanical submucosal dissection by using mesna

A class of thiol compounds, mesna (sodium-2-mercaptoethanesulfonate), has been used to facilitate tissue dissection in surgical fields. To evaluate the technical feasibility and efficacy of chemically assisted endoscopic mechanical submucosal dissection (CAEMSD) by using mesna. An in vivo controlled blind trial by using porcine models. Nonsurvival study in an animal laboratory. Six pigs were studied. Mucosal targets of about 2 cm (estimated) for treatment were created with a circle of cauterized spots along the greater curvature of the gastric body and the antrum. A mesna solution or the control hydroxypropyl methylcellulose solution was submucosally injected. The target mucosa was mechanically isolated with balloon dissection and removed by circumferential incision with a hook-knife inserted into the submucosal space. Necropsy and mucosal specimens from both groups were examined by histology. En bloc resection of the target was achieved in all 8 attempts of the mesna group and in 7 of 8 attempts of the control group. Use of mesna significantly reduced tissue resistance to the initial balloon-catheter insertion into the submucosa and the technical difficulty of subsequent submucosal balloon dissection by using a subjective grading system (P < .05). There was no difference in histology between both groups. CAEMSD is a unique methodology to facilitate mucosal resection.

Pilot study of transesophageal endoscopic epicardial coagulation by submucosal endoscopy with the mucosal flap safety valve technique (with videos)

We previously demonstrated that the thoracic cavity could be safely accessed by submucosal endoscopy with the mucosal flap safety valve (SEMF) technique. To evaluate the technical feasibility of transesophageal access to the heart and epicardial ablation. One-week survival study with 5 porcine models. Animal laboratory with general anesthesia. High-pressure carbon dioxide injection and balloon dissection created a large submucosal working space for insertion of a cap-fitted endoscope. A myotomy was performed inside the submucosal space. The thoracic cavity was endoscopically accessed through the myotomy site. A pericardial window was created with a needle-knife. A spot coagulation of the epicardium was performed with a heat probe and a hook-knife. The myotomy site was sealed with the overlying mucosal flap, and the mucosal entry site was closed with clips. An endoscopy and a necropsy were performed to study the esophagus, mediastinum, pericardial space, and cautery locations on the epicardium one week after the procedure. Epicardial coagulation was successfully performed within 30 minutes in 4 of the 5 pigs. Follow-up endoscopy demonstrated completely sealed myotomy sites by the overlying mucosal flap. There was no gross contamination or signs of contamination in the thoracic cavity. The pericardial space was normal in appearance. The epicardial coagulation sites were healing, without exudative ulceration. The SEMF technique allowed endoscopic access to the upper mediastinum, the pericardium, and the epicardium via the esophagus, along with a minimal intervention on the epicardium.

Advantages of Minimally Invasive, Balloon-Dissector-Assisted Tissue Expander Placement

Tissue expansion has been dependent upon healing the access incision after placement. Delay can be reduced with minimally placed expanders. Smaller, remote incisions allow for earlier expansion. Balloon-assisted tissue expander placement was evaluated in a pig model and compared with open placement. Open placement with delayed expansion versus minimally invasive placement with immediate expansion, and open placement with immediate expansion versus balloon dissection with delayed expansion were compared. Our clinical series with balloon dissector tissue-expander placement was reviewed. Fifty-two tissue expanders were placed minimally invasively and successfully expanded. Use of balloon dissector in the pig model yielded a shorter reconstructive period, faster expansion, and greater flap advancement. Clinical results revealed no infections, dehiscence, extrusion, or hematomas. All cases had expansion begun intraoperatively and were successfully expanded. Minimally invasively placed expanders resulted in shorter expansion times, the ability to institute immediate expansion, and improved expansion compared with open placement.

Balloon Dissection: An Unusual Source of Venous Air Embolism During Brain Surgery

Mongardon, Nicolas MD; Blanot, Stéphane MD; Orliaguet, Gilles MD, PhD; Meyer, Philippe-Gabriel MD Author Information

Submucosal endoscopy with mucosal flap safety valve (SEMF) technique: A safe access method into the peritoneal cavity and mediastinum

Natural orifice translumenal endoscopic surgery (NOTES) is a unique emerging surgical concept expanding flexible endoscopy beyond the gut wall. The methods and technology growing from this concept may minimize trauma from surgical access to the peritoneal cavity by completely eliminating body surface incisions. Our colleagues at the Mayo Clinic have explored, over several years, the concept of using the submucosa as a working space for endoscopic interventions, such as resection of mucosal neoplasias and submucosal tumors, as well as for the acquisition of muscular tissue for etiologic analysis of motility disorders. The submucosal space can also be utilized as a protective tunnel preventing peritoneal soiling by using the free overlying mucosa, as a sealant flap, and permitting a safer offset entry into the peritoneal and thoracic cavities for NOTES. In the SEMF technique, the submucosal space is mechanically created by balloon dissection facilitated by either high‐pressure CO2 gas injection or chemically ‘softening’ the submucosal connective tissues. This article reviews and describes SEMF in detail along with applications involving in vivo porcine models.

Use of Kirschner Wires as Endoscopic Retractors

We read with great interest the article of Dr. da Silva Freitas [1] titled Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases, which presents an up-to-date and useful therapy scheme. Of special interest to us was the use of the endoscopic technique for latissimus dorsi musculocutaneous flap harvest as an option for reconstruction of pectoralis major muscle agenesis in one of their cases. This demonstrates clearly that the number of endoscopic interventions in the repertoire of the plastic surgeon is growing very rapidly. Unfortunately, the steep learning curve and dependence on expensive equipment can be discouraging for the beginner. Innovative alterations of the technique are therefore of the utmost importance because they can cut down on equipment costs and overcome technical obstacles. The technique for endoscopically assisted harvest of latissimus dorsi muscle has been given detailed description in the literature previously by various authors [2,3]. Except for personal preferences and differences of infrastructure, the technique is well settled and reliable. One of the few technical points about which a disagreement still exists concerns the creation and maintenance of the optic cavity. Various techniques have been used besides carbon dioxide insufflation, with varying degrees of success, such as balloon dissection and hydrodissection [4]. Both of these methods have received positive and negative criticism. We present a simple method for assisting flap dissection and increasing exposure in a patient with Poland’s syndrome. A 19-year-old boy presented with a left pectoralis muscle agenesis. An axillary incision and three 5-mm ports were used for flap harvest and inset. Figure 1 shows the use of two Kirschner wires with a diameter of 3 mm to maintain the subcutaneous working space. The first Kirschner wire is placed through the axillary incision parallel to the anterior axillary line. The second wire is placed parallel and posterior to the first one. When both wires are elevated simultaneously, they create a ‘‘tent’’ over the dissected portion of the muscle, which leads to greater exposure of the working space. As the dissection proceeds, the wires can be repositioned for better visualization. The dissection of the most medial portions of the latissimus dorsi muscle where it fuses with the spinal muscles is especially facilitated. The wires can be used for the recipient site in a similar fashion. This innovation enabled us to control a wide field endoscopically with little effort and to reduce the operation time.

Total extra-peritoneal repair of groin hernia: prospective evaluation at a tertiary care center

The laparoscopic repair of groin hernia is increasingly being used. However, the relative merits and demerits of laparoscopic repair are debatable. The present study was undertaken to evaluate the total extra-peritoneal (TEP) repair of groin hernia. This prospective study was undertaken at a single surgical unit between January 2004 and June 2006. Consecutive patients with elective groin hernias were offered laparoscopic TEP repair. Indigenous balloon or telescopic dissection was used to create extra-peritoneal space. Polypropylene mesh was used in all of the patients and mesh fixation was performed with tackers. A total of 185 patients with age range 18-92 years were included; 180 were males. TEP repair was attempted in 298 groin hernias in 185 patients with a success rate of 89.5%. Indigenous balloon or telescopic dissection was used to create extra-peritoneal space. Thirty-one (31, 10.5%) TEP repairs were converted to transabdominal pre-peritoneal or open repair. Two patients developed recurrence during follow-up. TEP is an excellent technique for laparoscopic groin hernia repair, with acceptable rates of complication.

Minimally Invasive Video-Assisted Kidney Transplantation (MIVAKT)

Minimally invasive surgery has been applied to nearly all fields of surgery due to its advantages such as reduced morbidity, a better cosmetic outcome, and early recovery. The recent advances in its technique have allowed us to use modified minimally invasive surgery technique in the field of kidney transplantation. From January 2004 to March 2006, minimally invasive video-assisted kidney transplantation was carried out in 20 patients. Many clinical variables were compared with the conventional method. The operative procedure began with a 7 to 8 cm skin incision. A laparoscopic balloon dissector was used to create the retroperitoneal space for the placement of the grafted kidney. Vascular anastomosis and ureteroneocystostomy were performed under direct vision and with video-assisted TV monitoring. The average length of the wound was 7.8 cm and it was placed below the belt line. The average operating time was 186 min. Less analgesic was given compared with conventional methods. There was one postoperative complication, a mild lymphocele. All patients showed normalized serum creatinine levels within 4 d. All grafted kidneys showed normal findings on the postoperative ultrasound and renal scans. Minimally invasive video-assisted kidney transplantation is technically feasible and may offer benefits in terms of better cosmetic outcomes, less pain, and quicker recuperation than conventional kidney transplantation.

Subfascial endoscopic perforator vein surgery using balloon dissector and saphenous vein surgery in chronic venous insufficiency

Subfascial endoscopic perforator vein surgery (SEPS) has recently been a popular alternative to classical surgical methods in the treatment of severe venous insufficiency of the lower extremity. Yet, there are not many reports concerning this less invasive operation, and many modified methods are applied. We would like to report the clinical results of our country's first SEPS operations performed by using balloon dissector. The SEPS via two ports and using balloon dissector with saphenous vein stripping and phlebectomy in patients with severe venous insufficiency. Pneumatic tourniquet has never been applied. Twenty-eight operations were performed on 28 patients (13 female, 15 male). Active open ulcers were present in four legs, ulcer scars were present in two patients, skin changes were present in 12 legs and severe oedema was present in 10 legs. An improvement in all clinical findings and complaints was determined following the operations. A significant drop was determined in chronic venous insufficiency scores. No serious complication requiring rehospitalization of the patients was observed. All the patients were followed up for six months, and none presented again with any complaints. SEPS using balloon dissector with saphenous vein surgery we performed is an effective, reliable and promising method.

Laparoscopic Retroperitoneal Nephrectomy for Giant Hydronephrosis: When Simple Nephrectomy Isn't Simple

Retroperitoneoscopic nephrectomy (RN) for giant hydronephrosis (GH) is regarded as a more challenging procedure than RN for small nonfunctioning kidneys (SNFK). We describe specific technical modifications to facilitate surgery in the GH group and compare outcomes in the two groups. Data were collected in a prospective fashion on all patients undergoing upper urinary-tract laparoscopy at a single institution. Eleven patients (eight women, three men; mean age 41 years) underwent RN for GH. The etiologies were congenital ureteropelvic junction obstruction in 10 and obstruction secondary to endometriosis in 1. Technical modifications to facilitate surgery included initial fingerplasty, balloon dissection in two directions, initial intact dissection, subsequent pelvic puncture and aspiration, and extracorporeal retraction if required. The results were compared with those of a matched group of 19 patients who had RN for SNFK. All procedures were completed without open conversion. In the GH group, the mean operating time was 126 minutes (range 65-240 minutes) and the estimated blood loss 101 mL (range 5-450 mL). No patient required transfusion, and the mean length of the hospital stay was 2.9 days (range 1.5-6 days). In the group undergoing RN for SNFK, the mean operating time was 116 minutes (range 55-270 minutes), the estimated blood loss 46 mL (range 5-400 mL), and the mean length of stay 2.8 days (range 1-5 days). In the GH group, the estimated blood loss was significantly greater (P = 0.042), and the operative time was longer, although this difference did not reach statistical significance. An RN for GH is not as simple as laparoscopic simple nephrectomy for other benign lesions. Operative duration and blood loss are greater. Technical modifications have been vital to our success with this procedure.

Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique

Indications for NOTES (natural orifice transluminal endoscopic surgery) studied so far are limited to intra-abdominal surgery. To determine the technical feasibility and the safety of transesophageal mediastinocosopy by using the submucosal endoscopy with mucosal flap safety valve (SEMF) technique. Two-week survival study with 4 porcine models. High-pressure carbon dioxide injection and balloon dissection created a large submucosal working space for insertion of a cap-fitted endoscope. The muscularis propria was resected inside the submucosal space, and the mediastinoscopy was performed by using the endoscope inserted via the myotomy site. The muscular defect was sealed with the overlying mucosal flap, and the mucosal entry site was closed with clips. Repeated endoscopy and necropsy were performed 2 weeks after the procedure. With the SEMF technique, the posterior mediastinum was successfully accessed in all animals. Three pigs survived 2 weeks without clinical complications, and the defects were completely sealed by the mucosal flap. One pig with proximal esophageal mediastinal entry managed under voluntary respiration was euthanized because of pleural injury. The SEMF technique provided safe entry into the mediastinum, with a protective submucosal tunnel that prevented mediastinal soiling. Mid to distal esophageal access is safer than the higher level access. Mechanical ventilation might allow safer respiratory support.

Submucosal endoscopy with mucosal flap safety valve

There is no reliable endoscopic method to selectively resect deeper layers of the gut wall or to access the peritoneal cavity and prevent peritoneal soiling. To determine the technical feasibility and safety of submucosal endoscopy with mucosal flap (SEMF) in accessing the peritoneal cavity through a large full-thickness gastric-muscle-wall resection. Ex vivo feasibility exploration and survival animal study. Ex vivo samples were obtained from fresh harvested organs. In vivo procedures were conducted with the pigs under standard general anesthesia. High-pressure carbon dioxide (CO(2)) injection and balloon dissection created a large submucosal working space for insertion of a cap-fitted endoscope. By using the EMR cap, a full-thickness resection of the muscularis propria was performed. This full-thickness defect was sealed with the overlying mucosal flap and the use of hemoclips or tissue anchors. By using the SEMF technique in the ex vivo experiment, the gastric wall was successfully traversed in each stomach after submucosal dissection and full-thickness resection of the musclaris. Similarly, by using the SEMF technique in the in vivo procedures, the peritoneal cavity was successfully accessed and the defect was completely sealed by using the mucosal flap. All animals survived 1 week after the procedure. Ulceration was noted in 3 pigs, and a small bowel injury was noted in 1 pig. Leak testing was negative in all stomachs. By using the SEMF technique, submucosal space endoscopy and deep-layer gastric-wall resection were successfully performed. Furthermore, the mucosa overlying the dissected submucosal space served as a safe flap valve, preventing peritoneal leakage.