Flexible Gastrointestinal Endoscopy Research Articles

Use of current automatic smoke evacuation system in flexible gastrointestinal endoscopy: Its feasibility and potential usefulness.

Flexible endoscopy does not have a system that can automatically evacuate surgical smoke generated in the gastrointestinal lumen. We aimed to investigate the feasibility and potential usefulness of automatic smoke evacuation systems in flexible endoscopy. [Bench] After surgical smoke generated in the stomach was evacuated by the evacuator, the degree of residual smoke and gastric luminal collapse were evaluated to optimize the evacuator settings. [Animal] Insufflation, suction, and total operation time to complete the protocol of 10 cauterizations of the gastric mucosa were measured in three groups: "manual suction only," "manual suction with automatic evacuation (50% force)," and "manual suction with automatic evacuation (70% force)." The stability of endoscopic visualization and operability was evaluated by 10 endoscopists blinded to those suction settings, and the number of manual suctions, insufflations, and total operation time were measured. [Bench] The degree of residual smoke and gastric luminal collapse were inversely correlated. [Animal] When the automatic evacuator was partially used, there was no difference in the insufflation time, but the suction time (vs 50%; p = 0.011, vs. 70%; p = 0.011) and total operation time (vs. 50%; p = 0.012, vs. 70%; p = 0.036) were significantly reduced compared to manual operation only. Furthermore, manual suction with automatic evacuation (50% force) significantly improved the stability of endoscopic visualization and operability compared to manual operation only (p = 0.041, p = 0.0085). The automatic smoke evacuation in flexible gastrointestinal endoscopy was potentially feasible and useful by improving the device setting.

Control of bleeding from a recurrent tumor at a uretero‐ileal anastomosis by electrocoagulation via an ileal conduit

IntroductionBladder cancer is characterized by spatial and temporal recurrence in the urinary tract. We describe a case of recurrence at a uretero‐ileal anastomosis after radical cystectomy and nephroureterectomy. It was difficult to control bleeding from the tumor, but hemostasis was achieved.Case presentationA 73‐year‐old man with a history of radical cystectomy and reconstruction of the ileal conduit and right nephroureterectomy was diagnosed with recurrence at the uretero‐ileal anastomosis site. Bleeding from the tumor could not be controlled by flexible gastrointestinal endoscopy. The patient underwent coagulation via an ileal conduit approach using a rigid scope and bipolar electrocautery, which is usually a modality for transurethral resection.ConclusionThis is the first report in which a modality normally used for transurethral resection was used to control bleeding in a patient with an ileal conduit. This application is useful in cases open surgery or additional irradiation might be difficult.

A Novel Distal Hybrid Pneumatic/Cable‐Driven Continuum Joint with Variable Stiffness Capacity for Flexible Gastrointestinal Endoscopy

A Novel Distal Hybrid Pneumatic/Cable‐Driven Continuum Joint with Variable Stiffness Capacity for Flexible Gastrointestinal Endoscopy

A Novel Distal Hybrid Pneumatic/Cable‐Driven Continuum Joint with Variable Stiffness Capacity for Flexible Gastrointestinal Endoscopy

The robot‐assisted flexible access surgery represented by the emerging robot‐assisted flexible endoscopy (FE) and natural orifice transluminal endoscopic surgery demands flexible and continuum manipulators instead of the rigid and straight instruments in the traditional minimally invasive surgery (MIS). These flexible manipulators are required to advance through the tortuous and narrow anatomic paths via natural orifices for dexterous diagnostic examination and therapeutic operations. Therefore, developing flexible endoscopic manipulators with the capacity of snake‐like movements for flexible access and variable stiffness regulation for operations to address these flexible access surgical difficulties is demanding but remains challenging. To address such challenges, herein, it is proposed that a novel distal continuum joint based on the hybrid pneumatic and cable‐driven approach achieves variable stiffness capacity, excellent bending characteristics in both flexible and rigid states, satisfactory motion consistency and shape‐locking ability during the rigid‐flexible transition, and relatively high loading capacity for flexible gastrointestinal endoscopic robots. Characterization experiments validate these performances, and phantom and ex vivo experiments have been performed to demonstrate the feasibility and effectiveness for FE. The presented method demonstrates an effective and practical approach to enabling continuum robots with both flexible access and tunable stiffness capacity and supports a convenient extension for MIS applications.

Storage of gastrointestinal endoscopes: when is the safe time for re-use?

to identify the safe storage time for the use of flexible gastrointestinal endoscopes after high-level disinfection, as well as the defining criteria for this time. an integrative literature review was carried out in the Virtual Health Library, PubMed, Scopus, and Web of Science, considering original articles published since 2000. eleven articles were selected, whose storage times ranged from 1 to 56 days, with a predominance of one to seven days (73%). Several criteria were used to define this time, predominantly the premise of efficient processing (100%), use of alcohol flush (64%), use of drying cabinets (18%), among others. the criteria for determining the storage time did not show a consensus for clinical practice. Expanding the discussion of this theme with the definition of the minimum necessary conditions is of fundamental importance for the reduction of risks and safety of the procedure and the patient.

Remote training in flexible gastrointestinal endoscopy.

Video 1Remote training in flexible GI endoscopy.

Flexible gastrointestinal endoscope processing challenges, current issues and future perspectives

At present, the most frequent method for processing flexible gastrointestinal (GI) endoscopes is cleaning followed by high-level disinfection as terminal sterilization is often not practicable. Post-processing monitoring studies consistently show high levels of positive cultures remaining on endoscopes, which can lead to patient infection and even fatality. The processing deficiency is attributed to the complex design of endoscopes, incomplete cleaning, formation of biofilms and lack of margin of safety with high-level disinfection. To demonstrate that flexible GI endoscopes can be practicably terminally sterilized. An endoscope sterilization cycle was developed in a vaporized hydrogen peroxide sterilization system. The cycle was used to study the sterilization of flexible GI endoscopes which included colonoscopes and duodenoscope and material compatibility for both original flexible GI endoscopes and those experimentally modified endoscopes using compatible materials. Testing demonstrated that the vaporized hydrogen peroxide can sterilize flexible GI endoscopes (colonoscopes, duodenoscope) with a sterility assurance level of 10-6. Additionally, no recoverable survivors were detected when devices were artificially soiled with hard water and serum. Material compatibility test results demonstrated that replacing molybdenum disulphide lubricant with a graphite-based inert lubricant can make them compatible with vaporized hydrogen peroxide sterilizers. Flexible GI endoscopes can be practicably terminally sterilized using vaporized hydrogen peroxide sterilization technologies if their materials are revised to become compatible.

The endoluminal pressures during flexible gastrointestinal endoscopy

In flexible gastrointestinal (GI) endoscopy, endoscopic insufflation is crucial and directly affects visualization. Optimal visualization enables endoscopists to conduct better examinations and administer optimal treatments. However, endoscopic insufflation is typically performed manually and is subjective. We aimed to measure the GI endoluminal pressure during flexible GI endoscopy. Participants underwent esophagogastroduodenoscopy (EGD) at our endoscopy center. Pressure measurement was conducted after completing diagnostic or follow-up EGD. The endoluminal pressure in the esophagus and stomach was measured at 1-s intervals for 1 min while performing EGD for observational and diagnostic purposes. During the measurements, the endoscopists maintained what they subjectively considered to be adequate exposure for screening for lesions by dilating the lumen. Eighty patients were enrolled in this study. The upper GI endoluminal pressure was assessed during EGD without adverse events. The esophageal endoluminal pressure averaged 8.9 (− 3.0 to 20.7) mmHg, and the gastric endoluminal pressure averaged 10.0 (3.0–17.9) mmHg; the upper GI endoluminal pressures were not affected by patient-related factors or the number of endoscopists’ postgraduate years. We have successfully obtained the GI endoluminal pressures during EGD. Further accumulation of these data may lead to more stable and reproducible flexible endoscopic diagnosis and intervention.

Endotracheal intubation in patients with COVID-19 using an ultrathin flexible gastrointestinal endoscope.

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 occasionally becomes severe and requires endotracheal intubation. Endotracheal intubation is usually performed using a laryngoscope; however, the operator needs to be in close proximity to the patient’s face during the procedure, which increases the risk of droplet exposure. Therefore, we simulated fiberoptic endotracheal intubation on a mannequin representing the patient, using an ultrathin flexible gastrointestinal endoscope as an alternative to the bronchoscope, in order to maintain distance from the patient during the procedure. We performed this procedure 10 times and measured the time required; the median procedure time was 6.4 s (interquartile range, 5.7-8.1 s). The advantage of this method is the short procedure time and distance maintained from the patients. The flexible tip-steerable control and length of the gastrointestinal endoscope contributed to shortening the procedure time and maintaining distance from the patients. In addition, this method can handle difficult airways without risk of misplacement of the endotracheal tube. However, it is necessary to consider the risk of aerosol generation associated with this procedure. In the pandemic setting of coronavirus disease 2019, this approach may be useful when a gastrointestinal endoscopist is in charge of endotracheal intubation of patients with coronavirus disease 2019.

Multidisciplinary and Multisociety Practice Guidelines for Reprocessing Flexible Gastrointestinal Endoscopes and Endoscopic Accessories; Korean Association for the Study of the Liver, the Korean Society of Infectious Diseases, Korean College of Helicobacter and Upper Gastrointestinal Research, the Korean Society of Gastroenterology, Korean Society of Gastrointestinal Cancer, Korean Society of Neurogastroenterology and Motility, Korean Association for the Study of Intestinal Diseases, Korean Pancreatobiliary Association, the Korean Society of Gastrointestinal Endoscopy Nurses and Associates and Korean Society of Gastrointestinal Endoscopy

Background/Aims: The area of endoscopic application has been continuously expanded since its introduction in the last century and the frequency of its use also increased stiffly in the last decades. Because gastrointestinal endoscopy is naturally exposed to diseased internal organs and contact with pathogenic materials, endoscopy mediated infection or disease transmission becomes a major concern in this field. Gastrointestinal endoscopy is not for single use and the proper reprocessing process is a critical factor for safe and reliable endoscopy procedures. What needed in these circumstances is a practical guideline for reprocessing the endoscope and its accessories which is feasible in the real clinical field to guarantee acceptable prevention of pathogen transmission.Methods: This guideline contains principles and instructions of the reprocessing procedure according to the step by step. And it newly includes general information and updated knowledge about endoscopy-mediated infection and disinfection.Results: Multiple societies and working groups participated to revise; Korean Association for the Study of the Liver, the Korean Society of Infectious Diseases, Korean College of Helicobacter and Upper Gastrointestinal Research, the Korean Society of Gastroenterology, Korean Society of Gastrointestinal Cancer, Korean Association for the Study of Intestinal Diseases, Korean Pancreatobiliary Association, the Korean Society of Gastrointestinal Endoscopy Nurses and Associates and Korean Society of Gastrointestinal Endoscopy. Through this cooperation, we enhanced communication and established a better concordance.Conclusions: We still need more researches in this field and fill up the unproven area. And our guidelines will be renewed accordingly.

Endoscopic management of foreign bodies in the upper gastrointestinal tract

Background: Foreign body ingestion and food bolus impaction is a common clinical scenario and can present as an endoscopic emergency. Though majority of them pass spontaneously 10-20% require endoscopic intervention. Flexible endoscopy is recommended as therapeutic measure with minimal complications. The aim of our study is to present 5 years’ experience in dealing with foreign bodies in the upper gastrointestinal tract.Methods: Cases of foreign body ingestion admitted to department of general surgery from March 2015 to March 2020 were evaluated. The patients were reviewed with details on age, sex, type of FB, its location in gastrointestinal tract, treatment and outcome.Results: A total of 55 cases were studied. Age range was 1-85 years. Males were predominant 61.81%. Coins were found most commonly 63.6%. Esophagus was the commonest site of FB lodgement 70.9%. Upper esophagus being the most common 36.36%. Upper gastrointestinal flexible endoscopy was useful in retrieving FB in all the 55 cases. There were no complications throughout the study period.Conclusions: Flexible endoscopy should be used as definitive treatment and endoscopic treatment is safe and effective. 

Tu1106 STEAM STERILIZATION DECREASES CONTAMINATION OF FLEXIBLE GASTROINTESTINAL ENDOSCOPY'S VALVES : A PRACTICAL METHOD TO DECREASE ENDOSCOPY-RELATED IATROGENIC INFECTION

Endoscopy-associated pathogen transmission has been recognized as an important issue of safety. Inadequate decontamination procedures and equipment malfunction are two leading causes of post-endoscopic infection and contamination. The current guideline suggests manual cleaning, followed by high-level disinfection(HLD) as standard reprocessing procedure. The FDA has highlighted the cross-contamination risk associated with valves(suction, air/water and biopsy valve) when used with flexible gastrointestinal endoscope accessory in 2018. Single-use valves are still in development, and the feasibility remains unclear due to cost-effectiveness. In this study, we evaluated the effectiveness of manual cleaning, and the feasibility of HLD followed by steam sterilization(SS) as a practical method in real-world for valve reprocessing to decrease contamination rate. All valves from the endoscopy were reprocessed by 3 steps. Manual cleaning was followed by HLD, and HLD was followed by SS. We performed manual cleaning in 2 situations, under and without supervision. We cultured the samples of valves from the endoscopy after each reprocessing step. The SS protocol was under 134°C-136°C and 31-32 pounds per square inch for 4 minutes. The samples for cultures were acquired from 1ml bottom layer fluid by using 40 ml sterile distilled water soaking valves, followed by vibration with a vibrating tester for 1 minutes and centrifugation under 3000rmp for 5 minutes. All samples were cultured under 35°C for 48 hours. 22 sets of cultures were obtained(8 sets under real-time supervision and 14 sets without supervision when manual cleaning). The positive culture rate was 77% after manual cleaning(63% under supervision and 86% without supervision), 32% after HLD(including 9% of false negative cultures which became positive after SS, 13% under supervision and 43% without supervision) and 18% after SS(0% under supervision and 29% without supervision). The positive high-concern organisms culture rate was 59% after manual cleaning(25% under supervision and 79% without supervision), 14% after HLD(including 5% of false negative cultures which became positive after SS, 13% under supervision and 14% without supervision) and 5% after SS(0% under supervision and 7% without supervision). The major high-concern organisms were Pseudomonas, Klebsiella and Enterococcus species. The cost of SS was around 0.1 USD for 1 valve in Taiwan. Adequate and well-qualified manual cleaning plays a central role in decontamination procedures. However, it seems not reliable in terms of the consistency in real-word practice. HLD followed by SS is superior to HLD alone, and it could reduce 33% contamination rate in this situation. If adequate manual cleaning can be ensured, it is possible to erase all the contamination by HLD followed by SS.

Nosocomial outbreak linked to a flexible gastrointestinal endoscope contaminated with an amikacin-resistant ST17 clone of Pseudomonas aeruginosa.

Endoscope contamination is infrequent but can be the source of nosocomial infections and outbreaks. In August 2016, an unexpected increase in the incidence of amikacin-resistant P. aeruginosa isolates (AK-Pae) was observed at a tertiary care center in the south of Spain. An epidemiological and microbiological investigation (August-October 2016) was performed to explain this finding. Isolates from clinical and environmental samples (2 endoscopes used for retrograde cholangiopancreatography; ERCP) were identified by MALDI-TOF. Antimicrobial susceptibility testing was performed using the MicroScan system. Whole-Genome-Sequencing (Miseq, Illumina) was performed to determine the resistome and virulome. Clonal relatedness among isolates was assessed by SpeI-PFGE and MLST. A Caenorhabditis elegans killing assay was performed for virulence testing. Biofilm formation was performed using a colorimetric assay. Four of the 5 patients infected and/or colonized with AK-Pae in August 2016 had undergone ERCP ≤5days before sample collection. Two endoscopes were contaminated with AK-Pae. Isolates from one endoscope showed an identical PFGE pattern to 9 isolates (cluster I) and differed (1-2 bands) to 5 isolates (cluster II). Isolates from these clusters belonged to the ST17 clone. This S17 clone was characterized by its low virulence in the C. elegans killing assay, and its biofilm-forming ability, slightly superior to that of high-risk clones of P. aeruginosa ST175 and ST235. This outbreak was caused by an endoscope used for ERCP contaminated with an invasive, moderately virulent, biofilm-forming AK-Pae ST17 clone, suggesting the possible emergence of a new high-risk lineage of this clone.

Endoscopic removal of foreign bodies: A retrospective study in Japan.

BACKGROUNDThe ingestion of foreign bodies (FBs) and food bolus impaction (FBI) in the digestive tract are commonly encountered clinical problems. Methods to handle such problems continue to evolve offering advantages, such as the avoidance of surgery, reduced cost, improved visualization, reduced morbidity, and high removal success rate. However, to date, no studies have evaluated the endoscopic management of FBs in Japan.AIMTo elucidate level of safety and efficacy in the endoscopic management of FBs and FBI.METHODSA total of 215 procedures were performed at Keio University Hospital between November 2007 and August 2018. Data were collected from medical charts, and endoscopic details were collected from an endoscopic reporting system. Procedures performed with a flexible gastrointestinal endoscope were only taken into account. Patients who underwent a technique involving FB or FBI from the digestive tract were only included. Data on patient sex, patient age, outpatient, inpatient, FB type, FB location, procedure time, procedure type, removal device type, success, and technical complications were reviewed and analyzed retrospectively.RESULTSAmong the 215 procedures, 136 (63.3%) were performed in old adults (≥ 60 years), 180 (83.7%) procedures were performed in outpatients. The most common type of FBs were press-through-pack (PTP) medications [72 (33.5%) cases], FBI [47 (21.9%)], Anisakis parasite (AP) [41 (19.1%) cases]. Most FBs were located in the esophagus [130 (60.5%) cases] followed by the stomach [68 (31.6%) cases]. AP was commonly found in the stomach [39 (57.4%) cases], and it was removed using biopsy forceps in 97.5% of the cases. The most common FBs according to anatomical location were PTP medications (40%) and dental prostheses (DP) (40%) in the laryngopharynx, PTP (48.5%) in the esophagus, AP (57.4%) in the stomach, DP (37.5%) in the small intestine and video capsule endoscopy device (75%) in the colon. A transparent cap with grasping forceps was the most commonly used device [82 (38.1%) cases]. The success rate of the procedure was 100%, and complication were observed in only one case (0.5%).CONCLUSIONEndoscopic management of FBs and FBI in our Hospital is extremely safe and effective.

The importance of sampling technique and rinse water for assessing flexible gastrointestinal endoscope reprocessing: A 3-year study covering 59 centers

Various guidelines recommend several sampling techniques to verify endoscope reprocessing, but a comparative study of the efficiency for recovering microorganisms was rare. Our goal was to compare different sampling techniques for the postreprocessing endoscope to assess residual bacterial contamination and analysis of the critical factors affecting the endoscope reprocessing failure. From 2016 to 2018, 3 techniques, the conventional flushing sampling method, flush-brush-flush sampling method (FBFSM), and pump-assisted sampling method (PASM), were compared covering all 59 endoscope units in Tianjin, China. A total of 237 (84.64%) flushing channel samples and 110 (61.11%) final rinse water samples met the Chinese national standard. The univariate analysis showed that the qualified rates of endoscope reprocessing sampled by PASM (65.52%) and FBFSM (75%) were significantly lower than those of the conventional flushing sampling method (91.38%). Five other factors, including the final rinse water, dry, and hospital level, were potential factors besides sample technique. The multivariate logistic analysis indicated only 2 factors (sampling technique and final rinse water) remained in the model. FBFSM, PASM, and the purified water were significantly associated with the odds of endoscope reprocessing failure, with the odds ratio (95% confidence interval) of which were 4.206 (1.757-10.067), 5.326 (2.463-11.645), and 0.309 (0.137-0.695), respectively. The problem of residual microorganisms of the postreprocessing endoscope was severe. Sampling technique and final rinse water were critical for endoscope reprocessing verification.

Flexible Gastrointestinal Endoscopy in Nigerian Tertiary Hospitals: An Audit

Flexible Gastrointestinal Endoscopy in Nigerian Tertiary Hospitals: An Audit

Flexible Endoscopy: The Fundamentals

Endoscopy highlights the intersection of technological advancements and medical application. Innovation in optics, illumination, imaging, and manufacturing has allowed for the development of a complex array of instruments for use by endoscopists. Flexible gastrointestinal (GI) endoscopy has emerged to become a well-established minimally invasive aspect of prevention, diagnosis, and treatment of GI disease.Flexible endoscopes and their associated instruments and platforms are described, acknowledging that such lists are dynamic. The procedure environment is also described in terms of location, equipment, ergonomics, personnel involved, and recovery considerations.Recommendations from GI and anesthesiology associations are outlined to summarize current practices in the administration of sedative drugs to reduce patient discomfort, allow for a technically successful procedure, and reduce patient memory of the procedure.The training process for GI endoscopy is described for general surgery residents and GI fellows. Training involves didactic and technical curriculum along with mentor-supervised endoscopic procedures. After the completion of training, residents and fellows proceed through a credentialing process, which culminates in granting privileges to an individual to perform GI endoscopic procedures. Once in practice, providers must stay up to date on the ever-changing world of medical documentation, coding, and billing to ensure appropriate reimbursement.

Microbiologic assessment of flexible gastrointestinal endoscope reprocessing using a pump-assisted sampling technique: an investigation involving all endoscopy units in Tianjin, China

Microbiologic surveillance of flexible gastrointestinal endoscopes is recommended in several guidelines as the primary means of identifying reprocessing failures. This study aimed to evaluate the contamination level and prevalence of bacteria of post-reprocessing endoscopes and to access whether using a pump-assisted sampling method (PASM) improves the sensitivity of culture. All 59 endoscopy units in Tianjin, China, were investigated. The PASM and the conventional flushing sampling method (CFSM) were used to compare the results of the microbial culture. Logistic regression analysis was used to identify the influencing factors. One hundred four (56.52%) flushing channel samples of gastrointestinal endoscopes were positive for culture, and the maximum bacterial concentration was 14,100 colony-forming units (CFU)/channel. One hundred fifty-one (82.07%) flushing samples were qualified according to the national standard of China (≤ 20 CFU/channel). The qualified rate of the samples collected by PASM was significantly lower than the qualified rate by CFSM (65.52% vs 89.68%). Using PASM (odds ratio [OR]: 4.257; 95% confidence interval [CI]: 1.870-9.690) would increase the sensitivity of culture. The use of purified water (OR: 0.288; 95% CI: 0.102-0.814) could reduce the risk of endoscope reprocessing failure. Many endoscopes fail to meet the national standard for microbial culture after reprocessing. Our results suggest that using a pump-assisted method could increase the sensitivity of the test.

Comparison of the use of fresh-frozen canine cadavers and a realistic composite ex vivo simulator for training in small animal flexible gastrointestinal endoscopy.

OBJECTIVE To compare the usefulness of fresh-frozen canine cadavers (FFCCs) and a validated canine simulator model for training veterinary students in basic gastrointestinal endoscopic procedures. DESIGN Randomized trial. SAMPLE 48 veterinary students in their final year of training. PROCEDURES Students were randomly assigned to receive basic gastrointestinal endoscopic training on a canine simulator or FFCC. All students were trained as assigned in esophagogastroduodenoscopy, endoscopic gastric biopsy, and gastric foreign body removal for 2 h/d for 5 days. They then performed each procedure on a live dog, and procedure completion time and performance ability were compared between groups. Two experienced endoscopists used a validated Likert-type procedural rating scale to rate the students' performance. Students completed a survey to rate their training model. RESULTS No significant differences were identified between groups in quality of performance of the 3 endoscopic procedures on a live dog. Students required significantly less time to complete the procedures on a live dog when trained on an FFCC versus canine simulator. Although both training models were considered equally useful by students, training on the simulator was significantly more stimulating. CONCLUSIONS AND CLINICAL RELEVANCE Students showed the same skill level in performing basic endoscopic procedures on live dogs regardless of the training model used, although students who trained on the FFCC completed these procedures faster than students trained on the canine simulator. Use of the simulator appeared to be a viable alternative to use of FFCCs for veterinary endoscopic training, providing students with a good level of proficiency before performing endoscopic procedures on live dogs.

Novel regenerative therapy combined with transphrenic peritoneoscopy-assisted omentopexy.

We previously reported that cell sheet transplantation combined with an omentopexy (OP) procedure is more effective for repairing heart damage when compared with cell sheet transplantation alone. However, a simultaneous (conventional) laparotomy as part of the OP may adversely affect the general condition of critically ill heart failure patients who would otherwise benefit from cell sheet transplantation, which is a paradox to be reconciled before this treatment can be applied in a clinical setting. We devised a novel endoscopic approach termed 'transphrenic peritoneoscopy' (TPP) for minimal access to abdominal organs from the thoracic cavity. Herein, we evaluated the feasibility and safety of TPP with an OP in a porcine myocardial infarction model. Myocardial infarction was induced in 4 mini pigs by placing an ameroid constrictor around the left anterior descending artery. One month later, a left thoracotomy was performed in 2 randomly selected mini pigs, and a laparoscopic port was placed on the left diaphragm to gain access into the abdominal cavity. Using a low-pressure pneumoperitoneum, a flexible gastrointestinal endoscope was advanced, then the omentum was partially grasped with endoscopic forceps and brought back into the thoracic cavity via the diaphragm. Skeletal myoblast cell sheets were then implanted over the impaired myocardium, followed by placing the omentum over the sheets. TPP-assisted OP was accomplished in 2 post-myocardial infarction mini pigs with severe heart failure with an intra-abdominal pressure ≤8 mmHg within 30 min (22 and 27 min, respectively). Necropsy findings revealed a viable omentum flap and pedicle in both animals, with no evidence of procedure-related complications. Angiographic and histological analyses confirmed vessel communication between the omentum and the left ventricle. Our TPP approach was shown to be feasible and safe with a low-pressure pneumoperitoneum, while the omentum flap was durable. This successful combination of techniques may provide less-invasive endoscopic intervention and regenerative therapy.