Natural Orifice Translumenal Endoscopic Surgery approach holds tremendous potential as a hybrid technique that includes laparoscopic skills as well as advanced flexible endoscopic skills. This technique which avoids insufflating the abdominal cavity could ultimately represent a major paradigm shift in minimally invasive therapy.
The SLRHC NOTES laboratory is currently evaluating novel approaches of endoluminal surgery for weight loss and the treatment of GERD. Both procedures are designed as minimally invasive methods of treating GERD and morbid obesity. Predicted populations eligible for these approaches are patients who are medically unstable for traditional laparoscopic or open anti-reflux and weight loss procedures.
Visualization for the procedure is provided mainly via a gastroscope. Access to the gastric cavity is provided by one trans-abdominal port placed percutaneously under endoscopic visualization. Using this port, 5mm or 10mm laparoscopic instruments are introduced into the gastric cavity. A tunnel of gastric mucosa is then created along the posterior stomach from the gastro-esophageal junction towards the pylorus. This tunnel is created by over-sewing gastric mucosa around the retroflexed gastroscope. After the tunnel is created, inspection of the entire gastric cavity can be performed using both the gastroscope and a laparoscope placed via the one working port. A foley catheter is then inserted into the stomach via the trans-abdominal port and left as a temporary gastrostomy tube. This tube can be used for enteral feeding or gastric decompression in the immediate post-operative period. The foley catheter is then removed 10-14 days later or once a fistula tract has formed. This is envisioned as a bridge procedure that will allow patients to lose an initial amount of weight, eventually enabling them to tolerate standard weight-loss operations. The anti-reflux procedure consists of internal plication of the gastro-esophageal junction using modified Belsley Mark IV type sutures.
Dr. Scott Belsley is currently working on projects evaluating the use of the Da Vinci Robot for transgastric orifice surgery. Projects include an extension of the NOTES model proposed by Dr. Julio Teixeira as well as optical limitations using third party visualization devices with the Da Vinci Robot.
The Da Vinci arm ports are shown passing through the gastric wall via the retroflexed view of an endoscope.