Gastric full-thickness suturing following NOTES procedures for closure of the access site to the peritoneal cavity.

fice Transluminal Endoscopic Surgery (NOTES) in 2004 research interest has grown steadily [1 ±2]. It seems feasible that endoscopic surgery might be per− formed via a transgastric, transvaginal, or transcolonic route of access to the peri− toneal cavity [2± 4]. There is consensus on the criticality of a secure closure fol− lowing NOTES procedures [2 ±4]. By means of endoscopic full−thickness plica− tion (Plicator , NDO Surgical, USA), expe− ditious and easy placement of transmural sutures can be facilitated [5]. To evaluate the feasibility for gastric wall suturing, a standard nonmodified Plicator device and 4−mm sutures (l" Fig. 1) were used in two domestic swine following NOTES cholecystectomy. Due to the long snout and neck, the 60− cm Plicator device failed to gain transoral access to the gastric lesions and surgically created access to the esophagus was es− tablished (l" Fig. 2 a). Procedure time for endoscopic placement of two sutures in the first swine was 19 minutes. Following the procedures laparotomy was per− formed. In the first case, the NOTES ac− cess site was not closed properly mainly due to gastric debris and poor visibility of the NOTES access site to the peritoneal cavity. Therefore, in the second swine ex− tended gastric lavage was carried out, and complete occlusion was achieved within 17 minutes utilizing two sutures. Perito− neal serosa was found to be incorporated into the suture in the first case during laparotomy (l" Fig. 2 b ± c). No damage to adjacent organs was found in either case. Incorporated peritoneal serosa or damage to adjacent organs might represent a peril of transmural suturing but a more reli− able suture might be achieved compared with endoluminal clipping techniques (l" Fig. 2 d). Therefore, this technique seems worthy of wider evaluation. A modified thinner and longer device and the availability of resorbable sutures could further improve the applicability of the Plicator in combination with NOTES. Gastric full−thickness suturing following NOTES procedures for closure of the access site to the peritoneal cavity