Improving triangulation in notes by triple access

Abstract

Background: Triangulation is difficult to perform in flexible endoscopy. Maneuvers required for natural orifice transluminal endoscopic surgery (NOTES) procedures are challenging, if not impossible, even with a double-channel endoscope, mainly because the optical axis and the instruments cannot move independently. The aim of this acute experiment in swine was to investigate whether triangulation can be improved by using three endoscopes inserted through different natural orifices. Method: Fourteen swine were subjected to laparotomy. Three endoscopes were introduced into the peritoneal cavity via the transgastric, transrectal and transvaginal routes, respectively, under direct inspection and assistance, through the open abdomen. The laparotomy was then closed and pneumoperitoneum was created. Using one endoscope for vision [eyes] and two for manipulations [hands] all combinations were performed in relation to the orifice of insertion and the role of each endoscope. The cooperation of the three endoscopes was tested for grasping and manipulating tissues as well as for exposing, dissecting and approximating structures. Results: The most efficient and ergonomic combination for manipulations in the upper abdomen was found to be: endoscope "eyes" and one endoscope "hand" transrectally and the other "hand" transvaginally; the most efficient for manipulations in the lower abdomen involved both endoscope "hands" transgastrically and endoscope "eyes" transrectally or transvaginally, in retroflex position. Conclusions: In NOTES triangulation can be improved for some manipulations by using three endoscopes, inserted through different natural orifices.