Closure of a gastrotomy after transgastric tubal ligation by using the Eagle Claw VII: a survival experiment in a porcine model (with video)

Abstract

Background: Transgastric access to the peritoneal cavity presents new opportunities for novel endoscopic surgery. Secure closure of the gastrotomy site is critical to the success of transgastric endoscopic surgery.

Objective: To study the safety and efficacy of closure of a gastrotomy by using the Eagle Claw VII endoscopic suturing device after transgastric bilateral tubal ligation.

Design: A prospective survival study in a porcine model with ten 30-kg pigs.

Interventions: The gastrotomies were made by using a needle-knife and balloon dilation. Bilateral fallopian tube ligation was performed with detachable snares, and the tubes were transected by using the needle-knife. The gastrotomies were closed with endoscopic suturing by using the Eagle Claw VII.

Main outcome measurements: Included the survival of the pigs, security of the closure, number of plicating sutures used, operative time, peritoneal contamination, and histopathologic confirmation of the full-thickness healing of the gastrotomy.

Results: Transgastric fallopian-tube ligation was performed in 10 pigs, and all of the gastrotomies were successfully closed by using the Eagle Claw VII endoscopic suturing device. The operative time for bilateral tubal ligation was 38.2 minutes (range 18-50 minutes), whereas, the operative time for gastrotomy closure was 25.5 minutes (range 15-35 minutes). Three endoscopic sutures were necessary to achieve a secure gastrotomy closure. All the pigs survived and tolerated a full diet 24 hours after the operation. A postmortem confirmed full-thickness healing for all gastrotomies, with no evidence of leakage. One pig had an overtube-related esophageal perforation, which was successfully managed with endoscopic clip closure.

Limitations: The porcine gastric wall is thicker than the human gastric wall, and the posterior wall of the porcine stomach becomes the anterior-inferior wall after gaseous distention. Hence, all the gastrotomies were made through the posterior wall. The tissue tolerance and healing of the porcine stomach may be different from that of the human stomach.

Conclusions: Endoscopic suturing by using the Eagle Claw VII device is a feasible method for gastrotomy closure after a natural orifice transluminal endoscopic surgery procedure.