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Pierre ALLEMANN

Centre Hospitalier Universitaire Vaudois
Lausanne, Switzerland
MD
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Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
S Perretta, P Allemann, B Dallemagne, A Lobontiu, D Coumaros, J Marescaux
Surgical intervention
8 years ago
434 views
7 likes
0 comments
04:53
Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
NOTES left nephrectomy: retroperitoneal transvaginal approach
This video shows how to perform nephrectomy in the porcine model with a novel transvaginal retroperitoneal NOTES technique.
Conceivably, nephrectomy performed through a natural orifice could enhance cosmesis and minimize postoperative recovery. The vagina has been considered a viable route for kidney retrieval following laparoscopic nephrectomies. While NOTES nephrectomy has been previously described, the transvaginal retroperitoneal route has not been explored yet.
Under general anesthesia, with the pig supine, the left retroperitoneal space was entered with a double channel endoscope (Storz™) through a posterior colpotomy. A retroperitoneal tunnel was created with blunt dissection with the assistance of insufflation set at 12mm Hg. To prevent penetration of the peritoneal sac, the dissection is carried out in close contact with the psoas muscle up to the Gerota's fascia, which was opened to access the renal hilum. Renal vessels and the ureter were dissected and taken separately between clips. The kidney was dissected free bluntly. Limitations imposed by the porcine anatomy prevented transvaginal specimen retrieval.
S Perretta, P Allemann, B Dallemagne, J Marescaux
Surgical intervention
10 years ago
890 views
4 likes
0 comments
04:43
NOTES left nephrectomy: retroperitoneal transvaginal approach
This video shows how to perform nephrectomy in the porcine model with a novel transvaginal retroperitoneal NOTES technique.
Conceivably, nephrectomy performed through a natural orifice could enhance cosmesis and minimize postoperative recovery. The vagina has been considered a viable route for kidney retrieval following laparoscopic nephrectomies. While NOTES nephrectomy has been previously described, the transvaginal retroperitoneal route has not been explored yet.
Under general anesthesia, with the pig supine, the left retroperitoneal space was entered with a double channel endoscope (Storz™) through a posterior colpotomy. A retroperitoneal tunnel was created with blunt dissection with the assistance of insufflation set at 12mm Hg. To prevent penetration of the peritoneal sac, the dissection is carried out in close contact with the psoas muscle up to the Gerota's fascia, which was opened to access the renal hilum. Renal vessels and the ureter were dissected and taken separately between clips. The kidney was dissected free bluntly. Limitations imposed by the porcine anatomy prevented transvaginal specimen retrieval.