https://doi.org/10.1177/1553350617697184 Surgical Innovation 1–4 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350617697184 journals.sagepub.com/home/sri Original Article Introduction Advanced intraluminal or transluminal endoscopic sur- gery both require a reliable and reproducible closure and tissue apposition technique to restore the integrity of the gastrointestinal tract. 1 In fact, one of the main limitation to the widespread adoption of NOTES (natural orifice transluminal endoscopic surgery), the fascinating concept of no-scar surgery, is the lack of a secure and easy-to-use system to close the transluminal gateway to the peritoneal cavity. 2,3 Additionally, full-thickness perforations might complicate endoluminal surgical procedures like peroral endoscopic myotomy (POEM), endoscopic submucosal dissections (ESD) and interventions like dilations. Various flexible endoscopic tools and techniques have been developed to try to achieve such closure, and this remains today an active field of surgical innovation. 4 The size of the defect to close, deliberate or accidental, dictates the most suitable closing technique or device. Endoclips alone, or in combination with endoloops, can effectively seal injuries limited to the mucosa or small full thickness defects (around 1 cm). 5,6 Over-the-scope clips have a robust design and can achieve a rapid, point-and-shoot, effective full-thickness closure of lesions up to 2.5 cm. However, when dealing 697184SRI XX X 10.1177/1553350617697184Surgical InnovationHalvax et al research-article 2017 1 IHU-Strasbourg, Institute for Image-Guided Surgery, Strasbourg, France 2 IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France Corresponding Author: Lee L. Swanström, IHU-Strasbourg, Institute for Image-Guided Surgery, 1, Place de l’Hôpital, 67091, Strasbourg, France. Email: lee.swanstrom@ihu-strasbourg.eu Experimental Evaluation of the Optimal Suture Pattern With a Flexible Endoscopic Suturing System Peter Halvax, MD 1 , Michele Diana, MD 1,2 , Yoshihiro Nagao, MD 1 , Jacques Marescaux, MD, FACS (Hon), FRCS (Hon), FJSES (Hon), APSA 1,2 , and Lee Swanström, MD, FACS, FASGE, FRCSEng (Hon) 1 Abstract Background. The ability to perform reliable, secure endoluminal closure of the gastrointestinal tract wall, is a prerequisite to support the progress of the emerging field of endoluminal surgery. Along with advanced clipping systems, flexible endoscopic suturing devices are commercially available. Current systems can replicate traditional surgical suturing patterns in the endoluminal environment. The aim of this study was to evaluate the optimal endoluminal suturing technique using a flexible endoscopic suturing device. Materials and Methods. Procedures were performed on bench- top simulators containing 20 explanted porcine stomachs. A standardized 3-cm full-thickness incision was created on the anterior wall of each stomach using monopolar cautery. The gastrotomy was closed endoscopically using an over-the-scope suturing device (OverStitch, Apollo Endosurgery; Austin, TX). Three different techniques were used: single stitches, figure-of-8 pattern, and running suture. Material consumption and operation time were recorded and bursting pressure measurement of the closure was performed. Results. No statistically significant differences were identified in suturing time. Suturing time (minutes) was slightly shorter with the figure-of-8 technique (41.14 ± 4.6) versus interrupted (45.75 ± 1.1) versus continuous (51.44 ± 10.0), but the difference was not statistically significant. The number of sutures required was greater in the interrupted group. No significant difference was found in the burst pressure (mm Hg): figure-of-8 (45.85 ± 26.2) versus interrupted (30.5 ± 22.89) versus continuous (32.0 ± 26.5). In the figure-of-8 group, 85.5% of cases were leakproof above 30 mm Hg, while in the other groups only 50% of cases were so. Conclusion. A figure-of-8 suturing pattern seems to be the preferable suturing technique with the endoscopic suturing device. Keywords endoluminal suturing device, suturing techniques, OverStitch, endoscopy, perforation, suture, closure