Early Healing of Transcolonic and Transgastric Natural Orifice Transluminal Endoscopic Surgery Access Sites Jasmine C Mathews, MA, Michael S Chin, MD, Gloria Fernandez-Esparrach, MD, PhD, Sohail N Shaikh, MD, Giorgio Pietramaggiori, MD, PhD, Sandra S Scherer, MD, Michele B Ryan, MS, Massimo Ferrigno, MD, Dennis P Orgill, MD, PhD, FACS, Christopher C Thompson, MD, MSC, FACG, FASGE BACKGROUND: Natural OrificeTransluminal Endoscopic Surgery (NOTES) is a developing, minimally inva- sive surgical approach whose potential benefits are being investigated. Little is known about secure access site closure and early healing kinetics of transvisceral access. STUDY DESIGN: Transvisceral access incisions were created in the colon (C-NOTES, n = 8) and stomach (G-NOTES, n = 8) for peritoneal exploration. Incisions were closed primarily with endoloops, endoclips, or t-tags. Macroscopic and histologic analyses performed on postoperative day 7 assessed gross appearance, granulation tissue, inflammation, ulceration, and complications. RESULTS: Macroscopically, incisions appeared closed without intraperitoneal spillage. Incisions closed by endoloop and t-tags showed intense granulation tissue fill of defect despite partial (G-NOTES, n = 3) and transmural ulceration (C-NOTES, n = 8; G-NOTES, n = 3). Of the 30 t-tags applied, 40% broke or deployed into the peritoneal cavity. Endoclip closures (C-NOTES, n = 1; G-NOTES, n = 1) did not show histologic mucosal continuity. Healing complications included transmural necrosis (C-NOTES, n = 1; G-NOTES, n = 1), foreign body material (C-NOTES, n = 3; G-NOTES, n = 2), and microabscesses (G-NOTES, n = 1). CONCLUSIONS: This study provides a reproducible model to assess noninvasive repair of planned visceral perfora- tions. Of investigated technologies, endoloop closure was favored for transcolonic incisions, and t-tags with omental patch for transgastric incisions, although these have significant limitations. Endoclips were inadequate for primary closure, but may be useful as an adjunctive closure modality. Additional studies are needed to examine visceral repair at later time points, as they will help determine the quality and kinetics of repair of a variety of incision closure strategies. This study demonstrates the need for improved technologies to more reliably close visceral transluminal defects. (J Am Coll Surg 2010;210:480–490. © 2010 by the American College of Surgeons) Natural orifice transluminal endoscopic surgery (NOTES) is a novel and rapidly evolving approach to intra- abdominal surgery. Multiple procedures including trans- gastric peritoneoscopy, 1 gastrojejunoscopy, 2 hysterectomy, 3 fallopian tube ligation, 4-6 cholecystectomy, 7-9 splenec- tomy, 10 and nephrectomy 11 have been performed success- fully in pigs. The peritoneal cavity has also been accessed through the vagina, 12,13 bladder, 14 and colon. 15-17 Reports in humans using a hybrid approach, which combines nat- ural orifice access with 1 or more laparoscopic ports to Disclosure Information: Dr Thompson is a consultant for USGI Medical, BARD, and Olympus. All other authors have nothing to disclose. The research for this project was supported by an educational grant from the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) – A joint initiative supported by the American Society for Gas- trointestinal Endoscopy (ASGE) and the Society of American Gastrointesti- nal and Endoscopic Surgeons (SAGES). Dr Fernández-Esparrach was sup- ported by a grant from Generalitat de Catalunya (AGAUR, BE-100022). Presented at the American College of Surgeons 94th Annual Clinical Con- gress, San Francisco, CA, October 2008. Received July 20, 2009; Revised January 4, 2010; Accepted January 6, 2010. From the Division of Plastic Surgery, Department of Surgery (Mathews, Chin, Pietramaggiori, Scherer, Orgill), the Division of Gastroenterology, Department of Medicine (Fernandez-Esparrach, Shaikh, Ryan, Thompson), and the Department of Anesthesiology, Pain and Perioperative Medicine (Fer- rigno), Brigham and Women’s Hospital, Boston, MA; Tufts University School of Medicine (Mathews, Chin), Boston, MA; and the Departement chirurgie viscerale, Hopital Universitaire Geneve, Geneve, Switzerland (Pi- etramaggiori, Scherer). Dr Fernandez-Esparrach’s current address is: Hospital Clínic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain. Correspondence address: Christopher C Thompson, MD, MSc, FACG, FASGE, Brigham and Women’s Hospital, Division of Gastroenterology, 75 Francis St, Boston, MA 02115. 480 © 2010 by the American College of Surgeons ISSN 1072-7515/10/$36.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2010.01.005