Air and fluid leak tests after NOTES procedures: a pilot study in a live porcine model (with videos)

Background Transluminal access site closure remains a major challenge in natural orifice transluminal endoscopic surgery (NOTES). Objective Our purpose was to develop in vivo leak tests for evaluation of the integrity of transgastric access closure. Settings Survival experiments on 12 50-kg pigs. Design and Interventions After a standardized transgastric approach to the peritoneal cavity and peritoneoscopy, the gastric wall incision was closed with T-bars (Wilson-Cook Medical, Winston-Salem, NC) deployed on both sides of the incision and then cinched together. Gastrotomy closure was assessed with air and fluid leak tests. The animals were observed for 1 week and then underwent endoscopic evaluation and necropsy. Main Outcome Measurements (1) Leak-proof closure of the gastric wall incision. (2) Gastric incision healing 1 week after the procedure. Results The mean intraperitoneal pressure increased 10.7 ± 3.7 mm Hg during gastric insufflation when the air leak test was performed before closure compared with 0.9 ± 0.8 mm Hg after transmural closure of the transgastric access site with T-bars ( P < .001). Fluid leak tests demonstrated no leakage of liquid contrast from the stomach into the peritoneal cavity after closure. Necropsy in 1 week confirmed completeness of the gastric closure in all animals with full-thickness healing and no spillage of the gastric contents into the peritoneal cavity. Limitations Leak tests were only evaluated on an animal model. Conclusions Fluid and air leak tests are simple techniques to evaluate in vivo the adequacy of the transluminal access site closure after NOTES procedures. Leak-proof gastric closure resulted in adequate tissue approximation and full-thickness healing of the gastric wall incision.