Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos)

Background: Multiple studies have demonstrated the feasibility of natural orifice transluminal endoscopic surgery in animal models. Objective: To determine the feasibility of transgastric peritoneoscopy and liver biopsy in human beings. Setting: Our institutional review board approved the procedures in the operating room with the patients under general anesthesia. Design and Interventions: During laparoscopic gastric bypass surgery a flexible endoscope was introduced into the peritoneal cavity through the gastric-wall incision. A peritoneoscopy with a liver biopsy was performed, then the flexible endoscope was withdrawn into the stomach, and gastric bypass surgery was completed laparoscopically. Patients: Three patients who were morbidly obese (mean weight 115.22 ± 9.07 kg [254 ± 20 lb]). Main Outcome Measurements: The ability to navigate a flexible endoscope inside the peritoneal cavity, to visualize the intra-abdominal organs, and to perform a liver biopsy without laparoscopic assistance. Results: It was very easy to navigate the flexible endoscope inside the abdomen by using torque, advancement, and withdrawal of the endoscopic shaft, as well as by movement of the endoscope tip. The flexible endoscope provided an excellent view and adequate illumination of the peritoneal cavity. The orientation of the flexible endoscope inside the peritoneal cavity was technically easy, even in the retroflex position. Systematic visualization of the liver, the spleen, the omentum, and the small and large intestine was easily achieved through the flexible endoscope without laparoscopic assistance. A liver biopsy was successfully completed in all cases by obtaining adequate tissue samples for histologic examination. Limitation: This was a pilot feasibility study. Conclusions: Transgastric flexible endoscopic peritoneoscopy in human beings is technically feasible, simple, and can become a valuable tool that complements and facilitates laparoscopic interventions inside the peritoneal cavity.