Background and study aims: An incisionless endoscopic peroral transgastric approach to the peritoneal cavity has shown promise in animals as a potentially less invasive form of surgery. We present our experience with various endoscopic peroral transgastric procedures, reporting on the technical aspects and challenges that arose. Materials and methods: The following procedures were performed in 10 anesthetized pigs using a double-channel endoscope: peritoneoscopy (10 pigs), liver biopsy (one pig), cholecystectomy (six pigs), fallopian tube excision (one pig), and hysterectomy (one pig). Results: All the procedures were accomplished successfully. There were six minor intraoperative complications. Complete gastric cleansing and elimination of all bacteria was found to be impossible to achieve in the porcine model. Overinflation was a common problem. The lack of adequate endoscope support was a major limitation. Safe closure of the gastrotomy incision was difficult using the available clipping devices. Six pigs made an uncomplicated recovery after a follow-up period of 4 - 6 weeks. Subsequent pathological examination revealed deep gastric ulceration in one animal and a gastric wall abscess in another. Conclusions: Peroral transgastric surgery is technically feasible and safe in a porcine model. Although all the procedures were performed successfully, the study highlights some technical difficulties and illustrates the need for major technical innovations and extensive animal studies in order to evaluate the merits of incisionless surgery.
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