Inflammatory impact of NOTES peritoneoscopy is not different from that of laparoscopy: a randomized comparative study in a survival porcine model

Inflammatory changes of different NOTES approaches remain unknown. The aim of this study was to compare the inflammatory effects of NOTES and laparoscopy.

Forty female pigs were assigned to transgastric, transrectal, and transvaginal NOTES and laparoscopic peritoneoscopy groups. Antiseptic technique was utilized for NOTES whereas laparoscopy was performed sterile. Intraperitoneal pressures were monitored and maintained below 15 mmH₂O. Pneumoperitoneum was maintained with CO₂ in all groups. Pre- and postoperative blood samples of IL-6, Il-1β, and TNFα, and peritoneal fluid collected at surgery were analyzed. Animals were followed daily for 14 days. At necropsy, peritoneal fluid was collected for cytokine analysis.

Thirty-nine peritoneoscopies were successfully completed. The median procedure time was longer in the NOTES groups (57 min, range = 33–109) than in the laparoscopy group (33 min, range 32–36; P < 0.001); this was related to longer incision time and closure time. All 39 completed follow-up. Severe bleeding in the post-transrectal approach required early sacrifice of the remaining animal. Besides this, complications were similar among groups. At necropsy, adhesions were seen in four animals in the gastric group, five in the rectal group, two in the vaginal group, and two in the laparoscopic group (P = ns). There were no statistical differences in serum levels of TNFα among the groups. When serum TNFα values were expressed as the difference from the baseline, in the transvaginal group they were significantly lower than in the transrectal at 2 h [0.5 pg/ml (range = −14 to 59) vs. 60 pg/ml (range = −8 to 303); P = 0.041] and at 8 h [−5.5 pg/ml (range = −86 to 55] vs. 37 pg/ml (range = −30 to 62); P = 0.031]. The limitations of this study were that the analyses of IL-6 and Il-1β were not possible because most of the samples were below detectable levels, it was an animal model, and the sample size was small.

Inflammatory parameters are similar between NOTES and laparoscopic peritoneoscopy despite longer surgery time in the NOTES group. The vaginal route seems to reduce the inflammatory stress.