Surgical Endoscopy

, Volume 30, Issue 2, pp 783–788 | Cite as

Transtracheal thoracic natural orifice transluminal endoscopic surgery (NOTES) in a swine model

  • Mohamed Khereba
  • Vicky Thiffault
  • Eric Goudie
  • Mehdi Tahiri
  • Rachid Hadjeres
  • Maryam Razmpoosh
  • Pasquale Ferraro
  • Moishe LibermanEmail author
Dynamic Manuscript



Natural orifice transluminal endoscopic surgery (NOTES) has the potential to be the final frontier in minimally invasive procedures in thoracic surgery. In order for thoracic pleural NOTES to 1 day be ready for clinical trials, each step of the procedure must be independently evaluated for both safety and efficacy. The aim of this study was to evaluate the trachea as a portal of entry for thoracic NOTES.


Eight 40-kg swine underwent right thoracic pleuroscopy in a survival model. In order to avoid inadvertent injury to the superior vena cava, endobronchial ultrasound was employed to select the location of airway incision. A 7-mm linear incision was then performed at the chosen location using an endoscopic electrocautery needle knife through a therapeutic flexible videobronchoscope. The mediastinal fat and parietal pleura were then dissected with electrocautery, and complete right pleuroscopy was performed. The tracheal and mediastinal portal of entry were then sealed with 1–2 cc of fibrin sealant. The pigs were kept alive for 21 days postoperatively. Postmortem diagnostic bronchoscopy was performed to assess tracheal healing. All tracheal specimens underwent histologic examination for healing and signs of mediastinal infection.


Thoracic NOTES procedures on all eight pigs were successful. There were no intraoperative complications except for one minor bleeding episode within the mediastinal dissection site which stopped spontaneously. Two pigs died from severe laryngospasm in the early postoperative period. Six pigs survived for 21 days post-procedure and experienced uneventful postoperative courses. Postmortem examination demonstrated complete tracheal healing with appropriate scarring in all pigs.


The trachea appears to be a safe port of entry for thoracic NOTES procedures in a swine model. Smaller tracheal incisions followed by balloon dilatation are associated with less postoperative morbidity and mortality. Tracheal incisions sealed with fibrin sealant healed rapidly and without signs of mediastinal infection. This procedure represents a work in progress and is not yet ready for human trials.


Pulmonary (lungs) Ultrasonography Endoscopy Thoracoscopy 



Research funded by the Canadian Foundation for Innovation and the Marcel and Rolande Gosselin Chair in Thoracic Surgical Oncology. In-kind support provided by Olympus Canada and Baxter Pharmaceuticals.


Dr. Mohamed Khereba MD, Ms. Vicky Thiffault RN, Dr. Eric Goudie, Dr. Mehdi Tahiri MD, Dr. Rachid Hadjeres MD, Dr. Maryam Razmpoosh MD, Dr. Pasquale Ferraro MD, and Dr. Moishe Liberman MD PhD have no conflict of interest or financial ties to disclose.

Supplementary material

Video 1:

Balloon dilatation of the tracheal incision. (WMV 9661 kb)

Video 2

Pleuroscopy identifying all major intra-thoracic organs. (WMV 20552 kb)


  1. 1.
    Trunzo J, Cavazzola L, Elmunzer B, Poulose B, McGee M, Marks J et al (2009) Facilitating gastrotomy closure during natural-orifice transluminal endoscopic surgery using tissue anchors. Endoscopy 41:487–492CrossRefPubMedGoogle Scholar
  2. 2.
    Chen W, Chu Y, Wu Y, Liu C, Yuan H, Liu Y et al (2012) Endoscopic closure of a tracheal access site using bioglue after transtracheal thoracoscopy in a nonsurvival canine model. Eur Surg Res 48:26–33CrossRefPubMedGoogle Scholar
  3. 3.
    Willingham F, Gee D, Lauwers G, Brugge W, Rattner D (2008) Natural orifice transesophageal mediastinoscopy and thoracoscopy. Surg Endosc 22:1042–1047CrossRefPubMedGoogle Scholar
  4. 4.
    Gee D, Willingham F, Lauwers G, Brugge W, Rattner D (2008) Natural orifice transesophageal mediastinoscopy and thoracoscopy: a survival series in swine. Surg Endosc 22:2117–2122CrossRefPubMedGoogle Scholar
  5. 5.
    Turner B, Kim M, Gee D, Dursun A, Mino-Kenudson M, Brugge W (2011) Prospective randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site. Gastrointest Endosc 73:785–790CrossRefPubMedGoogle Scholar
  6. 6.
    Liu Y, Chu Y, Liu C, Liu HP, Wu Y, Liu H et al (2011) Feasibility of the transtracheal approach for the thoracic cavity in a large animal model. Surg Endosc 25:1652–1658CrossRefPubMedGoogle Scholar
  7. 7.
    Lima E, Henriques-Coelho T, Rolanda C, Pêgo JM, Silva D, Correia-Pinto J et al (2007) Transvesical thoracoscopy: a natural orifice translumenal endoscopic approach for thoracic surgery. Surg Endosc 21:854–858CrossRefPubMedGoogle Scholar
  8. 8.
    Liu Y, Liu H, Wu Y, Ko P (2010) Feasibility of transtracheal surgical lung biopsy in a canine animal model. Eur J Cardiothorac Surg 37:1235–1236CrossRefPubMedGoogle Scholar
  9. 9.
    Liu Y, Liu H, Wu Y, Ko P (2010) Feasibility of transtracheal thoracoscopy (natural orifice transluminal endoscopic surgery). J Thorac Cardiovasc Surg 139:1349–1350CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Mohamed Khereba
    • 1
  • Vicky Thiffault
    • 1
  • Eric Goudie
    • 1
  • Mehdi Tahiri
    • 1
  • Rachid Hadjeres
    • 2
  • Maryam Razmpoosh
    • 2
  • Pasquale Ferraro
    • 1
  • Moishe Liberman
    • 1
    • 3
    Email author
  1. 1.Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC)University of MontréalMontrealCanada
  2. 2.Department of Pathology, Centre Hospitalier de l’Université de MontréalUniversity of MontréalMontrealCanada
  3. 3.Division of Thoracic SurgeryCentre Hospitalier de l’Université de MontréalMontrealCanada

Personalised recommendations