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For the simulation of NOTES, a complete porcine peritoneal cavity explant is used in the EASIE-R for the simulation of endoluminal or transluminal surgical procedures. The model is particularly useful for the training of basic NOTES procedures, such as establishing transgastric and transcolonic access, peritoneal exploration, and tissue biopsy. For the more advanced ‘digestivist’, the EASIE-R can facilitate organ resection (cholecystectomy, distal pancreatectomy, liver lobe resection, hysterectomy, oophorectomy) or gastrointestinal anastomosis techniques (gastrojejunostomy, partial gastrectomy, colectomy). Multiple gastrotomies or colotomies can be performed in a single model. To facilitate multiple participants to train consecutively gastrotomy or colotomy, the access sites can be closed with a regular hand-tied suture from outside. In addition to the endoscopic view, surgical procedures can be observed through the clear acrylic cover. By removing the lid, a direct assessment of tissue incision, resection, and clip application can be undertaken by gross inspection of the the surgical site. Prior to its use, according to a technique developed by Matthes, the NOTES organ specimen is sterilized using a special embalming fluid. This method of preservation does not require freezing or refrigeration of the specimen, and can be used for multiple training days. Between workshops, the specimen is kept in the embalming solution, which preserves tissue elasticity and pliability. In contrast to using live animals for NOTES training, the use of ex-vivo specimens obtained from the meat industry, does not involve ethical concerns and is not subject to IRB approval. For the simulation of laparoscopy or hybrid NOTES procedures a special cover with laparoscopic ports is used instead of the clear lid. This permits the use commercially available laparoscopic instruments.
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