Endoscopic Closure of Large Defects With a Novel Clipping Device and a 4S-Modified Roeder Slipknot

Endoscopic closure is an essential procedure in gastrointestinal (GI) surgery, but currently it is difficult to close large defects endoscopically because of the lack of an appropriate device. Previously, we developed an endoscopic clipping device that has multifiring function and is equipped with an independent clamp. The goal of this study is to provide a new closure method with this device and 4S-modified Roeder (4SMR) slipknot. The feasibility of the closure method is examined by deploying two clips during one insertion onto the 4SMR slipknot to close a 5 cm full-thickness linear defect of an ex vivo porcine stomach from the center. Mechanical strengths of clip-knot closure and the slipknot as regards to tensioning forces are also evaluated. Specifically, the mechanical strength of the 4SMR slipknot is verified by mean peak forces to failure, while the knot is tensioning by 2.5, 5, 7.5, and 10 N force (n = 20 for each group), respectively. Experimental results indicate the clip-slipknot closure can withstand a distracting force of 6.3 $±$ 5.6 N. Tensioning force has a great influence on the mechanical strength of slipknot, with the mean peak force (tensioning force) being 7.1$±$ 6.5, 16.3 $±$ 9.3, 18.9 $±$ 10.4, and 24.2 $±$ 12.0 N, respectively. The proposed closure method can be used for large defects. Tensioning force higher than 5 N is suitable to ensure a stronger 4SMR slipknot.