The KING Closure: A Revolutionary Technique for Safer Gastrotomy Closures
"Discover how the single loop-and-clips technique (KING closure) is transforming gastrotomy closure after transgastric ovariectomy, offering a survival advantage in experimental settings."
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is changing surgery, allowing surgeons to operate through natural openings in the body. But to really take off, NOTES needs reliable ways to close up the surgical sites afterward. A weak closure can lead to major problems, making a strong closure technique a must-have.
One promising solution is the 'KING closure,' a technique that uses a single loop and clips to close gastrotomies—surgical openings in the stomach. Researchers have been putting it to the test, comparing it against standard closure methods to see if it really holds up.
This article dives into a study that explores how well the KING closure works in pigs undergoing transgastric ovariectomies (ovary removal through the stomach). We'll look at how it's done, what the results were, and what it could mean for the future of NOTES and other procedures.
KING Closure: A Step-by-Step Look at the Technique
The KING closure method was tested on pigs and works by first making a small incision in the stomach using a percutaneous endoscopic gastrostomy (PEG) technique. After this, surgeons performed a peritoneoscopy to remove the ovaries with a double-channel endoscope. The critical part comes next: closing the stomach incision.
- An endoloop is positioned around the gastrotomy site.
- Clips are strategically placed to secure the loop.
- A grasper pulls the incision edges together inside the loop.
- The loop is tightened, cinching the edges closed.
KING Closure in the Endoscopic Toolkit
Endoscopic literature lists the KING and QUEEN techniques among endoloop-based options for gastrotomy closure, alongside standard clips, over-the-scope clips (OTSC), and endoscopic suturing. One report notes that KING closure uses an endoloop with clips and cites studies reporting safe use and superior long-term histological healing outcomes compared with OTSC clipping. Another describes KING and QUEEN as techniques requiring a double-channel endoscope or multiple loops. These snippets identify the methods and reported findings but do not provide study details or outcome figures.
Evidence Limits and Alternative Closure Views
The cited survival experiment of KING closure for gastrotomy after transgastric ovariectomy states that its study has limitations, but the supplied material does not specify what they are. A ScienceDirect overview reports that the Johns Hopkins Apollo group considered closure of a balloon gastrotomy unnecessary, arguing that the muscular layer may remain intact and the opening may close through muscle contraction after endoscope withdrawal. A separate supplied abstract describes exposed endoscopic full-thickness resection as an emerging minimally invasive alternative to surgery for gastric submucosal tumors, but it does not provide evidence comparing closure methods. The available snippets therefore do not establish a general failure rate or a direct comparison of KING closure with these alternatives.
The Future of Gastrotomy Closure: Safer Procedures on the Horizon
The single loop-and-clips technique (KING closure) offers a promising alternative to traditional gastrotomy closure methods. The study showed that the KING closure had fewer complications, like abscesses and peritonitis, compared to using clips alone.
Closure Device Selection Requires Context
A 2013 ex vivo study description identifies gastrotomy closure as a major barrier to clinical application of natural orifice transluminal endoscopic surgery (NOTES). It says endoscopic suturing was presumed safer than endoclips and reports an evaluation involving 51 ex vivo porcine stomach models comparing the Eagle Claw VIII, endoclips, and surgical suturing. A 2026 international expert consensus summary says its panel reached agreement on practical guidance for indications, device selection strategies, and technical considerations in endoscopic closure. The supplied material does not state that the consensus specifically endorses KING closure.
Growing Need for Reliable GI Closure Devices
A review on advancements in endoscopic closure says that the expanding use of endoscopic mucosal resection, endoscopic submucosal dissection, NOTES, and full-thickness resection makes a broader range of safe, efficient, and reliable gastrointestinal defect-closure devices necessary. A U.S. market report attributes demand for endoscopic closure systems to increased use of interventions for gastrointestinal wall defects, bariatric procedures, and postoperative leakage management. It says providers are adopting these devices to reduce surgical conversions, minimize hospital stays, and strengthen safety for high-risk patients. These sources describe broader clinical needs and adoption drivers, not a specific future trajectory for KING closure.
Gastrotomy Closure as a Barrier to NOTES
A 2013 source describes gastrotomy closure as a major barrier to the clinical application of natural orifice transluminal endoscopic surgery (NOTES). It notes that full-thickness endoscopic suturing was presumed safer than closure with endoclips. The supplied snippet does not report comparative results or establish that this presumption was confirmed. This places closure reliability among the broader challenges facing NOTES, without specifying KING closure’s role.
While this research is a significant step forward, it's important to remember that it was performed on pigs. More studies are needed to confirm if the KING closure is as safe and effective in humans. But, the initial results are encouraging, suggesting that this technique could lead to fewer complications and better outcomes for patients undergoing NOTES procedures.
As NOTES and other minimally invasive surgeries continue to evolve, innovations like the KING closure will be crucial for making these procedures safer and more accessible.