Background: Intra-abdominal visceral adipose tissue (VAT) functions as an active pathological cytokine gland, releasing a continuous stream of metabolically noxious molecules (resistin, IL-6, angiotensinogen) directly into the hepatic portal circulation, initiating insulin resistance and type 2 diabetes. Traditional interventions such as restrictive and bypass bariatric surgeries exhibit significant long-term undesirable effects, while pharmaceutical therapies (GLP-1 receptor agonists) suffer from extremely high patient discontinuation rates, triggering weight rebound and permanent lean muscle loss. Direct surgical visceral fat removal represents a targeted solution. Pre-clinical feline and baboon studies established initial proof-of-safety, but the technology (high-pressure water liquefaction) used in them mandated a semi-open procedure with extensive manual exenteration of the small bowel with significant risk of complications such as adynamic ileus and peritoneal adhesions. This study introduces Endoscopic Visceral Lipectomy (EVL®) utilizing Twin Cannula Assisted Liposuction (TCAL) as a strictly laparoscopic, closed-cavity milestone in metabolic surgery to minimize those risks.

Methods: We evaluate the longitudinal metabolic outcomes of a human pilot trial (Baskoy et al. 13, 2025) of mesenteric visceral lipectomy and present the technical mechanism of the coaxial TCAL platform specifically designed to overcome historical safety constraints within the small bowel mesentery.

Results: Human pilot trial data [13] demonstrated a dramatic reduction in Fasting Plasma Glucose (FPG) from 211 ± 12 mg/dL at baseline to 140 ± 4 mg/dL at 6 months (p < 0.01), with HbA1c falling from 8.9% ± 0.6% to 7.7% ± 0.3% (p < 0.01). Continuous Glucose Monitoring (CGM) Time-in-Range surged 3.4-fold from 22% ± 3% to 74% ± 6% (p < 0.001). Liver-targeted stabilization was evidenced by a substantial drop in hepatic fat content from 23.9% ± 3.7% to 19.1% ± 3.4% (p < 0.004) at 12 months, and an increase in hepatic EGP suppression from 29% ± 4% to 43% ± 4% (p < 0.05).

Conclusions: While early trials verified the therapeutic potency of visceral fat removal, the coaxial TCAL system provides the necessary safety paradigm. By employing a completely stationary outer shield, TCAL protects bowel walls, blood vessels and nerves from physical or thermal damage, permitting a strictly laparoscopic intra-abdominal procedure that completely eliminates the need for manual bowel exenteration, reducing the likelihood of postoperative adynamic ileus and peritoneal adhesions.