An isolated transgastric port has some limitations in performing transluminal endoscopic cholecystectomy. However, transvesical access to the peritoneal cavity has recently been reported to be feasible and safe.
Objective
To assess the feasibility and the technical benefits of transgastric and transvesical combined approach to overcome the limitations of isolated transgastric ports.
Design
We created a transgastric and transvesical combined approach to perform cholecystectomy in 7 consecutive anesthetized female pigs. The transgastric access was achieved after perforation and dilation of the gastric wall with a needle knife and with a balloon, respectively. Under cystoscopic control, an ureteral catheter, a guidewire, and a dilator of the ureteral sheath were used to place a transvesical 5-mm overtube into the peritoneal cavity. By using a gastroscope positioned transgastrically and a ureteroscope positioned transvesically, we carried out cholecystectomy in all animals.
Results
Establishment of transvesical and transgastric accesses took place without complications. Under a carbon dioxide pneumoperitoneum controlled by the transvesical port, gallbladder identification, cystic duct, and artery exposure were easily achieved in all cases. Transvesical gallbladder grasping and manipulation proved to be particularly valuable to enhance gastroscope-guided dissection. With the exclusion of 2 cases where mild liver-surface hemorrhage and bile leak secondary to the sliding of cystic clips occurred, all remaining cholecystectomies were carried out without incidents.
Limitations
Once closure of the gastric hole proved to be unreliable when using endoclips, the animals were euthanized; necropsy was performed immediately after the surgical procedure.
Conclusions
A transgastric and transvesical combined approach is feasible, and it was particularly useful to perform a cholecystectomy through exclusive natural orifices.
Section snippets
Materials and methods
This was a nonsurvival study approved by the ethical review boards of Minho University (Braga, Portugal). For this study, we included 15 small (15-25 kg) female pigs (Sus scrofus domesticus) so that the current ureteroscope length could easily achieve the upper-abdominal organs. After a significant surgical and anesthetic learning curve, the results of which are not included in this report (9 animals), we performed the cholecystectomy exclusively through natural orifices (transgastric and
Results
All procedures involved in the creation of the vesical hole (cystoscopy, bladder mucosal incision, vesicotomy, transvesical overtube passage) were performed without complications. The ureteroscope was easily introduced into the peritoneal cavity, and insufflation of CO2 was performed without incident. By using the transvesical port, we could obtain a perfect view of the upper-abdominal organs (liver, gallbladder, stomach, spleen, and diaphragm). This was particularly useful in helping the
Discussion
Almost 20 years after the first human laparoscopic cholecystectomy, a procedure that was initially viewed with skepticism, many advances have occurred in surgery.1 Similarly, with the recent unexpected success of a transgastric approach in porcine model,3, 4, 5, 6, 7, 8, 9, 10, 11, 12 an exciting new frontier in minimally invasive surgery was born and is reenergizing the surgical world: NOTES. Whereas, laparoscopic advantages over the open cholecystectomy are well recognized, many potential
Acknowledgments
We thank Mr Paulo Pereira and Mr José Bragança (Ethicon EndoSurgery, Portugal) for their assistance in this project.
2017, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Its first application was described in 2004 in the porcine model by researchers at the Johns Hopkins University [3]. The feasibility of NOTES by gastroscopy has been demonstrated for performing appendectomy [4] or cholecystectomy [5]. Reported advantages include less postoperative pain, a shorter length of hospital stay, less complications and improved cosmetic results [6].
To critically appraise studies comparing benefits and harms in women with benign disease without prolapse undergoing hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) versus laparoscopy.
We followed the PRISMA guidelines. We searched MEDLINE, EMBASE and CENTRAL for randomised controlled trials (RCTs), controlled clinical trials (CCTs) and cohort studies comparing NOTES with laparoscopy assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH) in women bound to undergo removal of a non-prolapsed uterus for benign disease. Two authors searched and selected studies, extracted data and assessed the risk of bias independently. Any disagreement was resolved by discussion or arbitration.
We did not find RCTs but retrieved two retrospective cohort studies comparing NOTES with LAVH. The study quality as assessed by the Newcastle–Ottawa scale was acceptable. Both studies reported no conversions. The operative time in women treated by NOTES was shorter compared to LAVH: the mean difference (MD) was −22.04 min (95% CI −28.00 min to −16.08 min; 342 women; 2 studies). There were no differences for complications in women treated by NOTES compared to LAVH: the risk ratio (RR) was 0.57 (95% CI 0.17–1.91; 342 women; 2 studies). The length of stay was shorter in women treated by NOTES versus LAVH: the MD was −0.42 days (95% CI −0.59 days to −0.25 days; 342 women; 2 studies). There were no differences for the median VAS scores at 12 h between women treated by NOTES (median 2, range 0–6) or by LAVH (median 2, range 0–6) (48 women, 1 study). There were no differences in the median additional analgesic dose request in women treated by NOTES (median 0, range 0–6) or by LAVH (median 1, range 0–5) (48 women, 1 study). The hospital charges for treatment by NOTES were higher compared to LAVH: the mean difference was 137.00 € (95% CI 88.95–185.05 €; 294 women; 1 study).
At the present NOTES should be considered as a technique under evaluation for use in gynaecological surgery. RCTs are needed to demonstrate its effectiveness.
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a new approach that allows abdominal surgery to be performed through a natural orifice such as the oral cavity, vagina or rectum. We present our preliminary experience of laparoscopic assisted transvaginal cholecystectomy (LATC).
Women affected by cholelithiasis, age below 65 years, BMI under 30, ASA I or II, previous full-term pregnancies, and without previous abdominal surgery underwent LATC. Patients' biographic data, operative time, intraoperative and postoperative complications were collected.
We performed 21 LATCs. Median operative time was 58 min. There were no intraoperative complications. The postoperative course was uneventful in all patients. At 1 year there were no complications and no impaired sexual activity.
The results of NOTES are promising, but currently only hybrid NOTES can be safely performed. LATC seems to guarantee better cosmetic results, less postoperative pain, faster mobilization and shorter hospitalization than laparoscopic cholecystectomy.
This project was funded by grants: Bolsa de Investigação da Sociedade Portuguesa de Endoscopia Digestiva 2006, Bolsa de Investigação Básica JABA 2005 da Associação Portuguesa de Urologia, and Project POCI/SAU-OBS/56428/2004 from FCT-Portugal.
