A Single Transgastric Access System for NOTES® Is Able to Perform Gastric Access, Gallbladder Resection, and Organ Retrieval

Abstract

While the ability to safely create transgastric access has been widely reported, the feasibility of performing common peritoneal procedures with simple flexible endoscopic NOTES platform is critical to facilitating NOTES in humans. Aim: To assess the utility of a novel transgastric access system in facilitating access, dissection, and organ retrieval during a NOTES cholecystectomy. Methods: Under general anesthesia a dual channel colonoscope was inserted into the transgastric port included in the prototype access system (Apollo Endosurgery Inc.) and the instruments were advanced in unison into the stomach. The other system device, an over-the-wire gastrotomy dilation balloon, was then introduced into the 3.7 mm scope channel. A peg-like technique was used to orient the dilation balloon in the gastric wall where it was inflated to allow peritoneal access for the scope and overtube. Two cuffs (Peritoneal and gastric) on the port were then inflated to secure the device in the gastrotomy, and the transgastric port was temporarily connected to insufflation. A single 5mm laparoscopic grasper was used for traction while dissection of the gallbladder from the hepatic bed was conducted under endoscopic visualization and control using the electrocautery knife incorporated into the access system's dilation balloon. During dissection the balloon was used to provide precision saline irrigation and coagulation for the control of the minor bleeding encountered. Once dissection was completed an endoscopic polypectomy snare was used to retrieve the organ through the transgastric port. Results: The prototype transgastric peritoneal access system devices were used to create secure transgastric access successfully. The transgastric port enabled both the maintenance of the pneumoperitoneum and free endoscopic movement necessary to perform the cholecystectomy. With assistance from a single laparoscopic grasper the colonoscope and balloon's electrocautery knife were used to dissect approximately the gallbladder from the hepatic bed. The balloon features also effectively controlled the small vessel bleeding encountered. The transgastric access port served as the conduit for en bloc removal of the dissected organ. Conclusion: This prototype transgastric access system was capable of most functions necessary, with the exception of traction, for the dissection and removal of the gallbladder in the porcine model.