Endoscopic transgastric pure NOTES cholecystectomy with naso‐gallbladder drainage tube placement and injection of a hyaluronic acid mixture (with Video)

Abstract

Endoscopic transgastric pure natural orifice translumenal endoscopic surgery (NOTES) cholecystectomy is a difficult procedure, and most human female cases are performed as hybrid NOTES, using a transvaginal route. We tried a transgastric pure NOTES procedure without laparoscopic procedure in an animal study after placing an endoscopic naso-gallbladder drainage (ENGBD) tube and injecting a hyaluronic acid (HA) mixture. We performed the method in four pigs, using a standard single-channel endoscope. The ENGBD tube was placed first and the HA mixture was injected between the gallbladder (GB) serosa and liver bed. We determined the gastrotomy site using an ENGBD tube, which made the GB approach easy under fluoroscopic guidance. The scope was not retroflexed, but was rotated at the stomach fornix. The connecting tissues between the GB serosa and liver bed expanded following the injection of the HA mixture, facilitating GB removal with a Hook knife. The GB wall, liver, and vessels were observed clearly during the procedure, and there were no incorrect cuts. We successfully performed a transgastric pure NOTES cholecystectomy in pigs. An ENGBD tube was useful as a guide to the GB, and for recognizing the cystic duct, and injecting the HA mixture facilitated the GB dissection.