Natural Orifice Transluminal Endoscopic Surgery-Transgastric and Transvaginal Biliary Endosurgery in a Porcine Model

Abstract

Objectives: To determine the technical feasibility and safety of using a flexible endoscope to perform peroral transgastric and transvaginal cholecystectomy in a porcine model. Methods: Transgastric and transvaginal cholecystectomy was performed in 3 male and 2 female pigs respectively, in nonsurvival studies. Access to the peritoneal cavity was performed through a double-channel flexible videogastroscope. The peritoneal cavity was insufflated with air through a Veress needle which also served to monitor the pneumoperitoneum. The gallbladder was easily visualized by both routes. Using an endoscopic grasper and a unipolar round-tipped electrode, the gallbladder was dissected from the liver bed, once the cystic duct and artery were both clipped and divided. Results: Transgastric and transvaginal flexible endoscopic cholecystectomy was performed successfully in five pigs. There were no complications during gastric wall incision and entrance into the peritoneal cavity. Visualization of the visceral organs including gallbladder was very clear. Identification of the cystic duct, both proximal and distal clipping, and then transection and detachment of the gallbladder from the liver bed were achieved using standard endoscopic devices and accessories. The flexible endoscope after transgastric access the peritoneal cavity needed retroflexion to approach the gallbladder, while transvaginal route was more direct, allowing an easy in-line view and access to the gallbladder. The average operating time was 166 min in transgastric and 80 min in transvaginal routes of access. Conclusions: Our study revealed technical feasibility and possible safety of possible transgastric and transvaginal cholecystectomy, and we found that the transvaginal method is more feasible than others. We hope that this can be used in humans in the near future.