Searching the best approach for third-generation cholecystectomy

Abstract

To the Editor: We carefully read the study from Pai el al1Pai R.D. Fong D.G. Bundga M.E. et al.Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model.Gastrointest Endosc. 2006; 64: 428-434Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar that demonstrates the technical feasibility of transcolonic cholecystectomy. Recently, we also investigated an endoscopic approach to perform scarless cholecystectomy through a transgastric and transvesical combined approach.2Rolanda C. Lima E. Pêgo J.M. et al.Third generation cholecystectomy by natural orifices: transgastric and transvesical combined approach.Gastrointest Endosc. 2007; 65: 111-117Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar In our study, we also confirmed that an abdominal inferior port provides an en face orientation to the upper abdominal organs and allows better visualization and the ability to work straightforwardly. However, for these purposes, we used a transvesical instead of a transcolonic port. In fact, the transvesical access to the peritoneal cavity was feasible, easy to install, and safe in a survival porcine model study. Moreover, it should be emphasized that we did not experience any complications, such as adhesions or peritonitis, even when we left the vesicotomy point unclosed.3Lima E. Rolanda C. Pêgo J. et al.Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery.J Urol. 2006; 176: 802-805Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar However, previous studies that tried to perform cholecystectomy by natural orifice transluminal endoscopic surgery (NOTES) performed it by using a single port, either transgastric or transcolonic.1Pai R.D. Fong D.G. Bundga M.E. et al.Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model.Gastrointest Endosc. 2006; 64: 428-434Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar, 4Park P.O. Bergstrom M. Ikeda K. et al.Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis.Gastrointest Endosc. 2005; 61: 601-606Abstract Full Text Full Text PDF PubMed Scopus (420) Google Scholar, 5Swanstrom L.L. Kozarek R. Pasricha P.F. et al.Development of a new access device for transgastric surgery.J Gastrointest Surg. 2005; 8: 1129-1137Crossref Scopus (213) Google Scholar These approaches share common limitations, such as difficulties in performing effective retraction and dissection with triangulation. In fact, we should not forget that cholecystectomy is a moderately complex procedure, usually needing 4 to 5 trocars in the laparoscopic technique. To deal with these limitations, we combined 2 diametrically opposed ports (transgastric and transvesical), which was particularly useful.2Rolanda C. Lima E. Pêgo J.M. et al.Third generation cholecystectomy by natural orifices: transgastric and transvesical combined approach.Gastrointest Endosc. 2007; 65: 111-117Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar Although these studies clearly reinforce the idea that third-generation cholecystectomy (by NOTES) might be feasible in human beings in the near future, further experimental studies are needed to identify the most appropriate approach.