Third Generation Cholecystectomy by Natural Orifices

Abstract

Purpose: Isolated transgastric port raises some limitations in performing translumenal endoscopic cholecystectomy. Transvesical access to the peritoneal cavity has recently been reported to be feasible and safe. We assessed the feasibility and technical benefits of transgastric and transvesical combined approach to overcome those limitations in a porcine model. Methods: We created a transgastric and transvesical combined approach to perform cholecystectomy in seven consecutive anesthetized female pigs (15–25 Kg). Transgastric access was achieved after perforation and dilatation of gastric wall with a needle knife and 18 mm balloon, respectively. Under cystoscopic control, an open-end ureteral catheter, a 0.035 inch guide-wire and a dilator of ureteral sheath were used to place a transvesical 5 mm overtube into peritoneal cavity. Using a two working-channel gastroscope positioned transgastrically and a one-working channel ureteroscope positioned transvesically, we carried out cholecystectomy in all animals. Once the closure of the gastric hole revealed unreliable using endoclips, the animals were sacrificed and necropsy was performed immediately after surgical procedure. Results: Establishment of transvesical and transgastric accesses took place without complications. Under a CO2-pneumoperitoneum controlled by the transvesical port, gallbladder identification, cystic duct and artery exposure were easily achieved in all cases. Transvesical gallbladder grasping and manipulation revealed particularly valuable to enhance gastroscope-guided dissection. Excluding two 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. Conclusions: The transgastric and transvesical combined approach is feasible and revealed particularly useful to perform cholecystectomy through exclusive natural orifices.