Background: Natural-orifice transluminal endoscopic surgery (NOTES) procedures have been tested using numerous approaches, mainly in animals. In humans, only cholecystectomy has been assessed, using a combined transvaginal and transumbilical approach. We present another variant of a hybrid technique for cholecystectomy, namely the combination of a flexible transumbilical double-channel endoscope and a 3-mm rigid transcutaneous trocar placed in the left hypochondrium for liver retraction.
Patients and methods: The procedure was attempted in 10 well-selected young patients (M : F = 4 : 6, mean age 29.5 years). Instruments used through the two working channels of the endoscope were either a grasping forceps or snare for grasping and pulling and a hot-biopsy forceps for cold and hot preparation and dissection. Endoclips were used for cystic duct and artery closure. Postoperative analgesia consisted of one intravenous dose of analgesic, followed by oral administration for one further day. Follow-up visits were scheduled at 7 days, 30 days, 90 days, and 6 months.
Results: In 4 of the 10 cases the operation had to be converted to conventional laparoscopic cholecystectomy due to difficulty in dissection (in 2 cases) or uncontrollable hemorrhage (2 cases). The mean operating time was 148 minutes. Of the 6 cases in which the procedure was finished by the new approach, cystic artery bleeding occurred in 1 and was successfully clipped. One further patient had a postoperative cystic duct leak with a bilioma, successfully treated by endoscopic retrograde cholangiopancreatography with stenting. Five of the six patients reported themselves as satisfied at 3- or 6-month follow-up.
Conclusions: So far, our endoscope-based transumbilical cholecystectomy technique has not yielded satisfactory results in humans. Further instrument and accessory improvements may increase both success rate and acceptance. Scarless surgery without the inherent risks of a transluminal approach may then become feasible.
References
1
Pai 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
428-434
2
Meining A, Wilhelm D, Burian M. et al .
Development, standardization, and evaluation of NOTES cholecystectomy using a transsigmoid approach in the porcine model: an acute feasibility study.
Endoscopy.
2007;
39
860-864
3
Park P O, Bergström M, Ikeda K. et al .
Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecysto-gastric anastomosis (videos).
Gastrointest Endosc.
2005;
61
601-606
4
Lima E, Rolanda C, Pêgo J M. et al .
Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery.
J Urol.
2006;
176
802-805
5
Bessler M, Stevens P D, Milone L. et al .
Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery.
Gastrointest Endosc.
2007;
66
1243-1245
8
Zornig C, Emmermann A, von Waldenfels H A, Mofid H.
Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach.
Endoscopy.
2007;
39
913-915
9
Marescaux J, Dallemagne B, Perretta S. et al .
Surgery without scars: report of transluminal cholecystectomy in a human being.
Arch Surg.
2007;
142
823-826
13
Sclabas G M, Swain P, Swanstrom L L.
Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES).
Surg Innov.
2006;
13
23-30
14
Magno P, Giday S A, Dray X. et al .
A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial.
Endoscopy.
2007;
39
876-880
16
Pasricha P J, Kozarek R, Swain P. et al .
A next generation therapeutic endoscope: development of a novel endoluminal surgery system with ”birds-eye” visualization and triangulating instruments.
Gastrointest Endosc.
2005;
61
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