Endoscopy 2009; 41(9): 767-772
DOI: 10.1055/s-0029-1215025
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Laparoscopic-assisted transgastric cholecystectomy and secure endoscopic closure of the transgastric defect in a survival porcine model

A.  Arezzo1 , T.  Kratt2 , M.  O.  Schurr3 , M.  Morino1
  • 1Centre for Minimally Invasive Surgery, University of Torino, Italy
  • 2Department of Surgery, University of Tübingen, Germany
  • 3IHCI, Steinbeis University Berlin, Germany
Further Information

Publication History

submitted 6 March 2009

accepted after revision 7 July 2009

Publication Date:
14 August 2009 (online)

Background and study aims: Natural orifice transluminal endoscopic surgery holds promise for surgical interventions. Before the feasibility of this technique can be established, however, secure sealing of the transluminal access needs to be thoroughly investigated.

Patients and methods: Following antibiotic prophylaxis and gastric disinfection, nine pigs underwent transgastric cholecystectomy by means of a flexible endoscope with the aid of a transabdominal 5-mm trocar. The gastric wall was punctured and dilated. The gallbladder was retracted with a laparoscopic grasper. The cystic duct and artery were dissected with a flexible monopolar ball electrode. The cystic duct was interrupted with flexible scissors between endoclips. Cholecystectomy was completed and the gallbladder was retrieved through the stomach. The gastric defect was closed using a single modified over-the-scope clip (OTSC) (Ovesco, Tübingen, Germany) and grasping the serosal and muscle layer of the gastric wall. The animals were sacrificed 4 weeks later.

Results: Laparoscopic-assisted transgastric cholecystectomy was successful in all cases without significant perioperative complications. All animals survived without postoperative complications. The mean operating time was 128 minutes (range, 85 – 205 minutes). The gastric defect closure resulted in inversion of the gastric wall layers within an average time of 6.8 ± 5 minutes. At 4 weeks postoperative, only minimal thin adhesions were observed in the right hypochondrium.

Conclusions: We found gastric closure using the OTSC to be a reliable tool for closing the transgastric access. Laparoscopic-assisted transgastric cholecystectomy by means of a flexible endoscope was technically feasible, but remains a demanding procedure.

References

  • 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
  • 2 . ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery White Paper.  Gastrointest Endosc. 2006;  63 199-203
  • 3 Perretta S, Dallemagne B, Coumaros D, Marescaux J. Natural orifice transluminal endoscopic surgery: transgastric cholecystectomy in a survival porcine model.  Surg Endosc. 2008;  22 1126-1130
  • 4 Park P O, Bergstrom M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis.  Gastrointest Endosc. 2005;  61 601-606
  • 5 Swanstrom L L, Kozarek R, Pasricha P J. et al . Development of a new access device for transgastric surgery.  J Gastrointest Surg. 2005;  9 1129-1136
  • 6 Mühe E. Laparoscopic cholecystectomy – late results.  Langenbecks Arch Chir Suppl Kongressbd. 1991;  416-423
  • 7 . Gallstones and laparoscopic cholecystectomy.  NIH Consensus Statement. 1992;  10 1-28
  • 8 Reddy D N, Rao G V. Transgastric approach to the peritoneal cavity: are we on the right track?.  Gastrointest Endosc. 2007;  65 501-502
  • 9 Kirschniak A, Kratt T, Stuker D. et al . A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.  Gastrointest Endosc. 2007;  66 162-167
  • 10 Repici A, Arezzo A, De Caro G. et al . Clinical experience with a new endoscopic over-the-scope clip system for use in the GI tract.  Dig Liver Dis. 2009;  41 406-410
  • 11 Kirschniak A, Traub F, Kueper M A. et al . Endoscopic treatment of gastric perforation caused by acute necrotizing pancreatitis using over-the-scope clips: a case report.  Endoscopy. 2007;  39 1100-1102
  • 12 Kratt T, Küper M, Traub F. et al . Feasibility study for secure closure of natural orifice transluminal endoscopic surgery gastrotomies by using over-the-scope clips.  Gastrointest Endosc. 2008;  68 993-996
  • 13 Schurr M O, Arezzo A, Ho C N. et al . The OTSC clip for endoscopic organ closure in NOTES: device and technique.  Minim Invasive Ther Allied Technol. 2008;  17 262-266
  • 14 Arezzo A, Repici A, Kirschniak A. et al . New developments for endoscopic hollow organ closure in prospective of NOTES.  Minim Invasive Ther Allied Technol. 2008;  17 355-360
  • 15 Flora E D, Wilson T G, Martin I J. et al . A review of natural orifice transluminal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting.  Ann Surg. 2008;  247 583-602
  • 16 Ryou M, Fong D G, Pai R D. et al . Transluminal closure for NOTES: an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities.  Endoscopy. 2008;  40 432-436
  • 17 Merrifield B F, Wagh M S, Thompson C C. Peroral transgastric organ resection: a feasibility study in pigs.  Gastrointest Endosc. 2006;  63 693-697
  • 18 Dray X, Gabrielson K L, Buscaglia J M. et al . Air and fluid leak tests after NOTES procedures: a pilot study in a live porcine model.  Gastrointest Endosc. 2008;  68 513-519
  • 19 Sumiyama K, Gostout C J, Rajan E. et al . Submucosal endoscopy with mucosal flap safety valve.  Gastrointest Endosc. 2007;  65 688-694
  • 20 von Renteln D, Schmidt A, Riecken B, Caca K. Gastric full-thickness suturing during EMR and for treatment of gastric-wall defects.  Gastrointest Endosc. 2008;  67 738-744
  • 21 McGee M F, Marks J M, Onders J P. et al . Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator.  Surg Endosc. 2008;  22 214-220
  • 22 McGee M F, Marks J M, Jin J. et al . Complete endoscopic closure of gastric defects using a full-thickness tissue plicating device.  J Gastrointest Surg. 2008;  12 38-45
  • 23 Wagh M S, Merrifield B F, Thompson C C. Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model.  Clin Gastroenterol Hepatol. 2005;  3 892-896
  • 24 Sumiyama K, Gostout C J, Rajan E. et al . Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope.  Gastrointest Endosc. 2007;  65 1028-1035
  • 25 Vidyarthi G, Steinberg S E. Endoscopic management of pancreatic pseudocysts.  Surg Clin North Am. 2001;  81 405-410; xii
  • 26 Kobayashi T, Gotohda T, Tamakawa K. et al . Magnetic anchor for more effective endoscopic mucosal resection.  Jpn J Clin Oncol. 2004;  34 118-123

A. ArezzoMD 

Centre for Minimally Invasive Surgery
Dipartimento di Discipline Medico Chirurgiche
Università di Torino

Corso Dogliotti 14
10126 Torino
Italy

Phone: +39-335-8378243

Fax: +39-011-6336641

Email: alberto.arezzo@unito.it; alberto.arezzo@mac.com