Transluminal endoscopic cholecystectomy: changing the paradigm

Feasibility and safety of functional cholecystectomy by pure NOTES: a pilot animal study

BACKGROUND

NOTES cholecystectomy has become one of the hottest areas of research. But most of the cases need the assistance of the laparoscope. This study is conducted to evaluate the feasibility and safety of a newly proposed operative method-functional cholecystectomy by pure NOTES.

MATERIALS AND METHODS

The functional cholecystectomy was performed on eight female miniature pigs. An incision was made on the vaginal wall, and an endoscope was inserted into the peritoneal cavity to create a pneumoperitoneum to expose the intra-abdominal viscera, gallbladder, and cystic duct. The cystic duct was isolated and closed with a clip. Then, an injection needle was inserted into the gallbladder to suck up the bile. After the gallbladder was washed with saline, an incision was made on the wall of the gallbladder, and the tip of the endoscope was inserted into the gallbladder cavity. After the endoscope was withdrawn, the gallbladder incision was closed with clips in four pigs and was suspended in the other four pigs. The vaginal incision was closed with clips. All the animals were closely monitored and euthanized 28 days after the procedure. Necropsy was performed.

RESULTS

The functional cholecystectomy was successfully completed in all eight pigs. No severe intraoperative complications occurred. The animals recovered well postoperatively. At necropsy, no macroscopic signs of intraperitoneal infection or bile leakage in the peritoneal cavity were observed, and the clips were still present on the cystic duct in a good position in all cases. The gallbladder incision healed, with no sign of bile leakage or injury to the adjacent organs.

CONCLUSIONS

We successfully performed the functional cholecystectomy by transvaginal approach on pigs, which appears to be feasible, safe, and convenient. Functional cholecystectomy provides a new fitting path to pure NOTES.

Hybrid NOTES transvaginal cholecystectomy: operative and long-term results after 18 cases

PURPOSE

Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique that aims at reducing or abolishing skin incisions and potentially also postoperative pain. The purpose of this study was to analyse operative and long-term results of a series of hybrid transvaginal cholecystectomy.

MATERIALS AND METHODS

Between July 2007 and May 2009, transvaginal NOTES cholecystectomy for symptomatic cholelithiasis was performed by a hybrid technique in 18 women (mean age 54 years), including four women with a body mass index >30 kg/m(2). Dissection was conducted in the first four cases by a round-tip unipolar electrode (UE) introduced through the operative channel of the endoscope coming from the vagina and in the last 14 cases by a ultrasonic scalpel (US) introduced through a 5-mm abdominal port. The short-term outcomes and the long-term results of the two methods were compared.

RESULTS

The transvaginal approach entailed no intraoperative complication and no conversion. The overall mean duration of procedures was 75 min (range 40-190). In the first four cases (UE), the operating time was 148 min (range 140-190), whilst in the last 14 (US), it was considerably shorter, 53 min (range 40-60, p < 0.01). We experienced one biliary leak in the UE group, whilst morbidity with US was nil (p < 0.005). The biliary leak healed in 7 days with nasobiliary drainage. No other complications were encountered in either group. The mean follow-up was 12 months (range 1-22), and none of the patients has complained of dyspareunia or other colpotomy-related complications so far.

CONCLUSIONS

Until specifically designed endoscopic tools are available for NOTES, the hybrid technique with US dissection conducted through a 5-mm port should be preferred in transvaginal cholecystectomy in order to shorten the duration of surgery and make this approach effective, safe and reproducible. After a mean follow-up of 1 year, none of our patients has complained of any problem related to transvaginal approach.

Navigation systems and platforms in natural orifice translumenal endoscopic surgery (NOTES)

INTRODUCTION

The latest evolution in minimally invasive surgery is to avoid skin incisions by using natural orifices, called natural orifice translumenal endoscopic surgery (NOTES). However, to safely and efficiently perform NOTES, the requirements of the operating platform used need to be modified from the conventional endoscope. The aim of this paper is to systematically review specialised operating platforms used or in development for NOTES procedures.

METHODS

A review of the literature was conducted using Ovid EMBASE, Ovid MEDLINE, ISI Current Contents Connect and PubMed, a search tool of the National Library of Medicine and the national institute of Health, until the 1st of December 2008. Data was extracted to specifically characterise the available platforms, their availability, advantageous characteristics and potential disadvantages.

RESULTS

There were 9 studies included in this review describing 6 different navigation platforms and 3 robotic systems for NOTES. Based on this analysis, it is our opinion that although the described surgical systems and navigation platforms possess some attractive characteristics, such as maneuverability, stability, enhanced optics, and the ability to provide triangulation and insufflation with proper suction/irrigation maintenance, there does not appear to be one platform which is clearly superior to others.

CONCLUSION

Current instruments are not suited for effective surgery in a NOTES environment. There are several important requirements for NOTES platform: 1) to provide safe access to the peritoneal cavity; 2) to provide a stable channel for instrumentation passageway and safe navigation, 3) to provide good visualization and illumination, thereby decreasing disorientation, 4) to maintain proper insufflation and suction/irrigation, and 5) to provide maneuverability and triangulation of the instruments. Effective collaborations between clinicians, engineering departments and industry are essential to maximise and expedite the innovative process in producing an optimal NOTES platform.