NOTES transgastric cholecystectomy: our technique

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several benefits of the NOTES approach, decreased abdominal pain, wound infections, and hernia formation. This video demonstrates the technique by which we perform transgastric NOTES cholecystectomy in human patients.

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NOTES transgastric cholecystectomy: our technique

Authors

B Dallemagne, S Perretta, Gf Donatelli, J Marescaux

Abstract

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several benefits of the NOTES approach, decreased abdominal pain, wound infections, and hernia formation. This video demonstrates the technique by which we perform transgastric NOTES cholecystectomy in human patients.

Classification

clinical cases

Keywords

NOTES transgastric cholecystectomy

Media type

Surgical video

Duration

06'20''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2616.htm

NOTES transgastric cholecystectomy: our technique

1. Introduction 00'18''

This video shows our technique for NOTES transgastric cholecystectomy. Following induction of pneumoperitoneum using a Veress needle, a single 5mm transparietal port was introduced at the umbilicus to allow peritoneoscopy and ascertain the feasibility of transgastric cholecystectomy.

2. Transgastric access 00'38''

Once the operation was deemed to be feasible, transgastric access was obtained using a double-channel standard endoscope under laparoscopic visual control. An endoscopic monopolar needle-knife was used to create a 0.5cm gastrotomy onto the anterior gastric wall in the mid-body of the stomach. Then, an 18mm balloon was used to dilate the gastrotomy and allow the passage of the double-channel endoscope into the peritoneal cavity. Once the endoscope has entered the peritoneal cavity, the laparoscopic optic is switched to a 5mm standard laparoscopic grasper, which is used to expose the gallbladder.

3. Calot\'s triangle dissection by endoscopic blunt-tipped electrode 01'24''

The operation starts with the endoscopic dissection of the Hartmann’s pouch and skeletonization of the elements of the triangle of Calot. This dissection is performed with the endoscope using a blunt-tipped electrode. Counter-traction is provided by an endoscopic deflectable forceps. With this one trocar start-up configuration used initially to retract the gallbladder, the dissection can be carried out by using exclusively flexible instruments inserted via the two working channels of the endoscope. Nevertheless, these instruments are not obviously designed or adapted to perform such tasks, and as a result, the dissection becomes very time-consuming.

4. Cystic duct and rtery clpping through umbilical port 02'32''

Once efficiently skeletonized, the cystic duct and artery are clipped using a 5mm laparoscopic clip applier through the umbilical port.

5. Endoscopic gallbladder dissection 03'04''

After division of the cystic duct and artery, the gallbladder is dissected from its fossa using the blunt-tipped electrode. If retraction is efficient, this dissection can be easily performed, even with such a small instrument. Once cholecystectomy is completed, the operative site is checked to ensure hemostasis and biliostasis and to exclude any inadvertent injury to the adjacent organ. Although this is a hybrid technique and may seem to part from the initial philosophy of NOTES, the no-scar surgery, it does show merit by re-shaping technological development and by exploring the potential benefits to patients.

6. Gallbladder extraction 05'11''

Under laparoscopic control, the gallbladder is fetched using an endoscopic snare and retrieved through the gastrotomy.

7. Gastrotomy closure 05'43''

The gastrotomy is then closed with extracorporeal interrupted 3/0 stitches by means of a 2mm laparoscope in a 3mm needle-holder inserted side by side into the 5mm umbilical port.

8. Gastroscopic control 00'00''

Gastroscopy is repeated to ensure the safety of the closure. This initial cholecystectomy procedure, although delivered in a hybrid format, is a firm step in the direction of new methods and devices to explore the potentials of incisionless natural orifice transluminal endoscopic surgery.