Transgastric hybrid cholecystectomy

In this era of scarless surgery, hybrid NOTES procedures seem to be a valuable option in human beings. In order to maintain the principle of no scar surgery, the transgastric approach seems to be a feasible way to perform a cholecystectomy in male patients for symptomatic cholelithiasis. We present a stepwise approach for this developing technique.

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Transgastric hybrid cholecystectomy

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

In this era of scarless surgery, hybrid NOTES procedures seem to be a valuable option in human beings. In order to maintain the principle of no scar surgery, the transgastric approach seems to be a feasible way to perform a cholecystectomy in male patients for symptomatic cholelithiasis.
We present a stepwise approach for this developing technique.

Keywords

Transgastric hybrid cholecystectomy, symptomatic cholelithiasis

Media type

Surgical video

Duration

09'38''

Publication

2008-12

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E-publication

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2483.htm

Transgastric hybrid cholecystectomy

1. Transgastric access 00'23''

Once the feasibility is clarified, transgastric access is obtained to allow the introduction of the double-channel gastroscope. This is performed under laparoscopic visual control through the 5mm umbilical trocar. A double-channel endoscope is first used to inspect the stomach. Then a monopolar needle knife is used to create a 0.5cm gastrotomy on the anterior wall of the mid-body of the stomach, and an 18mm balloon dilator expands the enterotomy. This easily allows the passage of the 12mm operating scope.

2. Falciform ligament retraction 01'20''

Once the NOTES endoscope has entered the peritoneal cavity, the laparoscope could be switched to a 5mm standard laparoscopic needle holder, which was used to pass transcutaneously a retracting tape that suspends the falciform ligament and exposes the gallbladder.

3. Dissection of Calot\'s triangle 01'52''

Endoscopic dissection of the Hartmann’s pouch and skeletonization of the triangle of Calot is initiated once proper orientation and identification of the relevant structures is achieved and at all time follows the same precepts of safe dissection that have been developed for laparoscopic operations. In short, laparoscopic hook diathermy is used to begin the dissection in close proximity to the gallbladder at the junction between the infundibulum and the cystic duct. Assistance during this dissection is provided by the endoscopic grasper, passed through one of the two working channels of the endoscope. The peritoneum covering the cystic duct is incised anteriorly and posteriorly, and gently brushed away with blunt dissection. Once sufficiently skeletonized, the cystic duct and artery are clipped twice on the patient side and once on the gallbladder side using a 5mm clip applicator inserted via the trans-abdominal port.

4. Clipping of the cystic duct and artery 03'22''

The placement of this 5mm trocar is mandatory when performing transgastric NOTES with contemporary instrumentation to ensure safe clipping of the cystic duct and artery, but also safe gastrotomy creation and closure, insufflation and monitoring of the pneumoperitoneum.

5. Gallbladder dissection 03'46''

After division of the cystic duct and artery, the gallbladder is dissected from its fossa with a hook diathermy. Counter traction is provided by the endoscopic grasper. Multiple repositioning of the grasper may be needed. At the end of the dissection, the operative site is checked to ensure hemostasis and biliostasis and rule out any inadvertent injury to the adjacent organ.

6. Gallbladder extraction 04'56''

The gallbladder is then fetched with an endoscopic snare and removed through the gastrotomy under laparoscopic control. Here you see the gallbladder being retrieved trans-orally.

7. Gastrotomy closure 05'30''

The gastrotomy is then closed with extracorporeal interrupted 3/0 Vicryl stitches by means of a 2mm scope and a 3mm needle holder inserted together side by side into the same 5mm umbilical port.

8. Airtight seal 06'09''

Gastroscopy is then repeated to inspect the closure and to confirm an airtight seal by the obtainment of a satisfactory pneumogastrum.