Per-oral dual scope NOTES cholecystectomy in porcine model (with video)

Background Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument [1-3]. Therefore, "pure NOTES" transgastric cholecystectomy has not yet been described. The authors successfully performed "pure NOTES" transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure [41) that allows completion of the procedure by pure NOTES without an external instrument. Methods With the subject under general anesthesia, a double-channel gastroscope (Storz (R), Tuttlingen, Germany) passed by mouth entered the peritoneum through the distal anterior gastric wall. The most ideal site for a second gastric exit was then selected for another single-channel scope. With the gallbladder retracted by the assistant operating the double-channel scope, retrograde cholecystectomy was performed by the primary surgeon using the single-channel scope. Four animals were killed immediately to study the quality of the operative dissection, whereas the other four pigs were kept alive. The gastrotomy was closed using a 27- to 30-mm cardiac septal occluder (Occlutech (R), GmbH, Jena, Germany) according to a previously described method [5]. The postoperative follow-up assessment of these animals included laparoscopy and necropsy 2 weeks later. Results All the cholecystectomies were immediately successful without any intraoperative complication. Scope withdrawal caused no injuries to the esophagus or pharynx. Although no overt postoperative complication was evident, two surviving pigs had signs of minor peritoneal infection. Conclusions This study investigated "pure NOTES" transgastric cholecystectomy using tentative experimentation to overcome the "retraction" and "triangulation" issues and to realize a "pure NOTES" operation. The use of two endoscopes with selected differentiation of their gastric placements compensated for the lack of triangulation and retraction.