Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video).
BACKGROUND
Transgastric cholecystectomy is a natural orifice transluminal endoscopic surgery (NOTES) procedure that has been reported in 2 nonsurvival studies. Both studies detail substantial technical limitations, with only a 33% success rate when limited to 1 gastric incision site, despite the use of a multichannel locking endoscope.


OBJECTIVE
The aim of this study was to evaluate the feasibility and technical limitations of transcolonic cholecystectomy in a survival model.


METHODS
Animal feasibility study.


METHODS
Five pigs, under general anesthesia, were prepared with tap-water enemas, a peranal antibiotic lavage, and a Betadine rinse. A dual-channel endoscope was advanced into the peritoneum through an anterior, transcolonic incision 15 to 20 cm from the anus. After cystic duct and artery ligation, dissection of the gallbladder was achieved by using grasping and cutting instruments. After removing the gallbladder, the colonic incision was closed by using Endoloops and/or endoclips. The animals lived for 2 weeks after the procedure, then they were euthanized, and a necropsy was performed.


RESULTS
All 5 gallbladders were successfully resected. Four of the 5 animals flourished in the postoperative period, with appropriate weight gain. In 1 animal, complete closure of the colonic incision was not possible, and it was euthanized at 48 hours for suspected peritonitis.


CONCLUSIONS
This study reports the first transcolonic organ resection and demonstrates the first successful NOTES cholecystectomy in a survival model. The transcolonic approach provided improved endoscope stability and biliary exposure compared with the transgastric route, and complete incision closure appeared critical for procedural success.
Pai
Reina D
RD
Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Fong
Derek G
DG
Bundga
Michele E
ME
Odze
Robert D
RD
Rattner
David W
DW
Thompson
Christopher C
CC
D000818:Animals; D017081:Cholecystectomy, Laparoscopic / Q000379:methods* / Q000401:mortality; D003106:Colon; D005240:Feasibility Studies; D005260:Female; D015996:Survival Rate; D034421:Sus scrofa