Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video).
BACKGROUND
An isolated transgastric port has some limitations in performing transluminal endoscopic cholecystectomy. However, transvesical access to the peritoneal cavity has recently been reported to be feasible and safe.


OBJECTIVE
To assess the feasibility and the technical benefits of transgastric and transvesical combined approach to overcome the limitations of isolated transgastric ports.


METHODS
We created a transgastric and transvesical combined approach to perform cholecystectomy in 7 consecutive anesthetized female pigs. The transgastric access was achieved after perforation and dilation of the gastric wall with a needle knife and with a balloon, respectively. Under cystoscopic control, an ureteral catheter, a guidewire, and a dilator of the ureteral sheath were used to place a transvesical 5-mm overtube into the peritoneal cavity. By using a gastroscope positioned transgastrically and a ureteroscope positioned transvesically, we carried out cholecystectomy in all animals.


RESULTS
Establishment of transvesical and transgastric accesses took place without complications. Under a carbon dioxide pneumoperitoneum controlled by the transvesical port, gallbladder identification, cystic duct, and artery exposure were easily achieved in all cases. Transvesical gallbladder grasping and manipulation proved to be particularly valuable to enhance gastroscope-guided dissection. With the exclusion of 2 cases where mild liver-surface hemorrhage and bile leak secondary to the sliding of cystic clips occurred, all remaining cholecystectomies were carried out without incidents.


CONCLUSIONS
Once closure of the gastric hole proved to be unreliable when using endoclips, the animals were euthanized; necropsy was performed immediately after the surgical procedure.


CONCLUSIONS
A transgastric and transvesical combined approach is feasible, and it was particularly useful to perform a cholecystectomy through exclusive natural orifices.
Rolanda
Carla
C
Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal.
Lima
Estêvão
E
Pêgo
José M
JM
Henriques-Coelho
Tiago
T
Silva
David
D
Moreira
Ivone
I
Macedo
Guilherme
G
Carvalho
José L
JL
Correia-Pinto
Jorge
J
D000818:Animals; D002763:Cholecystectomy / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D013552:Swine