title: Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video).
abstract: 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.
authors.affiliation: Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal.
authors.forename: Carla
authors.initials: C
authors.lastname: Rolanda
authors.forename: Estêvão
authors.initials: E
authors.lastname: Lima
authors.forename: José M
authors.initials: JM
authors.lastname: Pêgo
authors.forename: Tiago
authors.initials: T
authors.lastname: Henriques-Coelho
authors.forename: David
authors.initials: D
authors.lastname: Silva
authors.forename: Ivone
authors.initials: I
authors.lastname: Moreira
authors.forename: Guilherme
authors.initials: G
authors.lastname: Macedo
authors.forename: José L
authors.initials: JL
authors.lastname: Carvalho
authors.forename: Jorge
authors.initials: J
authors.lastname: Correia-Pinto
mesh_terms: D000818:Animals; D002763:Cholecystectomy / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D013552:Swine