title: Hybrid minimally invasive surgery--a bridge between laparoscopic and translumenal surgery.
abstract: BACKGROUND
  The peroral transluminal approach to the peritoneal cavity appears safe, feasible, and may further reduce the invasiveness of surgery. However, flexible endoscopes have multiple limitations inside the peritoneal cavity, which can potentially be overcome by blending the use of both a laparoscope and a flexible upper endoscope--a hybrid approach. The goal of the present study was to evaluate a hybrid minimally invasive technique for cholecystectomy in a porcine model.
  
  
  METHODS
  Hybrid cholecystectomies were performed in acute experiments on 50-kg pigs under general anesthesia. Pneumoperitoneum was created with a Veress needle, and a laparoscopic 10-mm port was inserted. Under laparoscopic observation, the gastric wall incision was done with an endoscopic needle-knife and sphincterotome, and the upper endoscope was advanced into the peritoneal cavity. A laparoscopic 10-mm port was inserted into the right upper quadrant of the abdomen for gallbladder traction to facilitate exposure of the cystic duct and artery. Via the biopsy channel of the flexible endoscope, and using a knife with an isolated tip, a needle knife, and clips, both the cystic duct and artery were identified, clipped, and transected. The gallbladder itself was then dissected and retracted through the mouth, and the gastric wall incision was closed with endoscopic clips.
  
  
  RESULTS
  Five hybrid cholecystectomies were performed without complications. The laparoscopic port enabled a stable pneumoperitoneum, good traction and counter-traction, and improved spatial orientation and visualization. Necropsy did not reveal any intraperitoneal complications.
  
  
  CONCLUSIONS
  The hybrid approach increases safety of initial gastric puncture and gastric wall incision, improves orientation and navigation of the flexible endoscope inside the peritoneal cavity, simplifies peroral transgastric cholecystectomy, and could be used to decrease invasiveness of laparoscopic surgery and to facilitate development and clinical introduction of transgastric endoscopic procedures.
  
  
  BACKGROUND
  The online version of this article (doi:10.1007/s00464-007-9329-2) contains supplementary material, which is available to authorized users.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Halsted 608, Baltimore, Maryland 21287, USA.
authors.forename: S P
authors.initials: SP
authors.lastname: Shih
authors.forename: S V
authors.initials: SV
authors.lastname: Kantsevoy
authors.forename: A N
authors.initials: AN
authors.lastname: Kalloo
authors.forename: P
authors.initials: P
authors.lastname: Magno
authors.forename: S A
authors.initials: SA
authors.lastname: Giday
authors.forename: C-W
authors.initials: CW
authors.lastname: Ko
authors.forename: N V
authors.initials: NV
authors.lastname: Isakovich
authors.forename: O
authors.initials: O
authors.lastname: Meireles
authors.forename: E J
authors.initials: EJ
authors.lastname: Hanly
authors.forename: M R
authors.initials: MR
authors.lastname: Marohn
mesh_terms: D000818:Animals; D002763:Cholecystectomy / Q000379:methods*; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D019723:Endoscopes; D005774:Gastrostomy; D034421:Sus scrofa