Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments.
BACKGROUND
Natural orifice translumenal endoscopic surgery (NOTES) is an evolving field and suitable instruments are lacking. The purpose of this study was to perform transvaginal cholecystectomies using instruments incorporated into a magnetic anchoring and guidance system (MAGS).


METHODS
Non-survival procedures were conducted in pigs (n = 4). Through a vaginotomy created under direct vision, a rigid access port was inserted into the peritoneal cavity and used to maintain a CO(2) pneumoperitoneum. MAGS instruments were deployed through the port and held in place on the peritoneal surface using magnetic coupling via an external handheld magnet which was optionally exchanged for an 18 ga percutaneous threaded needle anchor; instruments included a tissue retractor (a clip-fixated magnet or flexible graspers) and a cautery dissector. A gastroscope was used for visualization.


RESULTS
The first two procedures ended prematurely due to instrumentation shortcomings and inadvertent magnetic coupling between instruments; one case required a laparoscopic rescue. Three new forms of instrumentation were developed: (1) a longer access port (50 cm) which provided easier deployment of instruments and suitable reach, (2) a more robust cauterizer with a longer, more rigid, pneumatically deployed tip with better reach and sufficient torque to allow blunt dissection, and (3) a more versatile tissue retractor with bidirectional dual flexible graspers which provided excellent cephalad fundus retraction and inferiolateral infundibulum retraction. With these modifications, 100% of the cholecystectomy was completed in the third and fourth animals using only a NOTES/MAGS approach. Retrieval of the tissue retractor resulted in a rectal injury in the third animal but further procedural modifications resulted in a successful procedure in the fourth animal with no complications.


CONCLUSIONS
While still under development with more refinements needed, completely transvaginal cholecystectomy using MAGS instruments is feasible. By offering triangulation and rigidity, MAGS may facilitate a NOTES approach while alleviating shortcomings of a flexible platform.
Scott
Daniel J
DJ
Southwestern Center for Minimally Invasive Surgery, Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9156, USA. daniel.scott@UTSouthwestern.edu
Tang
Shou-jiang
SJ
Fernandez
Raul
R
Bergs
Richard
R
Goova
Mouza T
MT
Zeltser
Ilia
I
Kehdy
Farid J
FJ
Cadeddu
Jeffrey A
JA
D000818:Animals; D002763:Cholecystectomy / Q000295:instrumentation* / Q000379:methods*; D019723:Endoscopes; D004724:Endoscopy / Q000379:methods*; D004867:Equipment Design; D005240:Feasibility Studies; D005260:Female; D008280:Magnetics; D013525:Surgical Instruments; D013552:Swine; D014621:Vagina / Q000601:surgery*
Gastrointest Endosc. 2006 Sep;64(3):428-34
16923495
Gastrointest Endosc. 2004 Jul;60(1):114-7
15229442
J Am Assoc Gynecol Laparosc. 1999 Nov;6(4):487-90
10548710
J Urol. 2007 Jul;178(1):288-91
17499803
Gastrointest Endosc. 2005 Mar;61(3):449-53
15758923
Obstet Gynecol. 2000 Jun;95(6 Pt 1):787-93
10831967
Surg Endosc. 2007 Dec;21(12):2308-16
17704871
Gastrointest Endosc. 2005 Aug;62(2):287-92
16046997
Gastrointest Endosc. 2006 Mar;63(3):473-8
16500399
J Urol. 2006 Aug;176(2):802-5
16813951
Gastrointest Endosc. 2005 Jul;62(1):122-9
15990831
J Gastrointest Surg. 2005 Nov;9(8):1129-36; discussion 1136-7
16269384
Gastrointest Endosc. 2004 Jan;59(1):89-95
14722559
Best Pract Res Clin Obstet Gynaecol. 2006 Feb;20(1):73-87
16275095
J Obstet Gynaecol. 2005 Feb;25(2):160-5
15814396
Ann Surg. 2007 Mar;245(3):379-84
17435544
Gastrointest Endosc. 2006 Feb;63(2):307-12
16427940
Surg Innov. 2006 Jun;13(2):86-93
17012148
Surg Endosc. 2006 Aug;20(8):1179-92
16865615
Gastrointest Endosc. 2005 Apr;61(4):601-6
15812420
Surg Endosc. 2006 Feb;20(2):329-33
16402290
Endoscopy. 2006 Jan;38(1):86-9
16429361
Surg Endosc. 2006 Mar;20(3):522-5
16432652
Urology. 2002 Mar;59(3):446-50
11880100