title: Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments.
abstract: 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.
authors: 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
authors: Daniel J
authors: DJ
authors: Scott
authors: Shou-jiang
authors: SJ
authors: Tang
authors: Raul
authors: R
authors: Fernandez
authors: Richard
authors: R
authors: Bergs
authors: Mouza T
authors: MT
authors: Goova
authors: Ilia
authors: I
authors: Zeltser
authors: Farid J
authors: FJ
authors: Kehdy
authors: Jeffrey A
authors: JA
authors: Cadeddu
mesh_terms: 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*
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