title: Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes.
abstract: OBJECTIVE
  This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy.
  
  
  METHODS
  Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope.
  
  
  RESULTS
  A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1).
  
  
  CONCLUSIONS
  This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.
authors.affiliation: Department of Surgery, Kyorin University School of Medicine, Mitaka, Tokyo, Japan. abenbtg@kyorin-u.ac.jp
authors.forename: Nobutsugu
authors.initials: N
authors.lastname: Abe
authors.forename: Hirohisa
authors.initials: H
authors.lastname: Takeuchi
authors.forename: Hisayo
authors.initials: H
authors.lastname: Ueki
authors.forename: Hiroyoshi
authors.initials: H
authors.lastname: Matsuoka
authors.forename: Osamu
authors.initials: O
authors.lastname: Yanagida
authors.forename: Tadahiko
authors.initials: T
authors.lastname: Masaki
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Mori
authors.forename: Masanori
authors.initials: M
authors.lastname: Sugiyama
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Atomi
mesh_terms: D000818:Animals; D017081:Cholecystectomy, Laparoscopic / Q000295:instrumentation / Q000379:methods*; D004195:Disease Models, Animal; D020776:Endoscopes, Gastrointestinal; D016099:Endoscopy, Gastrointestinal; D004867:Equipment Design; D005240:Feasibility Studies; D005705:Gallbladder Diseases / Q000601:surgery; D013270:Stomach / Q000601:surgery; D015996:Survival Rate; D013552:Swine