title: Transjejunal Extraction of Gallbladder After Mini-Laparoscopic Cholecystectomy in Patients with Previous Roux-en-Y Gastric Bypass: A Small Case Series.
abstract: BACKGROUND
  The length of incisions on the abdominal wall directly correlates with wound-related morbidities and patient comfort. Both mini-laparoscopy (only ≤5-mm trocars) and natural orifice specimen extraction avoid larger abdominal incisions. This study described a new natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) cholecystectomy technique by combination of these two advanced laparoscopic techniques for cholelithiasis in patients who had prior laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity.
  
  
  METHODS
  Three patients (two males, one female; 39, 62, and 34 years old, respectively) were admitted with symptomatic cholelithiasis (multiple millimeter-sized gallstones), and all had previously had LRYGB. They were treated by mini-laparoscopic cholecystectomy using three 5-mm trocars. The gallbladder was removed through the dilated efferent limb of the jejunum, 5 cm distal from the gastrojejunostomy. Transjejunal extraction was performed under endoscopic guidance. The gallbladder in the jejenum was passed through the anastomosis and extracted with an endoscopic snare by the transoral way. The enterotomy was closed intracorporeally.
  
  
  RESULTS
  There was no conversion or additional trocar requirement. All the procedures were completed successfully without problems. Respective operating times were 95, 75, and 120 minutes. Only 1 patient required postoperative analgesic; the others did not. The patients started to get a liquid diet on the night of surgery and were discharged on Days 1, 1, and 2, respectively, with normal diet recommendations. There were no morbidities.
  
  
  CONCLUSIONS
  Mini-laparoscopic cholecystectomy is technically feasible in patients with previous LRYGB. Prior LRYGB was not an obstacle for transoral specimen extraction. The dilated efferent jejunal limb is a good alternative route for natural orifice specimen extraction. This report described the first natural orifice surgery through the small bowel.
authors.affiliation: Department of Surgery, Inonu University , Malatya, Turkey .
authors.forename: Cuneyt
authors.initials: C
authors.lastname: Kayaalp
authors.affiliation: Department of Surgery, Inonu University , Malatya, Turkey .
authors.forename: Ali
authors.initials: A
authors.lastname: Tardu
authors.affiliation: Department of Surgery, Inonu University , Malatya, Turkey .
authors.forename: Mehmet Ali
authors.initials: MA
authors.lastname: Yagci
authors.affiliation: Department of Surgery, Inonu University , Malatya, Turkey .
authors.forename: Fatih
authors.initials: F
authors.lastname: Sumer
mesh_terms: D000328:Adult; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D016099:Endoscopy, Gastrointestinal; D005260:Female; D042882:Gallstones / Q000601:surgery; D015390:Gastric Bypass; D006801:Humans; D007583:Jejunum / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects / Q000379:methods*; D061646:Operative Time; D010149:Postoperative Pain / Q000188:drug therapy; D016896:Treatment Outcome