Per-oral transgastric abdominal surgery

Laparoscopic surgery has several advantages over traditional surgery because it has been shown to be less invasive. The next logical step in the evolution of minimally invasive surgery may be to eliminate all abdominal incisions. The natural orifices provide a port of entry via the gastrointestinal tract to the peritoneal cavity. This approach would require the creation of a perforation, which is considered to be a major complication of endoscopy with significant morbidity and mortality. However, there are several recent studies that have described the technical feasibility and safety of a per-oral transgastric approach to the peritoneal cavity using conventional endoscopes. Theoretically, this approach could reduce postoperative abdominal wall pain, wound infection, hernia formation, and adhesions. This article aims to summarize the current status of transgastric surgery, currently referred to as natural orifice transluminal endoscopic surgery (NOTES), and to address some of its future challenges.     

Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video)

BACKGROUND: The ability to access the abdominal cavity though a direct (modified-PEG type) gastric incision to perform natural orifice transluminal endoscopic surgery (NOTES) has been demonstrated in the literature. However, the optimal technique to access the abdomen remains unknown. OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of a transgastric approach to the abdominal cavity through an extended submucosal tunnel. DESIGN: Animal feasibility study. INTERVENTIONS: Transgastric endoscopic peritoneoscopy was performed in 7 anesthetized swine, including 2 acute and 5 survival animals. After the creation of a 10-cm to 12-cm tunnel in the gastric submucosal plane, the peritoneal cavity was accessed by needle-knife puncture through the gastric wall near the greater curvature. The peritoneal cavity was examined before the gastric mucosal incision was closed with endoclips. Survival animals were euthanized two weeks after the procedure, and a necropsy was performed. RESULTS: The abdominal cavity was successfully entered without complication in all 7 animals. The mucosal incisions were able to be closed by endoscopy. In the survival experiments, all animals recovered and gained weight. Two animals experienced clinically unapparent infectious complications. LIMITATIONS: Small sample size. CONCLUSIONS: A peroral transgastric approach to the abdominal cavity through an extended submucosal tunnel is technically feasible and allows safe abdominal access and reliable closure with currently available technology. It has potential benefits as an alternative to direct transgastric access for NOTES procedures.     

Endoskopisch geführte Gastroenteroanastomose – bald Realität?

Endoscopic procedures have become more invasive over the recent years. This tendency has resulted in a transgastric approach involving, for example, necrosectomy. Recently transgastric gastrojejunostomy has been developed as an entirely endoscopic procedure. This has resulted in a new endoscopic surgical approach into the peritoneal cavity, where an iatrogenic opening has to be cut into the gastrointestinal wall with the necessity of endoscopically closing this incision. The techniques and challenges, but also the advantages and disadvantages of this new approach are discussed in this review.     

Initial experience from the transgastric endoscopic peritoneoscopy and biopsy: a stepwise approach from the laboratory to clinical application

Background and Aim: Natural‐orifice translumenal endoscopic surgery (NOTES) is a newly minimally invasive technique that gives access to the abdominal cavity via transgastric, transcolonic, transvaginal or transvesical routes. The aim of the present study was to evaluate the safety and feasibility of transgastric endoscopic peritoneoscopy and biopsy from laboratory to clinical application. Methods: With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle‐knife and through‐the‐scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. After 2 weeks, another transgastric endoscopic exploration was performed in a different location of the stomach. The peritoneal cavity was examined before the gastric incision was closed. After 4 weeks of observation, necropsy was performed. In the clinical application, after gastric lavage, the first step was the creation of the gastrotomy under general anesthesia, sometime under direct vision of the laparoscopic scope. Then the endoscope can be maneuvered in the peritoneal cavity. And peritoneoscopy and biopsy were performed. Biopsies can be obtained from any suspicious areas using punch biopsy forceps. The gastrotomy was then closed with clips. The gastroscopy was examined after one week. Results: Twenty‐eight transgastric endoscopic peritoneoscopies and biopsies in pigs and a total of five transgastric human endoscopic peritoneoscopies and biopsies have been performed. All procedures were completed satisfactorily in the pig model and all patients. There were no intraoperative or postoperative complications. Conclusions: The advantages of peritoneoscopy and biopsy appeared to be enhanced by this approach. Patients had minor postoperative pain and minimal scarring. It is safe and feasible for us to use transgastric endoscopic peritoneoscopy and biopsy in humans.     

NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY FOR PREOPERATIVE STAGING IN A PANCREATIC CANCER PATIENT

Background: Many experimental studies have shown the technical feasibility of natural orifice translumenal endoscopic surgery (NOTES). We report the first clinical application of natural orifice transgastric endoscopic peritoneoscopy in Japan for preoperative staging in a patient with pancreatic cancer. Methods: A submucosal tunnel was created for safe peritoneal access and secure closure of the gastric‐incision site. Results: Transgastric peritoneoscopy provided an excellent view and allowed approach to various areas of the abdominal cavity. After confirmation of operative curability, the patient underwent an open standard operation without complication. Conclusions: Natural orifice transgastric endoscopic peritoneoscopy for cancer staging using the submucosal tunnel technique appears to be feasible and safe.     

Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model.

BACKGROUND & AIMS: The evolution of flexible endoscopes and endoscopic devices has recently enabled per-oral transgastric abdominal exploration in animal models. This study was undertaken to assess the ability to systematically identify abdominopelvic organs and to determine the feasibility of organ resection via the transgastric route. METHODS: Female Yorkshire pigs were used for the study. Under general anesthesia, a gastroscope was used to place a sterile overtube into the esophagus. After antibacterial lavage, the gastric wall was incised, and a sterile dual-channel endoscope was advanced into the peritoneal cavity. Endoscopic abdominal exploration was then methodically performed in 9 animals with oophorectomy and partial hysterectomy in 6 animals. The gastric incision was closed with endoclips. Of the animals that underwent organ resection, 3 were sacrificed immediately after surgery, and the subsequent 3 survived. RESULTS: The peritoneal cavity was accessed uneventfully, and the stomach, liver, small bowel, colon, urinary bladder, uterus, fallopian tubes, and ovaries were able to be evaluated in all cases. The gallbladder could be visualized in only 5 of the 9 animals, and retroperitoneal structures could not be consistently identified. Oophorectomy with partial hysterectomy was performed in 6 animals. The 3 animals in the survival group did well for 24 hours without sequelae. CONCLUSIONS: This study shows the ability of endoscopic transgastric peritoneal exploration to successfully identify most abdominopelvic organs and demonstrates the technical feasibility of transgastric organ resection.     

经胃腹腔内镜手术的研究进展

自从人类首次行腹腔镜胆囊手术以来,微创手术已有了巨大发展.近2a来人们又开始了由天然管腔(natural orifice)进入腹腔进行一系列内镜下的手术操作,特别是由胃腔进入腹腔.人们已先后在动物完成了经胃内镜胃空肠吻合术和胆囊切除术;经胃腹腔内组织活检;经胃胆道系统内镜手术;经胃输卵管接扎;经胃内镜脾切除;经胃阑尾切除;经胃内镜腹膜后胰腺清创术等手术.其中一些手术已在人类完成,这为腹部手术进入真正微创提供了一个新平台.但此项技术仍处于早期发展阶段,他涉及多专科的合作,仍需要克服许多不足,不断使之完善,最终服务于临床.     

Rendezvous gastrotomy technique using direct percutaneous endoscopic gastrostomy for transgastric cholecystectomy in hybrid natural orifice translumenal endoscopic surgery

Background/purpose

Transgastric access is a major route in natural orifice translumenal endoscopic surgery (NOTES); gastrotomy should be performed unless it would damage surrounding organs in the peritoneal cavity. This article describes a novel rendezvous gastrotomy technique over a direct percutaneous endoscopic gastrostomy (PEG).

Methods

In six live porcines, the gastrotomy involved applying a direct PEG through the abdominal wall into the stomach and exchanging to a needle trocar. An endoscopic balloon catheter was passed through the trocar by rendezvous technique. Then the inflated balloon and endoscope were advanced to the peritoneal cavity through the gastrotomy. Transgastric cholecystectomy was performed with a hybrid needle grasper through the same percutaneous site and the gastrotomy was closed with endoscopic clips.

Results

The rendezvous gastrotomy technique could reduce guidewire exchange. The success rate was 100% (6/6). Mean times for transgastric peritoneoscopy and cholecystectomy were 25.5 and 83.5 min. Mortality and morbidity was 0%. The addition of the extra trocar was unnecessary in all procedures.

Discussions/conclusions

The advantage of this introduction system includes the creation of controlled gastric perforation, which is easier to close. It provides reliable transgastric access and increases safety. It simplifies transgastric NOTES and provides less invasive hybrid NOTES procedure.     

NOTES: approach to the liver and spleen

Background

Minimally invasive abdominal surgery means minimal trauma to the abdominal wall, thus reducing postoperative pain and wound complications, and facilitating earlier mobilization and shorter hospitalization in comparison with conventional surgery. Natural orifice translumenal endoscopic surgery (NOTES) has the potential to further reduce the invasiveness of surgery in human patients. Here we report an experimental study of NOTES to access the liver and spleen, discuss its current status, and review the related literature.

Methods

The utility of transgastric peritoneoscopy was evaluated using one 15-kg pig and four 8-kg dogs on the basis of acute experiments. Under general anesthesia with endotracheal intubation, a forward-viewing, double-channel endoscope was advanced into the peritoneal cavity through a gastric hole. Liver biopsy from the edge of the liver was performed using routine biopsy forceps. Splenectomy was performed using a laparoscopically assisted procedure, and then the spleen was pulled into the stomach using an endoscopic polypectomy snare after enlargement of the gastric orifice. The animals were then sacrificed and necropsy was performed.

Results

There were no complications during incision of the gastric wall and entry into the peritoneal cavity. Peritoneoscopy gave satisfactory visualization of the abdominal cavity in all directions. Liver biopsy was performed successfully without any bleeding and adequate samples were obtained in all cases. Splenectomies were also accomplished uneventfully, except for injury of the splenic parenchyma due to excessive force during pulling into the stomach. Necropsy revealed no particular damage to other intraperitoneal organs related to this transgastric procedure.

Conclusion

Although NOTES is a feasible procedure and offers several advantages to patients, surgeons and endoscopists need to resolve several key issues before its clinical introduction for routine surgical work and to establish a training system for NOTES in order to avoid critical complications.     

Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model

BACKGROUND: We have previously reported the feasibility and safety of the peroral transgastric endoscopic approach for diagnostic peritoneoscopy, liver biopsy, and gastrojejunostomy with long-term survival in a porcine model. This approach eliminates incisions of the abdominal wall, providing a less invasive alternative to diagnostic and therapeutic laparoscopy. We now report successful performance of peroral endoscopic transgastric ligation of Fallopian tubes with long-term survival in a porcine model. METHODS: Six female 50-kg pigs had general anesthesia and irrigation of the stomach with an antibiotic solution. Gastric puncture was performed with needleknife electrocautery followed by balloon dilatation of the tract with 20-mm TTS dilating balloon (Microvasive). A standard upper endoscope that underwent high-level disinfection and gas sterilzation was advanced into the peritoneal cavity through a sterile overtube. Both Fallopian tubes were identified and one was ligated using Olympus Endoloops. The other patent tube served as a control. Tubal patency was evaluated by hysterosalpingogram before and after ligation. After a follow-up period of 2-3 weeks, the pigs were sacrificed for postmortem examination. RESULTS: The Fallopian tubes were easily accessed, identified and ligated in all 6 pigs. In each pig, fluoroscopy confirmed complete obstruction of the ligated tube with preserved patency of the other tube. All pigs survived well and ate heartily without any ill-effects. Postmortem examination did not reveal any peritonitis or intra-abdominal adhesions. The Endoloops were in place with complete obstruction of the ligated tubes and patency of the controls. Histopathologic examination of the tubes showed chronic inflammatory infiltrates without abscesses. CONCLUSIONS: The peroral endoscopic transgastric approach to ligation of the Fallopian tubes with long-term survival is technically feasible and safe in a porcine model. The endoscopic transgastric approach to the peritoneal cavity has potential for a wide array of diagnostic and therapeutic procedures.     

Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video)

BACKGROUND: An isolated transgastric port has some limitations in performing transluminal endoscopic cholecystectomy. However, transvesical access to the peritoneal cavity has recently been reported to be feasible and safe. OBJECTIVE: To assess the feasibility and the technical benefits of transgastric and transvesical combined approach to overcome the limitations of isolated transgastric ports. DESIGN: We created a transgastric and transvesical combined approach to perform cholecystectomy in 7 consecutive anesthetized female pigs. The transgastric access was achieved after perforation and dilation of the gastric wall with a needle knife and with a balloon, respectively. Under cystoscopic control, an ureteral catheter, a guidewire, and a dilator of the ureteral sheath were used to place a transvesical 5-mm overtube into the peritoneal cavity. By using a gastroscope positioned transgastrically and a ureteroscope positioned transvesically, we carried out cholecystectomy in all animals. RESULTS: Establishment of transvesical and transgastric accesses took place without complications. Under a carbon dioxide pneumoperitoneum controlled by the transvesical port, gallbladder identification, cystic duct, and artery exposure were easily achieved in all cases. Transvesical gallbladder grasping and manipulation proved to be particularly valuable to enhance gastroscope-guided dissection. With the exclusion of 2 cases where mild liver-surface hemorrhage and bile leak secondary to the sliding of cystic clips occurred, all remaining cholecystectomies were carried out without incidents. LIMITATIONS: Once closure of the gastric hole proved to be unreliable when using endoclips, the animals were euthanized; necropsy was performed immediately after the surgical procedure. CONCLUSIONS: A transgastric and transvesical combined approach is feasible, and it was particularly useful to perform a cholecystectomy through exclusive natural orifices.     

Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model

BACKGROUND: Published reports on NOTES (natural orifice transluminal endoscopic surgery) have thus far been limited to the transgastric method. OBJECTIVE: The aim of this study was to assess the transcolonic approach as a means of accessing and systematically exploring the abdominal cavity in a survival study design. DESIGN: Six pigs were placed under general anesthesia and were prepped with multiple tap-water enemas, followed by instillation of a cefazolin suspension and a povidone-iodine lavage. Equipment was prepared with a high-level chemical disinfection, and an aseptic technique was used. An incision was made in the anterior colonic wall, and abdominal exploration was performed by using a double-channel endoscope. The incision was subsequently closed with endoscopic clips, endoloops, or a prototype closure device. PATIENTS: Six female Yorkshire pigs that weighed 25 to 30 kg. RESULTS: Stomach, liver, gallbladder, spleen, small bowel, colon, and peritoneal surfaces were identified in all animals in less than 3 minutes. The lower pelvic organs were not consistently visualized. All animals were alive for 14 days without apparent complications. At necropsy, the colonic incision sites were completely closed and appeared well healed. Microscopic inflammatory changes were seen at the closure site in all animals, including microabscesses. Incision-related adhesions were identified in 4 of 6 animals. CONCLUSIONS: This study demonstrated the use of a novel transcolonic approach to successfully access and explore the abdominal cavity. In contrast to the transgastric method, a transcolonic approach provides more consistent identification of structures in the upper abdomen and provides better en face orientation and scope stability. Therapeutic interventions in the upper abdomen, including organ resection, may be more tenable by using a transcolonic method; however, further studies are needed to address issues of sterility and colonic closure.     

Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity

BACKGROUND: A novel endoscopic peroral transgastric approach to the peritoneal cavity was tested in a porcine model in acute and long-term survival experiments. METHODS: Transgastric peritoneoscopy was evaluated in 50-kg pigs. After upper endoscopy, the peritoneal cavity was accessed by needle-knife puncture of the gastric wall, followed by extension of the incision either with a pull-type sphincterotome or by balloon dilation. The peritoneal cavity was examined, and a liver biopsy specimen was obtained. The gastric wall incision was closed with clips. OBSERVATIONS: Twelve acute and 5 survival experiments were performed. Both techniques of gastric wall incision were without complication. The acute experiments demonstrated the technical feasibility of the approach. In the survival experiments, all pigs recovered and gained weight. CONCLUSIONS: The peroral transgastric approach to peritoneal cavity technically is feasible and has the potential to be an alternative to laparoscopy and laparotomy.     

Surgery insight: natural orifice transluminal endoscopic surgery--an analysis of work to date

Traditional flexible endoscopy has been limited to the confines of the gastrointestinal lumen; however, recent developments involving transluminal access to intra-abdominal structures hold the potential to revolutionize flexible endoscopy. Over the past few years various studies have detailed techniques that intentionally breach the lumen and provide endoscopic access to the peritoneal cavity for diagnostic and therapeutic procedures. Unlike standard surgical approaches, which require incisions to be made in the abdominal wall, natural orifice transluminal endoscopic surgery (NOTES) avoids the need for abdominal incisions and can offer specific advantages to select patient populations. Animal models have been used to demonstrate the possible applications of NOTES, including transgastric peritoneoscopy, tubal ligation, gastrojejunostomy, partial hysterectomy, oophorectomy, and transcolonic exploration, liver biopsy and cholecystectomy. In this Review, we highlight important advances in NOTES since it was first described and analyze the hazards and potential benefits associated with this innovative approach.     

A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures

BACKGROUND: We have previously reported the feasibility and safety of per-oral transgastric endoscopic procedures in a porcine model. OBJECTIVE: Our purpose was to evaluate the safety and feasibility of a PEG-like approach to the peritoneal cavity. SETTINGS: Acute experiments on 50-kg pigs under general anesthesia. DESIGN AND INTERVENTIONS: After per-oral intubation, the endoscope was positioned into the body of the stomach, the anterior abdominal wall was transilluminated and punctured with a needle, and a guidewire was inserted into the stomach through the needle. The guidewire was grasped with endoscopic forceps and pulled through the biopsy channel of the endoscope. A sphincterotome was inserted into the gastric wall over the guidewire. Gastric incision was performed and the endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated and endoscopic peritoneoscopy was performed. Then the animal was euthanized and necropsy was performed. MAIN OUTCOME MEASURES: Safety of transgastric entrance to peritoneal cavity. RESULTS: The PEG-like approach was used in 12 pigs. The average procedure time was 11.4 +/- 3.7 minutes. There was only 1 complication related to the access: bleeding from the gastric wall incision was documented when a pure cut (without coagulation) current was used for incision of the gastric wall. There were no complications in the other 11 pigs. The necropsy did not reveal any damage to organs adjacent to the stomach. LIMITATIONS: Gastric wall incision is located on anterior gastric wall. CONCLUSIONS: The PEG-like transgastric approach to the peritoneal cavity appears technically simple and safe.     

Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model

BACKGROUND: Advances in endoscopic equipment have enabled endoluminal techniques to supplant select surgical procedures. Access to extraluminal structures holds the potential to revolutionize flexible endoscopy but, to date, has been limited. The aim of this study was to demonstrate the feasibility of endoscopic transgastric organ resection (oophorectomy and tubectomy) with 2-week survival. METHODS: Female Yorkshire pigs underwent general anesthesia, and a sterile esophageal overtube was placed. Antibacterial gastric lavage was performed, and a sterile gastroscope was passed through the overtube. Subsequently, a transgastric incision was made with a needle knife. The endoscope then was advanced into the peritoneal cavity, and the ovaries and the fallopian tubes were identified. An endoloop was used to secure the ovary, the fallopian tube, and the mesosalpinx. Snare cautery oophorectomy and tubectomy was performed, and the specimen was retrieved through the gastrotomy. The incision was closed with endoclips, and 2-week survival studies were performed. OBSERVATIONS: The peritoneal cavity was accessed in all animals (n = 6) without significant complications. The ovaries and the fallopian tubes were easily identified, and unilateral oophorectomy and tubectomy were successfully performed. Postoperative 2-week survival was uneventful in all animals. At necropsy, the gastric incision was seen as a well-healed scar with giant-cell reaction. There was histologic evidence of chronic inflammation at the resection site, without abscess, hematoma, adhesion, or damage to surrounding viscera. CONCLUSIONS: Endoscopic transgastric oophorectomy and tubectomy with 2-week survival is feasible with meticulous closure of the gastrotomy. This novel technique may extend the applications of flexible endoscopy to include aspects of abdominal surgery.     

Feasibility of endoscopic transgastric distal pancreatectomy in a porcine animal model

BACKGROUND: In contrast to laparoscopic tubal ligation, oophorectomy, and appendectomy, laparoscopic distal pancreatectomy is associated with a morbidity rate of more than 50% and a mortality rate of more than 3%. OBJECTIVE: To develop a minimally invasive, transgastric endoscopic technique for distal pancreatectomy in a nonsurvival series in swine. DESIGN: Experimental study. SETTING: Animal trial at a tertiary-care academic hospital. SUBJECTS: Six healthy Yorkshire swine under general anesthesia. INTERVENTIONS: A double-channel gastroscope was introduced into the stomach, and a gastric incision was created by using a triple-lumen, 4-mm, cutting-wire needle knife. The peritoneal cavity was accessed. An Endoloop was placed endoscopically around the distal aspect of the pancreas, and the tail of the pancreas was transected by using a diathermic snare. One to 3 hemoclips were placed across the pancreatic duct. The pancreatic specimen was retrieved, and the gastrotomy was closed endoscopically with metal clips. The animals were euthanized after the procedure. The abdominal cavity was examined grossly, and the resected pancreas was examined histologically. MAIN OUTCOME AND MEASUREMENTS: Feasibility of endoscopic transgastric distal pancreatectomy and rate of complications. RESULTS: The pancreatic tail was successfully resected via a transgastric endoscopic approach in all animals. The procedure took an average (standard deviation) of 77.3 +/- 18.9 minutes. There was 1 complication, an episode of bleeding from a splenic laceration, which resulted in the loss of 250 mL of blood. LIMITATIONS: Nonsurvival series, animal study. CONCLUSIONS: Transgastric endoscopic distal pancreatectomy is technically feasible and can be performed in the porcine animal model.     

Laparoscopy for ventriculoperitoneal shunt implantation and revision surgery

Ventriculoperitoneal shunting(VPS) is a widely accepted technique for the treatment of hydrocephalus. The probability of shunt dysfunction is pretty high throughout life. Laparoscopy has become a valuable tool to perform VPS and treat abdominal complications. An electronic literature search was performed to reveal the published data relating laparoscopy and ventriculoperitoneal shunt in Medline, Embase, Scielo and Lilacs databases. The keywords employed were "laparoscopy" OR "laparoscopic surgery" AND "ventriculoperitoneal shunt" OR "shunt" AND "surgery" OR "implantation" OR "revision" OR "complication". No high quality trials were developed comparing conventional laparotomic incision vs laparoscopic approach. Both approaches have evolved and currently there are less invasive options for laparotomy, like periumbilical small incisions; and for laparoscopy, like smaller and less incisions. Operating room time, blood loss and hospital stay may be potentially smaller in laparoscopic surgery and complications are probably the same as laparotomy. In revision surgery for abdominal complications after VPS,visualization of whole abdominal cavity is fundamental to address properly the problem and laparoscopic approach is valuable once it is safe, fast and much less invasive than laparotomy. Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. Laparoscopy assisted shunt surgery in selected cases might be a less invasive and more effective option for intrabdominal manipulation. The laparoscopic approach allows a better catheter positioning, lysis of fibrotic bundles and peritoneal inspection as well, without any additional complication.     

Endoscopic fibrin glue injection for closure of pancreatocutaneous fistula following transgastric endoscopic necrosectomy

Transgastric endoscopic necrosectomy has been recently introduced as the effective and alternative management of infected pancreatic necrosis and pancreatic abscess. However, up to 40% of patients who undergo endoscopic necrosectomy may need an additional percutaneous approach for subsequent peripancreatic fluid collection or non-resolution of pancreatic necrosis. This percutaneous approach may lead to persistent pancreatocutaneous fistula, which remains a serious problem and usually requires prolonged hospitalization, or even open-abdominal surgery. We describe the first case of pancreatocutaneous fistula and concomitant abdominal wall defect following transgastric endoscopic necrosectomy and percutaneous drainage, which were endoscopically closed with fibrin glue injection via the necrotic cavity.     

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

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).

Conclusion

This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.