Biliary - Human NOTES Transgastric Cholecystectomy
Comments: Natural Orifice Translumenal Endoscopic Surgery has captured the interest of surgical endoscopists and may represent the next stage of evolution of minimally invasive surgery. We describe out technique of transgastric cholecystectomy in humans as developed during several years of laboratory work. Standard endoscope is first used to inspect the stomach and lavage it with antibiotic solution. A critical step is selection of the site of the gastrotomy. The ideal site to exit the stomach is anterior, mid-body which obviates the need for scope retrofelxion during the procedure. We prepare full-thickness sutures 2cm apart to create an imbricated ridge. This will provide a valve to prevent loss of pneumogastrium after removal of the endoscope. To create the ridge and deposits a pledgeted permenant suture. Subsequently a second pledget is deposited on the other side and a cinching device used to tighten it down. A monopolar needle-knife is used to create one centimeter gastronomy; a balloon dilator is then used to expand the hole to two centimeters. This easily allows passage of the 18mm operating endoscope. Once the endoscope passes through the gastric wall into the peritoneal cavity, thorough exploration is performed. Our IRB protocol calls for laparoscopic observation for patient safety. A single 5mm umbilical port is placed for monitoring. The laparoscopic monitor is positioned to not be visible to the endoscopic team. A percutaneous 2mm suture passer or micrograsper is placed in subxiphoid position to retract the dome of the gallbladder. Endoscopic dissection is performed using a hook cautery IT knife and follows the same precepts of safe dissection developed for laparospopic monitor is positioned to not be visible to the endoscopic team. A percutaneous 2mm suture passer or micrograsper is placed in the subxiphoid position to retract the dome of the gallbladder. Endoscopic dissection developed for laparoscopic surgery. Endoscopic dissection is performed using a dome down method, completely freeing the gallbladder form the liver bed. Once it is completely freed, endoscopic endoloops are used to ligate both the cystic artery and cystic duct. After two endoloops are placed, endoscopic scissors are used to divide the cystic duct. The then completely mobilized gallbladder is withdrawn into the gastric lumen. The previously created gastric fold allows maintenance of pneumogastrium. Once the specimem is inside the stomach, attention is turned to gastronomy closure. We now see the value of the ridge or infolding created before gastronomy. This allows CO2 pneumogastrium to be maintained and allows precise closure to be performed. The G-prox endolumenal suturing device is used to place full-thickness sutures on both sides of the defect. The 5mm toothed grasper of the device is used to robustly grab the full thickness of the stomach wall. A needle is then fired perpendicularly across the tissue. Self-expanding tissue anchors are then deployed. A one way cinch is used to approximate the anchors and close the defect. As many sutures as are needed are deployed to tightly close the defect. Finally, suture tails are trimmed. Finally, a toothed grasper is used to grasp the gallbladder and carefully withdraw it through the esophagus and out the mouth, completing the procedure. Our IRB approves protocol calls the methylene blue instillation to check the integrity of the gastronomy closure. To date we have had no leaks in our human NOTES cholecystectomies. We demonstrate our technique of trangastric cholecystectomy using specially developed endoscopic instrumentation. Percutaneous retraction of the gallbladder is still required pending development of novel endoscopic methods. Our endoscopic technique has proven to be safe and feasible to date.
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Michael B. Ujiki, MD
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Citation: Ujiki, MB (May 19 2008). Biliary - Human NOTES Transgastric Cholecystectomy. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=758 Times viewed since Feb 2006: 3799 |
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