Endoscopic transgastric cholecystectomy: a novel approach for minimally invasive cholecystectomy
Natural-orifice transluminal endoscopic surgery (NOTES) has been developed as a step towards less invasive procedures. Transvaginal, transgastric, and transcolonic cholecystectomy have been described, but mostly carried out with the assistance of laparoscopic guidance, or with another device for extraction, such as a second endoscope or transabdominal instrument   . We report a novel technique called endoscopic transgastric cholecystectomy (ETGC) that is carried out with a single scope and without laparoscopic guidance or other transabdominal instruments.
The anterior wall of the gastric antrum is actively perforated with a sterile colonoscope. The gallbladder is then exposed and dissected from the fundus to the neck. Intermittent injection of normal saline to the connective tissues is necessary to create working space. Then, a thorough dissection of the hepatocystic triangle is performed to obtain the “critical view of safety.” The cystic artery is dissected and electrocoagulated. Once the cystic duct is fully dissected, it is closed with clips and then incised, and the gallbladder is extracted with a snare. To prevent bile leakage, the cystic duct stump is ligated. Careful hemostasis and scope reflection should be carried out to check for potential bleeding in the serosa of the gastric wall. Finally, the gastric wall is closed with clips or purse suture techniques ([Fig. 1]; [Video 1]).
Video 1 Endoscopic transgastric cholecystectomy in a 55-year-old gentleman.
Between March 2019 and December 2019, eight patients underwent ETGC in our center. All the procedures were successful and there were no procedure-related adverse events. The median operation time was 4 h. The patients all had an uneventful course after the procedure. Median hospital stay was 2.5 days.
ETGC offers the potential for performance of truly scarless cholecystectomy and reduces pain. At the current stage the procedure should only be performed on selected patients without severe inflammation or abdominal adhesion, by experienced hands and with surgeons on standby. Innovations in endoscopic instruments will likely yield better outcomes.
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05 June 2020 (online)
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