Endoscopic transgastric pure NOTES cholecystectomy with naso-gallbladder drainage tube placement and injection of a hyaluronic acid mixture (with Video)
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Endoscopic transgastric pure natural orifice translumenal endoscopic surgery (NOTES) cholecystectomy is a difficult procedure, and most human female cases are performed as hybrid NOTES, using a transvaginal route. We tried a transgastric pure NOTES procedure without laparoscopic procedure in an animal study after placing an endoscopic naso-gallbladder drainage (ENGBD) tube and injecting a hyaluronic acid (HA) mixture.
We performed the method in four pigs, using a standard single-channel endoscope. The ENGBD tube was placed first and the HA mixture was injected between the gallbladder (GB) serosa and liver bed.
We determined the gastrotomy site using an ENGBD tube, which made the GB approach easy under fluoroscopic guidance. The scope was not retroflexed, but was rotated at the stomach fornix. The connecting tissues between the GB serosa and liver bed expanded following the injection of the HA mixture, facilitating GB removal with a Hook knife. The GB wall, liver, and vessels were observed clearly during the procedure, and there were no incorrect cuts.
We successfully performed a transgastric pure NOTES cholecystectomy in pigs. An ENGBD tube was useful as a guide to the GB, and for recognizing the cystic duct, and injecting the HA mixture facilitated the GB dissection.
KeywordsEndoscopic naso-gallbladder drainage (ENGBD) Natural orifice translumenal endoscopic surgery (NOTES) Cholecystectomy Hyaluronic acid Transgastric surgery
Endoscopic naso-gallbladder drainage
Endoscopic submucosal dissection
Natural orifice translumenal endoscopic surgery
We appreciate the materials supplied by Zeon Medical Inc. and the help provided by Mr. Kouta Inoue, Mr. Chimyon Gon, Mr. Yoshihide Toyokawa, and Mr. Nobukazu Nishimura in preparing the animals. We are also grateful to Dr. Yousuke Nakai, Dr. Takashi Sasaki, and Dr. Takeshi Tsujino of Tokyo University Hospital for assistance with the endoscopic procedures.
Supplementary Video. The video shows the endoscopic transgastric pure NOTES cholecystectomy technique using a previously placed naso-gallbladder drainage tube and endoscopic submucosal dissection technique after injecting a mixture of hyaluronic acid, indigo carmine, and epinephrine between the gallbladder serosa and liver bed. (MPG 47296 kb)
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