Completely Transvaginal NOTES Cholecystectomy in a Porcine Model Using Novel Endoscopic Instrumentation

Introduction: Transvaginal NOTES Cholecystectomy has been successfully performed but all reports have required laparoscopic assistance. The purpose of this study was to perform completely transvaginal cholecystectomy in a porcine model.
Methods: Pigs 1-5 underwent non-survival and Pigs 6-8 underwent 14-day survival procedures. Through a vaginotomy, a 2T gastroscope and an 18mm x 38cm access port were inserted into the peritoneal cavity using a Veress needle-balloon system, a rigid optical obturator, or blunt dissection. A long 5mm rigid grasper inserted transvaginally was used for tissue manipulation. Percutaneous or endoscopic T-tags were used to fixate the gallbladder fundus to the peritoneum for retraction. Dissection was performed using prototype and conventional endoscopic instruments including a straight or articulating hook cautery, snare, maryland dissector, clip applier, grasper, scissors and injection needle. Values are mean ± s.d.
Results: Operative time was 207 ± 43 minutes, blood loss was 90 ± 136 cc, and bile spillage was minimal. Procedures were terminated in Pig 1 due to liver bleeding and in Pig 5 due to endoscope malfunction. Six procedures (3 non-survival, 3 survival) were completed, with only partial cholecystectomy achieved in Pig 2 but complete cholecystectomies achieved in Pigs 3-4 and 6-8. Percutaneous T-tags were used only in Pig 1; in Pigs 2-8, endoscopic T-tag suturing required substantial operative time for placement (20-80 min) but provided uniformly successful retraction. The articulating endoscopic hook and snare, as well as the non-articulating maryland dissector, proved most useful for dissection. The long transvaginal grasper (Pigs 2-8) and creation of a saline lift (Pigs 3-8) greatly facilitated infundibulum manipulation and dissection, respectively. A second generation endoscopic clip applier with tightly approximating clips (Pigs 6-8) improved artery and duct occlusion. At autopsy, Pigs 1, 4 & 5 had liver and/or cystic artery bleeding; in all other animals there were no complications and all survival animals thrived post-operatively.
Discussion: Transvaginal cholecystectomy without laparoscopic assistances is feasible in a porcine model by combining gallbladder suture retraction, a transvaginal rigid grasper, and novel endoscopic instrumentation. Further improvements in these technologies and operative strategies are expected to improve reproducibility and efficiency.

Session: Poster

Program Number: P273

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