Novel Endoscope Fixation for Natural Orifice Transgastric Cholecystectomy

Introduction: Transgastric, scar-free cholecystectomy is an electrifying prospect. Unfortunately, multiple barriers have hampered early investigation into this technique. Some of the principle obstacles encounered are; a gastroscope which is too flexible for adequate dissection, a surgical site that is located at almost 180° from the direction of scope insertion requiring retro-flexion and significant scope looping, and a need for superolateral gall bladder (GB) retraction which is opposite to the vector of dissection.
We describe our method of using a suture to act as a GB retractor and a guide for the endoscope. The suture not only acts to triangulate and maintain the scope in the area of interest but also acts as a baffle to allow strong retraction and dissection.
Methods: Using a swine model, a gastrotomy was performed with a needle knife over a guidewire. A standard flexible endoscope was then introduced intraperitonealy and retroflexed. Under direct vision a 2mm Maryland dissector was introduced into the abdominal cavity via a stab incision. A straight needle was introduced into the abdominal cavity and using the 2mm instrument the stitch was grasped, taken through and through the GB fundus and then back through the posterior fascia of the abdominal wall. The suture was then grasped using an endoscopic grasper and brought out through the scope’s working channel. As the suture is tightened at the working channel, the scope is simultaneously drawn towards the GB and the fundus retracted. Using a combination of the 2mm dissector and a needle knife cautery the GB was resected from the GB fossa and removed via the mouth.
Results: This novel method of anchoring the flexible endoscope allowed its use a stable platform from which to retract , dissect, and cauterize. In addition, using this fixation method allowed for significant reduction in operative time that compared favorably to standard laparoscopic cholecystectomy.
Conclusions: Using a suture for endoscope fixation as we have described, is a simple and cheap solution to many of the impediments encountered in performing transgastric GB surgery.

Session: Poster

Program Number: P190

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