Transgastric and Transvaginal Endoscopic Cholecystectomy in Human Beings

TRANSGASTRIC AND TRANSVAGINAL ENDOSCOPIC CHOLECYSTECTOMY IN HUMAN BEINGS

Gustavo Salinas MD, Lil Saavedra MD, Hellen Agurto MD, * Jeffrey M. Marks MD, Edwin Ramírez MD, José Grande MD, Juan Tamayo MD, Victoria Sánchez MD.

Minimally Invasive Surgery. Avendaño Clinic, Lima, Peru, * University Hospitals Case Medical Center

INTRODUCTION: The abdominal procedures have been performed for a long time through the anterior abdominal wall. Since the first reports in the 80’s, laparoscopy has become the standard for cholecystectomy with many advantages over open procedures. Now a natural orifice approach to the peritoneal cavity may further reduce the invasiveness of surgery, either by diminishing or avoiding abdominal incisions. Several orifice routes to the abdominal cavity have been described: transgastric, transvaginal, transvesical and transcolonic. Although most experiences in a porcine model showed the possibility of these approaches, few surgeons reported experiences with humans. The authors present their experience with transgastric (TG) and transvaginal (TV) cholecystectomies in human beings.
METHODS AND PROCEDURES: Twenty seven patients (1 male and 26 females) underwent hybrid NOTES procedures from January 2007 to September 2008. The mean age was 47 yr (20-83). The BMI ranged 21-41 and ASA I-II. Transgastric cholecystectomy was performed in 15 patients and 12 patients had a transvaginal cholecystectomy.
RESULTS: The mean operative time was 139 min. Although operative times were slightly shorter in the TG group, 132 min ± 35.7 (75-190) when compared to the TV route, 147 min ± 31.5 (95-220), there were not significant differences between the two groups (p=0.3, Mann Whitney U test). This may be not real because in TV procedures we did more endoscopic steps and in TG procedures were more laparoscopic because TG is challenging. Patients were started on liquids within an hour and discharged two hours later. An overall 25 % morbidity rate and no mortality were found. The complication rates for the TG and TV groups were 26 % (4/15) and 25 % (3/12) respectively, which was not statistically significant (p=0.5, chi-square test). Sixty six percent of complications occurred the first year and 33 % the 2nd year of our experience. These complications were: biliary leakage, hematoma of greater curvature, abdominal sepsis, colon injury secondary to the vaginal closure, wound infection (2) and laceration of the esophageal mucosa. The hematoma required conversion to open procedure, the colon injury was repaired laparoscopically while the biliary leakage and abdominal sepsis were managed both by relaparoscopy after readmissions. The intraperitoneal fluid in the septic patient was cultured and Streptococcus faecalis was found. Three patients (11 %) were readmitted for biliary leakage, abdominal sepsis and pain management.
CONCLUSIONS: Transgastric and transvaginal cholecystectomies are feasible. Although these NOTES procedures were laparoscopically-assisted and current flexible endoscopes were used, it seems possible that major intraabdominal surgeries may one day be performed without skin incisions, but a learning curve is mandatory. These trends toward incisionless surgery demands coordinated research in an interdisciplinary setting, involving both surgeons and device manufacturers.


Session: Podium Presentation

Program Number: S071

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