Natural orifice access: Next wave in endoscopic surgery

A third-generation intra-abdominal surgery technique in which endoscopic access is gained through natural orifices using a combined transgastric and transvesical approach has been shown feasible in the hands of Portuguese surgeons.

Speaking at the 2007 AUA annual meeting on behalf of colleagues from the University of Minho in Braga, Portugal, Estêvão A. Lima, MD, FEBU, described success using the natural orifice transluminal endoscopic surgery (NOTES) approach to perform cholecystectomy and nephrectomy in animal models. For both procedures, operative time was less than 2 hours and complications were minimal.







Gall bladder removal

The cholecystectomy procedure was performed in seven female pigs under general anesthesia. Transvesical access was achieved under cystoscopic control. Once the ureteroscope was introduced into the bladder, the bladder was emptied and instilled with saline. The vesicotomy was made on the ventral bladder wall with scissors, and a 5F open-end ureteral catheter was advanced through the incision into the peritoneal cavity. A 0.035-inch guidewire and the dilator of a ureteroscope sheath were used to place a transvesical 5-mm overtube into the peritoneal cavity to create a pressure-controlled CO2 pneumoperitoneum.

Transgastric access with a gastroscope was achieved using guidance provided through the transvesical port. After the stomach was lavaged and filled for 10 minutes with an antibiotic solution, the gastric wall was perforated using a needle knife and was dilated with an 18-mm balloon.

"The ureteroscope provided a perfect view of the upper abdominal organs in these animals that was very helpful in guiding the gastrotomy step," Dr. Lima said.

With intra-abdominal access achieved through both ports, the gallbladder was identified and the cystic duct and artery exposed and manipulated with rigid instrumentation. Dissection was performed with gastroscope guidance and was enhanced through transvesical gallbladder grasping.

"We use a special gastroscope with two working channels that provides a superb image, similar to that of a laparoscope, and the transvesical port allows us to introduce 5-mm rigid instruments that facilitate the surgical manipulations and dissection," Dr. Lima said.