Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Osaka, Japan.
Surg Endosc. 2010 Oct;24(10):2624-5. doi: 10.1007/s00464-010-0992-3. Epub 2010 Mar 31.
Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument. Therefore, "pure NOTES" transgastric cholecystectomy has not yet been described. The authors successfully performed "pure NOTES" transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure) that allows completion of the procedure by pure NOTES without an external instrument.
With the subject under general anesthesia, a double-channel gastroscope (Storz®, Tuttlingen, Germany) passed by mouth entered the peritoneum through the distal anterior gastric wall. The most ideal site for a second gastric exit was then selected for another single-channel scope. With the gallbladder retracted by the assistant operating the double-channel scope, retrograde cholecystectomy was performed by the primary surgeon using the single-channel scope. Four animals were killed immediately to study the quality of the operative dissection, whereas the other four pigs were kept alive. The gastrotomy was closed using a 27- to 30-mm cardiac septal occluder (Occlutech®, GmbH, Jena, Germany) according to a previously described method. The postoperative follow-up assessment of these animals included laparoscopy and necropsy 2 weeks later.
All the cholecystectomies were immediately successful without any intraoperative complication. Scope withdrawal caused no injuries to the esophagus or pharynx. Although no overt postoperative complication was evident, two surviving pigs had signs of minor peritoneal infection.
This study investigated "pure NOTES" transgastric cholecystectomy using tentative experimentation to overcome the "retraction" and "triangulation" issues and to realize a "pure NOTES" operation. The use of two endoscopes with selected differentiation of their gastric placements compensated for the lack of triangulation and retraction.
多个工作组已经证明了使用柔性内窥镜进行经胃手术的可行性。然而，自然腔道内镜外科手术（NOTES）的技术限制（例如，暴露、牵引、充气和三角化）目前仍然需要至少使用一种外部器械。因此，尚未描述“纯 NOTES”经胃胆囊切除术。作者成功地使用经口双镜技术（类似于作者之前报道的胃闭合方法）进行了“纯 NOTES”经胃胆囊切除术，该技术允许通过纯 NOTES 完成手术，而无需外部器械。
在全身麻醉下，经口进入的双通道胃镜（STORZ®，德国图特林根）通过远端前胃壁进入腹膜。然后选择第二个单通道镜的最佳胃出口位置。在助手操作双通道镜将胆囊牵引的同时，主刀医生使用单通道镜进行逆行胆囊切除术。立即处死 4 只动物以研究手术解剖质量，而另外 4 只猪则存活。根据之前描述的方法，使用 27 至 30 毫米的心脏间隔堵塞器（Occlutech®，GmbH，耶拿，德国）关闭胃切开术。这些动物的术后随访评估包括 2 周后的腹腔镜检查和尸检。
所有胆囊切除术均立即成功，无任何术中并发症。镜体退出不会导致食管或咽部损伤。尽管没有明显的术后并发症，但 2 只存活的猪出现了轻微腹膜感染的迹象。
本研究使用试探性实验调查了“纯 NOTES”经胃胆囊切除术，以克服“牵引”和“三角化”问题并实现“纯 NOTES”手术。使用具有胃放置选择差异的两个内窥镜补偿了缺乏三角化和牵引的问题。
