Katagiri Toshio, Otsuka Yuichiro, Horgan Santiago, Sandler Bryan J, Jacobsen Garth R, Coker Alisa M, Tsuchiya Masaru, Maeda Tetsuya, Kaneko Hironori
*Department of Surgery, Division of General and Gastroenterological Surgery, Toho University School of Medicine, Omori, Tokyo, Japan †Department of Surgery, Division of Minimally Invasive Surgery, University of California, San Diego, CA.
Surg Laparosc Endosc Percutan Tech. 2017 Feb;27(1):e6-e11. doi: 10.1097/SLE.0000000000000367.
Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR).
Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures.
Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver.
Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.
经自然腔道内镜手术（NOTES）是一种具有挑战性的微创手术。尽管腹腔镜肝切除技术在全球范围内逐渐被接受，但很少有研究调查NOTES肝切除。我们使用猪模型评估经阴道NOTES肝切除（TV NOTES LR）的可行性和安全性。
9只雌性猪接受了TV NOTES LR。所有病例均采用非存活急性猪模型并进行全身麻醉。使用混合NOTES技术，我们仅在腹壁放置1个12毫米的脐部套管针，用于建立气腹。然后插入腹腔镜以获得腹腔内视野。在腹腔镜直视下插入一个15毫米的阴道套管针，并通过阴道套管针引入一个柔性内窥镜。使用一个长的柔性抓钳和腔内牵开器稳定地牵拉肝脏。通过脐部套管针插入能量装置部分横断肝边缘。为了横断左外叶，在阴道套管针旁边插入一个柔性线性吻合器。展开一个标本提取袋并经阴道取出。评估失血量、胆漏、手术时间和标本大小。术后进行尸检研究。
在9只猪上成功进行了18例经阴道NOTES部分肝切除和4例经阴道NOTES左外叶切除。平均手术时间为165.8分钟，平均估计失血量为76.6毫升。所有TV NOTES LR均无并发症或死亡。尸检显示残余肝脏无胆漏。
我们的猪模型表明，TV NOTES LR在技术上是可行和安全的，并且有可能作为传统腹腔镜肝切除的微创替代方法用于临床。
