Transvaginal laparoscopically assisted endoscopic cholecystectomy: report of 3 cases

Brief Reports

signs of inflammation.1 The diagnosis of ischemic biliary stricture after TACE is usually based on clinical and radiologic findings in concert. However, in patients with known malignancy, it is difficult to differentiate the diagnosis from other causes, such as bile duct involvement of HCC. In contrast to ERCP and other radiologic studies, excellent visualization of the bile duct lesion was achieved by PTCS even in difficult anatomical situations.4 In addition, endoscopically targeted biopsy of the stenotic lesion is feasible so that it is possible to determine whether the stricture is benign or malignant. In Japan and in Western studies, sensitivity rates of 76% to 82% have been reported.5-7 PTCS is a relatively safe and well-tolerated method. In addition, it is used to dilate biliary stricture by cholangioscopic balloon dilation. Therefore, PTCS provides advantages over ERCP or other radiologic studies in the diagnosis and treatment of biliary stricture, especially when the differential diagnosis is not easy.8 In summary, when clinical symptoms or signs of progressive obstructive jaundice occur among patients with HCC previously treated by TACE, although no evidence of disease progression is shown, ischemic stricture of the bile duct must be suspected. PTCS might be considered as another modality for the diagnosis and treatment of ischemic biliary stricture when it is difficult to distinguish clinically from biliary involvement of HCC.

DISCLOSURE The authors report that there are no disclosures relevant to this publication. This study was supported by the Inha University Research Grant.

Abbreviations: TACE, transcatheter arterial chemoembolization; PTCS, percutaneous transhepatic cholangioscopy; HCC, hepatocellular carcinoma; PTBD, percutaneous transhepatic biliary drainage.

REFERENCES 1. Kim HK, Chung YH, Song BC, et al. Ischemic bile duct injury as a serious complication after transarterial chemoembolization in patients with hepatocellular carcinoma. J Clin Gastroenterol 2001;32:423-7. 2. Northover JM, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 1979;66:379-84. 3. Sandrasegaran K, Alazmi WM, Tann M, et al. Chemotherapy-induced sclerosing cholangitis. Clin Radiol 2006;61:670-8. 4. Shim CS, Neuhaus H, Tamada K. Direct cholangioscopy. Endoscopy 2003;35:752-8. 5. Neuhaus H, Hoffmann W, Classen M. The benefits and risks of percutaneous transhepatic cholangioscopy. Dtsch Med Wochenschr 1993;118: 574-81. 6. Maier M, Kohler B, Benz C, et al. Percutaneous transhepatic cholangioscopy (PTCS)dan important supplement in diagnosis and therapy of biliary tract diseases (indications, technique and results). Z Gastroenterol 1995;33:435-9. 7. Nimura Y, Kamiya J. Cholangioscopy. Endoscopy 1998;30:182-8. 8. Oh HC, Lee SK, Lee TY, et al. Analysis of percutaneous transhepatic cholangioscopy-related complications and the risk factors for those complications. Endoscopy 2007;39:731-6.

Division of Gastroenterology, Department of Internal Medicine (B.W.B., D.H.L., S.J., J. L., J-W.L., K.S.K., H.G.K., Y.W.S., Y.S.K.), Center for Advanced Medical Education by Brain Korea 21 project (D.H.L.), Department of Pathology (J.M.K.), Department of Radiology (Y.S.J.), Inha University College of Medicine, Incheon, South Korea. Reprint requests: Seok Jeong, MD, Division of Gastroenterology, Department of Internal Medicine, Inha University Hospital, 7-206, 3-Ga, Sinheung-Dong, Jung-Gu, Incheon, 400-711, South Korea. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.03.004

Transvaginal laparoscopically assisted endoscopic cholecystectomy: report of 3 cases Paolo Rossi, MD, Walter Bugiantella, MD, Luigina Graziosi, MD, Emanuel Cavazzoni, MD, Annibale Donini, MD Perugia, Italy

Natural orifice transluminal endoscopic surgery (NOTES) is a growing new surgical technique that allows minimally invasive access to the peritoneal cavity for the diagnosis and treatment of abdominal pathologies, while avoiding abdominal-wall incisions and the related complications. Since 2004, NOTES procedures, such as peritoneoscopy,1 biopsies,2 tubal ligations,3 cholecystectomy,4,5 and

gastrojejunal anastomosis,6,7 have been successfully explored in the pig model. In March 2007, Bessler et al8 successfully performed the first human transvaginal laparoscopically assisted endoscopic cholecystectomy, and, in April 2007, Marescaux et al9 demonstrated the first completely transvaginal cholecystectomy. Herein we will report our preliminary experience with NOTES.

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Brief Reports

Figure 1. The endoscope enters the peritoneal cavity under laparoscopic vision.

lecystectomy, the specimen was retrieved by using a 10-mm retrieval bag through the vagina. All the principles of laparoscopic cholecystectomy were strictly observed. The colpotomy was closed with interrupted 2/0 absorbable stitches. Transvaginal laparoscopically assisted endoscopic cholecystectomies were successfully performed in all patients, without intraoperative complications. Endoscopic vision allows an excellent orientation of the operative field. The mean operative time in our experience was 97 minutes (range 91-115 minutes). The introduction of laparoscopic instruments through the 5-mm trocar was useful in helping to assist the endoscopic devices with dissection and closure of Calot’s triangle structures, providing shorter operative times. During the operation, the pneumoperitoneum pressure was kept at approximately 7 to 8 mm Hg to ensure optimal endoscopic vision and operability, while minimizing peritoneum stretching. Gas leakage was limited by the use of wet gauze placed in the posterior vaginal fornix. All patients were discharged, in good clinical conditions, on the second postoperative day. There were no early or late morbidities.

DISCUSSION

Figure 2. The gallbladder is suspended through the abdominal wall.

CASE REPORT During May 2007, we performed transvaginal laparoscopically assisted endoscopic cholecystectomy in selected cases. Three patients, ages 39, 55, and 70 years, who presented with symptomatic gallbladder stones, were offered the option of transvaginal laparoscopically assisted endoscopic cholecystectomy. The possible aesthetic advantage, without increasing the risk of complications, was presented, and this technique was widely accepted by all of them. We ensured the absence of unknown pelvic anomalies by gynecological assessment and transvaginal US (TVUS). A pneumoperitoneum was induced with a Veress needle placed in the right hypochondrium, followed by the introduction of a 5-mm trocar in the left flank. Under laparoscopic optical control, we made a linear incision in the posterior vaginal cul-de-sac and entered the peritoneal cavity with a standard sterile operative endoscope (Olympus Optical Co, Ltd, Tokyo, Japan) (Fig. 1). The cystic duct and artery were ensured by 5-mm laparoscopic clips. In 2 patients, we retracted the fundus of the gallbladder by passing a 1-0 suture through the abdominal wall to obtain better exposure of Calot’s triangle (Fig. 2). After a chowww.giejournal.org

Transvaginal access to the peritoneal cavity is a well established and safe procedure used by gynecologists for fertiloscopy.10 Our preliminary experience demonstrates the technical feasibility and safety of the transvaginal access for laparoscopic-assisted cholecystectomy; once pelvic anomalies or diseases are excluded by objective assessment (TVUS, magnetic resonance imaging, or CT). The procedure is well tolerated by patients (probably because of a single minimal abdominal-wall scar and less intraoperative peritoneal stretching) and allows for reduced recovery times, with improved cosmetic outcomes. Dedicated NOTES platforms and devices are needed to achieve completely ‘‘no-scar’’ procedures, which provide for safe creation and closure of the viscerotomy11 (ie, gastrotomy) and increasing the ease of intra-abdominal organ manipulation.12 So the transvaginal approach is the safer access for NOTES to date because of the easiness in performing and closing the colpotomy. Until the availability of dedicated NOTES instruments, we believe the best technique is the hybrid, because it ensures control of the endoscope entry into the peritoneal cavity, which allows a safer and faster procedure. Through technical improvements and clinical trials, NOTES will soon be the future of minimally invasive surgery.

DISCLOSURE The authors report that there are no disclosures relevant to this publication. Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1227

Brief Reports

Abbreviations: NOTES, natural orifice transluminal endoscopic surgery; TVUS, transvaginal US.

REFERENCES 1. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004;60:114-7. 2. Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model. Clin Gastroenterol Hepatol 2005;3:892-6. 3. Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 2005;61:449-53. 4. Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 2005;61:601-6. 5. Pai RD, Fong DG, Bundga ME, et al. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 2006;64:428-34. 6. Bergstrom M, Ikeda K, Swain P, et al. Transgastric anastomosis by using flexible endoscopy in a porcine model. Gastrointest Endosc 2006; 62:307-12. 7. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 2005;62:287-92.

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8. Bessler M, Stevens PD, Milone L, et al. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 2007;66:1243-5. 9. Marescaux J, Dallemagne B, Perretta S, et al. Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 2007;142:823-6. 10. Shibahara H, Shimada K, Kikuchi K, et al. Major complications and outcome of diagnostic and operative transvaginal hydrolaparoscopy. J Obstet Gynaecol Res 2007;33:705-9. 11. Swain P. Endoscopic suturing: now and incoming. Gastrointest Endosc Clin N Am 2007;17:505-20. 12. Swanstrom LL, Whiteford M, Khajanchee Y. Developing essential tools to enable transgastric surgery. Surg Endosc 2008;22:600-4.

Received November 27, 2007. Accepted March 8, 2008. Current affiliations: Department of General and Emergency Surgery, University of Perugia, ‘‘Santa Maria della Misericordia’’ Hospital, Perugia, Italy. Reprint requests: Paolo Rossi, MD, Via Ruggero D’Andreotto 16, 06100 Perugia, Italy. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.03.1060

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