Laparoscopic-assisted transgastric cholecystectomy and secure endoscopic closure of the transgastric defect in a survival porcine model

Background and study aims: Natural orifice transluminal endoscopic surgery holds promise for surgical interventions. Before the feasibility of this technique can be established, however, secure sealing of the transluminal access needs to be thoroughly investigated. Patients and methods: Following antibiotic prophylaxis and gastric disinfection, nine pigs underwent transgastric cholecystectomy by means of a flexible endoscope with the aid of a transabdominal 5-mm trocar. The gastric wall was punctured and dilated. The gallbladder was retracted with a laparoscopic grasper. The cystic duct and artery were dissected with a flexible monopolar ball electrode. The cystic duct was interrupted with flexible scissors between endoclips. Cholecystectomy was completed and the gallbladder was retrieved through the stomach. The gastric defect was closed using a single modified over-the-scope clip (OTSC) (Ovesco, Tubingen, Germany) and grasping the serosal and muscle layer of the gastric wall. The animals were sacrificed 4 weeks later. Results: Laparoscopic-assisted transgastric cholecystectomy was successful in all cases without significant perioperative complications. All animals survived without postoperative complications. The mean operating time was 128 minutes (range, 85 - 205 minutes). The gastric defect closure resulted in inversion of the gastric wall layers within an average time of 6.8 +/- 5 minutes. At 4 weeks postoperative, only minimal thin adhesions were observed in the right hypochondrium. Conclusions: We found gastric closure using the OTSC to be a reliable tool for closing the transgastric access. Laparoscopic-assisted transgastric cholecystectomy by means of a flexible endoscope was technically feasible, but remains a demanding procedure.