Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope

BackgroundTransgastric cholecystectomy is thought to technically and anatomically challenge a single entry flexible endoscopic approach.ObjectivesTo examine the feasibility of a transgastric-only cholecystectomy, endoscope performance in an upper-abdominal operation, and the usefulness of an offset gastrotomy.Study DesignAnimal survival study.SettingAnimal research laboratory.PatientsSix domestic pigs.Main Outcome MeasurementsTransgastric access to the gallbladder and technical feasibility of unassisted transgastric cholecystectomy.InterventionsA cephalad submucosal tunnel was created in the anterior gastric wall with a high-pressure CO2 injection. An EMR-cap myotomy was performed distally within the submucosal space and created an offset gastrotomy. An endoscope was inserted into the peritoneal cavity through the myotomy. Access to the gallbladder was compared by using a multibending therapeutic endoscope (R-scope), with a standard double-channel endoscope. A cholecystectomy was performed by using both types of endoscopes. The myotomy site was sealed with the overlying mucosal flap. The mucosal entry point was closed with clips or tissue anchors.ResultsA standard double-channel endoscope could access the gallbladder in 2 of 4 attempts. A multibending endoscope accessed the gallbladder in all 4 attempts, including 2 pigs in which the standard scope failed to access the gallbladder. In 4 pigs, a cholecystectomy was completed. Two pigs died during surgery, with air embolization observed in 1. Two pigs survived a planned 1-week survival period.ConclusionsTransgastric cholecystectomy is technically feasible. Transgastric access to the gallbladder may be improved by using submucosal endoscopy with an offset exit gastrotomy by means of the mucosal flap safety-valve technique and a multibending gastroscope.