Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments

Daniel J Scott, Shou Jiang Tang, Raul Fernandez, Richard Bergs, Mouza T. Goova, Ilia Zeltser, Farid J. Kehdy, Jeffrey A Cadeddu

Research output: Contribution to journalArticlepeer-review

169 Scopus citations

Abstract

Introduction: Natural orifice translumenal endoscopic surgery (NOTES) is an evolving field and suitable instruments are lacking. The purpose of this study was to perform transvaginal cholecystectomies using instruments incorporated into a magnetic anchoring and guidance system (MAGS). Methods: Non-survival procedures were conducted in pigs (n = 4). Through a vaginotomy created under direct vision, a rigid access port was inserted into the peritoneal cavity and used to maintain a CO2 pneumoperitoneum. MAGS instruments were deployed through the port and held in place on the peritoneal surface using magnetic coupling via an external handheld magnet which was optionally exchanged for an 18ga percutaneous threaded needle anchor; instruments included a tissue retractor (a clip-fixated magnet or flexible graspers) and a cautery dissector. A gastroscope was used for visualization. Results: The first two procedures ended prematurely due to instrumentation shortcomings and inadvertent magnetic coupling between instruments; one case required a laparoscopic rescue. Three new forms of instrumentation were developed: (1) a longer access port (50 cm) which provided easier deployment of instruments and suitable reach, (2) a more robust cauterizer with a longer, more rigid, pneumatically deployed tip with better reach and sufficient torque to allow blunt dissection, and (3) a more versatile tissue retractor with bidirectional dual flexible graspers which provided excellent cephalad fundus retraction and inferiolateral infundibulum retraction. With these modifications, 100% of the cholecystectomy was completed in the third and fourth animals using only a NOTES/MAGS approach. Retrieval of the tissue retractor resulted in a rectal injury in the third animal but further procedural modifications resulted in a successful procedure in the fourth animal with no complications. Conclusions: While still under development with more refinements needed, completely transvaginal cholecystectomy using MAGS instruments is feasible. By offering triangulation and rigidity, MAGS may facilitate a NOTES approach while alleviating shortcomings of a flexible platform.

Original languageEnglish (US)
Pages (from-to)2308-2316
Number of pages9
JournalSurgical Endoscopy and Other Interventional Techniques
Volume21
Issue number12
DOIs
StatePublished - Dec 1 2007

Keywords

  • Cholecystectomy
  • Endoscopy
  • MAGS
  • Magnetic instrumentation
  • NOTES
  • Natural orifice translumenal endoscopic surgery
  • Transvaginal surgery

ASJC Scopus subject areas

  • Surgery

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