Transvesical peritoneoscopy with rigid scope: feasibility study in human male cadaver

Abstract

Transvesical port refers to the method of accessing the abdominal cavity through a natural orifice (i.e., urethra) under endoscopic visualization. Since its introduction in 2006, various reports have been published describing different surgical interventions using a rigid ureteroscope in a porcine model. The aim of this study was to test the access and feasibility of peritoneoscopy by using a rigid ureteroscope in a human male cadaver. Background Transvesical port refers to the method of accessing the abdominal cavity through a natural orifice (i.e., urethra) under endoscopic visualization. Since its introduction in 2006, various reports have been published describing different surgical interventions using a rigid ureteroscope in a porcine model. The aim of this study was to test the access and feasibility of peritoneoscopy by using a rigid ureteroscope in a human male cadaver.

Methods Two adult male cadavers were used to perform the procedures. A rigid ureteroscope was used for the creation of transvesical access into the peritoneal cavity. Peritoneoscopy, liver biopsy, and identification and manipulation of the ileocecal appendix were performed.

Results Transvesical access into the peritoneal cavity was quickly established. The rigid ureteroscope easily allowed visualization of the abdominal cavity with good image quality. Liver biopsy and manipulation of ileocecal appendix were carried out without difficulties.

Conclusions Peritoneoscopy, liver biopsy, and ileocecal appendix manipulation using a rigid ureteroscope through a transvesical port is feasible in a cadaver model. The development of a specific rigid scope for the transvesical port might herald a promising future for this NOTES access.

The craving for the discovery of new, minimally invasive surgical procedures allowed a new surgery concept to emerge: natural orifice transluminal endoscopic surgery (NOTES). The main challenge of this new concept is the execution of numerous surgical procedures through natural orifices, with the consequent advantages that may result, such as cosmetic benefits due to the absence of a surgical incision. The absence of a surgical incision also means less risk of wound infection and potentially less pain. In 2004, Kalloo et al. [1] described access to the peritoneal cavity through the transgastric port in a porcine model. Since then, several studies have been performed using transgastric access [2–6]. However, many limitations were described, particularly when singly performed by transgastric port.

In 2006, Lima et al. [7] described the transvesical port going beyond the wall of bladder for access to the peritoneal cavity in a porcine model. Soon it became apparent that this access was not only a major shift in how the bladder was seen, but also a safe and fast means of access to the peritoneal cavity, with an excellent view of all the upper peritoneal structures [7]. This same group of researchers also described the execution of complex surgical procedures, including nephrectomy [8] and cholecystectomy [9, 10], which were carried out by an approach combining the transvesical port with the transgastric port. In both surgical procedures, the transvesical port represented not only a working port through which many instruments are used, but also a way of support and guidance in choosing the site of entry into the peritoneal cavity via the transgastric port [9, 10]. The transvesical port, although at the lower end of the abdomen, also allowed the execution of thoracic procedures in the porcine model [11].

Some critics question the feasibility and reproducibility of these procedures in the human being, particularly regarding the use of rigid instruments. The distance from the bladder to other organs in the abdominal cavity is larger than in the animal model, which could limit the imaging and manipulation of the organs of the upper abdominal cavity. Another questioned aspect is the possibility of obtaining images of the upper abdomen using rigid instruments without angulation, which might preclude the use of the scopes currently on the market in the transvesical approach in humans. Therefore, transvesical access to the peritoneal cavity might be a reality not only in the animal model, but also in the human model in the near future, especially if it is possible to use rigid instruments in this procedure.

The aim of this study was to describe and test the feasibility of NOTES procedures performed in a human male cadaver, with access to the abdominal cavity made through the transvesical port and by using rigid instruments.