Searching the best approach for third-generation cholecystectomy

Abstract

[Excerpt] We carefully read the study from Pai el al1 that demonstrates the technical feasibility of transcolonic cholecystectomy. Recently, we also investigated an endoscopic approach to perform scarless cholecystectomy through a transgastric and transvesical combined approach.[2] In our study, we also confirmed that an abdominal inferior port provides an en face orientation to the upper abdominal organs and allows better visualization and the ability to work straightforwardly. However, for these purposes, we used a transvesical instead of a transcolonic port. In fact, the transvesical access to the peritoneal cavity was feasible, easy to install, and safe in a survival porcine model study. Moreover, it should be emphasized that we did not experience any complications, such as adhesions or peritonitis, even when we left the vesicotomy point unclosed.[3] However, previous studies that tried to perform cholecystectomy by natural orifice transluminal endoscopic surgery (NOTES) performed it by using a single port, either transgastric or transcolonic.[1,4,5] These approaches share common limitations, such as difficulties in performing effective retraction and dissection with triangulation. In fact, we should not forget that cholecystectomy is a moderately complex procedure, usually needing 4 to 5 trocars in the laparoscopic technique. To deal with these limitations, we combined 2 diametrically opposed ports (transgastric and transvesical), which was particularly useful.[2] [...]