Animal Experiment And Primarily Clinical Application Of Transgastric And Transvaginal Endoscopic Cholecystectomy

BackgroundAs the development of minimally invasive surgery, "no scar" has become the common goal of surgeons and patients, therefore natural orifice transluminal endoscopic surgery (NOTES) has been put forward. NOTES is an endoscopic technique to provide access to the abdominal cavity through the gastric (TG), vaginal (TV), colorectal, vesical or other natural orifices and perform mini-invasive operation in peritoneal cavity. In 1998, Kalloo in the Johns Hopkins University put forward this definition, and published a report about TG endoscopic abdominal exploration animal experiment in 2004, which gained widespread interest. From then on, NOTES developed quickly. After accumulation of animal experiments experience, nowadays, NOTES has been primarily applied in clinic.The advantage of NOTES is remarkable. This procedure avoids incisions on the abdominal wall, its cosmetic result is superior than classic laparoscopy, transumbilical single port surgery and other mini-invasive operations, the abdominal wall of the latter remains incisions. NOTES is a really scarless operation without risk of abdominal incision infection or hernia, it has superiority of less postoperative pain and more rapid recovery, but the enthusiasm associated with it has been tempered by its obvious shortcomings. Contamination of the peritoneum caused by endoscopic passage via the nonsterile natural orifice, intraoperative spillage and inadequate closure of the transmural incision, may cause intra-abdominal infection. The normal endoscope is designed for intra-gastrointestinal circumstance, and it is not suitable for intra-abdominal cavity. The pure endoscopic operation has problems, such as unstable view field, poor dynamism and rigidity, mutual interference and difficult manipulation. More experiments are needed for prevention of peritoneal infection and reliable incision closure.TV NOTES is the most common procedure reported, the TG route is less than it because of more complex manipulation, difficult closure of gastric wall and risk of peritoneal infection. TV route only can be used in female patients, the indication is relatively narrow. The prevention of abdominal infection should be insured so that TG NOTES can be generalized in clinic.The purpose of this study is investigating the feasibility of TG and TV cholecystectomy, designing a live porcine model which undergoes TG and TV endoscopic peritoneal exploration and transumbilical laparoscopic-assisted cholecystectomy in NOTES view, to investigate, on the premise of a safe and reliable closure, the appropriate antiseptic measures for the TG and TV cholecystectomy, and compare the abdominal infection rate of the TG and TV cholecystectomy when strictly antiseptic measures are applied. After accumulation of experience about animal experiments, TG cholecystectomy is primarily applied in clinic to provide evidence for its further clinical application.Part I Feasibility study of transgastric and transvaginal endoscopic cholecystectomyObjectiveExperiment animals (female porcine) were randomly divided into 2 groups to undergo TV or TG abdominal exploration and transumbilical laparoscopic-assisted cholecystectomy. The gastric incision was sutured with laparoscopic instruments, while vaginal incision was closed under direct view. The reliability of incision closure and feasibility of TG and TV cholecystectomy were investigated, so was the effective measure for gastric and vaginal disinfection, the pathogenic bacteria and sensitive antibiotics in this animal experiment.Methods(1) Preparation and grouping of experiment animal.Female domestic pigs were randomly divided into TG group (n=10) and TV group (n=10). After oral samples were taken, sterile gastric tube was inserted in TG group to maximally aspirate stomach contents.4000ml sterile stroke-physiological saline solutions were injected through the gastric tube, and recovered as samples per 500ml after agitation. Vagina was douched by 200ml Iodophor. Per 50ml Iodophor stayed in vagina for 5min and was washed by saline, the recovered fluid was sampled. All specimens were sent for bacterial identification of species, colony counts and drug sensitivity.(2) Surgical procedure Small incision was made at umbilicus, from which the Veress needle was inserted. The pneumoperitoneum was created, and laparoscope was inserted.In TG Group, gastroscope advanced through mouth, needle knife was used to make transgastric incision. The endoscope was sent into abdominal cavity for exploration and location of gallbladder. The laparoscope was removed and laparoscopic devices were inserted to excise gallbladder under the direct view of endoscope. The gallbladder was drawn with endoscope through mouth. Transgastric incision was closed with interrupted suture by laparoscopic instruments.TV Group:Transvaginal incision was created by Trocar, endoscope advanced into peritoneal cavity through vagina, the excision of gallbladder was similar with TG group. Gallbladder was taken out through vagina, and transvaginal incision was sutured under direct view.(3) Observation indexesThe surgery time of 2 groups was strictly recorded, the postoperative recovery, and the occurrence of postoperative complications were observed and recorded carefully, in order to assess the operation tolerance of the animals. At autopsy 2 weeks later, laparotomy and exploration of abdomen were performed to detect organ injury and healing of transgastric/transvaginal incision.Results(1) TG Group:Rate of operative success was 100% and no death occurred. Mean operative time was 97.6±17.8min, mean intraoperative blood loss was 62.3±15.2ml, and mean postoperative recovery time (defined to begin at the end of the operation and to end with the first defecation) was 23.5±3.6h. No swine died after operation.(2) TV Group:All operations were successfully performed. Mean operative time was 66.3±15.5min, mean hemorrhage during operation was 56.6±13.9ml, and the mean postoperative recovery time was 21.5±3.1h. The postoperative mortality was 0.(3) The operative time of TG group was longer than TV group (P<0.05). The difference of intraoperative blood loss and postoperative recovery was not statistically significant (P>0.05).(4) The postoperative body temperature of two pigs in TG group and one in TV group slightly rose, their appetites were poor. After use of broad-spectrum antibiotics, the symptoms improved, and no other complications occurred. The recovery of other animals were uneventful, their body weigh increased till the end of observation period (2 weeks after operation).(5) As the increase of gastric lavage volume, the bacterial load in stomach decreased till 3000ml. After 3000ml, the decrease was not significant.100ml Iodophor could significantly decrease the amount of bacteria in vagina, the difference of effect between more than 100ml Iodophor and 100ml Iodophor was not significant.(6) At autopsy, no organ injury was found in 2 groups, and all natural orifice incisions healed well.(7) According to the results of bacterial cultivation and drug sensitivity, the main pathogenic bacterium was Escherichia coli, Cefazolin and so on were effective antibiotics.Conclusions(1) TG and TV cholecystectomy is feasible. Closure of transgastric incision by laparoscopic interrupted suture and suture of vaginal incision under direct view are safe, reliable and effective.(2) The operation of TG NOTES is complex, and its operative time is longer than TV NOTES, which is relatively easy.(3) Association of laparoscopy can improve the safety of NOTES, and make up the insufficiency of normal endoscopic instruments.(4) 3000ml saline gastric lavage and 100ml Iodophor for vaginal douche can effectively reduce the bacterial load in natural orifice, saline more than 3000ml and Iodophor more than 100ml could not significantly further decrease the amount of microphyte. It is dicided that 3000ml saline and 100ml Iodophor will be used as antiseptic measures for experiment group in PartⅡ.(5) Escherichia coli is the main pathogenic category of bacteria, the sensitive antibiotics used perioperatively in next experiment--Cefazolin and Metronidazole were selected according to the result of drug sensitivity and clinical experience.(6) Because of magnanimous oral bacteria, sterilization of oral cavity and sterile overtube, which prevent endoscope from contact of mouth and esophagus, are necessary.Part II The comparative study of transgastric and transvaginal endoscopic cholecystectomy in prevention of peritoneal infectionObjectiveDifferent kinds of antiseptic measures were applied in TG and TV cholecystectomy, intraoperative situation and postoperative recovery in each group was observed, in order to investigate effective anti-infection procedures. On the premise of strictly antiseptic procedures, the comparisons of peritoneal infection rate of two operative procedures were made.Methods (1) Preparation and grouping of animalsTG group was divided into control group (group A), middle volume saline gastric lavage group (group B) and high volume saline gastric lavage group (group C). TV group included control group (group D) and experiment group (group E). There were 9 female pigs in each group. Swine began to take fluid diet 3d before operation, and were restrained from food (24 hours) and water (12 hours). Before operation, oral cavity of TG group was sterilized by Iodophor, gastric juice before and after gastric lavage (0ml saline in group A,500ml saline in group B and 3000ml in group C) was drained and sampled, vaginal fluid before and after vaginal douche (none in group D and 100ml Iodophor in group E) was aspirated and labeled. All specimens were sent for bacterial quantitation and qualitation. Antibiotics were given iv drip after anesthesia.(2) Surgical procedureAfter laparoscope advanced into peritoneum, the abdominal fluid was taken as samples before endoscope was inserted into peritoneal cavity. The endoscope advanced into stomach through a sterile overtube, into vagina through Trocar. The operative method was the same with the first part, after the gallbladder was removed through stomach/vagina and transmural incision was sutured, peritoneal fluid around transmural incision was sampled. Antibiotics were used to wash stomach/vagina incision, abdominal cavity and pelvic cavity in group B, C and E, the rinse was sent for examination.(3) Postoperative treatmentAntibiotics were given for 3d after surgery, and the recovery of animals was carefully surveyed, such as diet, body temperature, change of body weight and so on. If infection symptoms such as fever occurred, swine would be given antibiotics until the symptoms disappeared. After the 2-week observation period, animals were sacrificed and abdominal infection signs were viewed, samples taken from operative area and transgastric/transvaginal incisions were tested for bacterial inspection.Results(1) The swine in each group survived till 2 weeks. Fever and peritonitis was found in 2 pigs of group A, the symptoms improved after continuous application of antibiotics. The recovery of other pigs was uneventful.(2) Two weeks later, autopsy was applied in all animals. All the transmural incisions healed well, without injury of organs. Abdominal infection was found in 5 pigs of group A, including 2 cases of peritoneal abscess, and 3 cases of abdominal adhesion and exudate. The infection rate in group A was significantly higher than other groups (P<0.05).(3) Before endoscope advanced into abdomen, only 1 pig in group C was positive in peritoneal bacteria culture (10cfu/ml).(4) The main pathogenic bacteria found in peritoneum were Escherichia coli.(5) Nine pigs in group A,7 pigs in group B,6 pigs in group D, and none in group C and E had positive intraperitoneal culture results. The colony-forming units in group B was 600cfu/ml.Conclusions(1) The following procedures are effective in reduction of intraperitoneal bacterial load after NOTES:3000ml saline gastric lavage, vagina douching with 100ml Iodophor, sterile overtube through which gastroscope is inserted, Trocar from which colonoscope is inserted, irrigation of abdomen with antibiotics and antibiotics given during perioperative period.2 weeks later, the peritoneal infection rate was zero in TG high volume gastric lavage group (group C) and TV experiment group (group E). (2) There are no clinical symptoms after 500ml saline gastric lavage, but the bacterial evidence still exists.PartⅢThe primarily clinical application of laparoscopic-assisted transgastric cholecystectomyObjectiveTo apply transumbilical laparoscopic-assisted TG cholecystectomy for the patient who suffered from gastric benign lesion and benign cholecyst disease. The intraoperative and postoperative data were detected to investigate the superiority, shortcoming and clinical application perspective of TG cholecystectomy.Methods(1) Preoperative preparationSemi-fluid diet was given to the patient 3d before operation. On the day just before the operation, only intake of fluid food was permitted. Patient was restrained from food and water 12h before operation. The following vital signs were detected: body temperature, pulse, blood pressure, etc.(2) Surgical procedureThe gastroscope was inserted through mouth, and gastric mass was located by endoscopy. The introperative fast pathologic examination revealed that the mass was ectopic pancreatic tissue. The pancreatic tissue and normal gastric wall 1cm away from it was cut off. Endoscope advanced into abdominal cavity from the defect of gastric wall. Two 5mm Trocars and instruments were sent into abdominal cavity through umbilicus. The gallbladder was excised under NOTES view and taken out from mouth. The gastric wall was sutured under laparoscopy.(3) Postoperative management The postoperative vital signs were monitored. The recovery of diet and hospital stay were observed and recorded.ResultsThe operation was successful, the perioperative vital sign was smooth, no operative complications occurred. The patient resumed normal diet 7d after the procedure and was discharged on the 8th postoperative day.ConclusionsTG cholecystectomy is suitable for patients with gallbladder benign disease and gastric benign lesion which should be locally excised. Laparoscopy combined with gastroscopy can conquer the shortage of endoscopic devices and decrease the difficulty of operation. Specimen is removed from natural orifice, so that the incision and scar is minimal, this procedure has the superiority of less pain and quicker recovery.