[Transrectal hybrid NOTES versus laparoscopic cholecystectomy--a randomized prospective study in a large laboratory...

NOTES (Natural Orifice Transluminal Endoscopic Surgery) technique was developed to achieve less invasive surgery with the aim to lower frequency of postoperative complications. Cholecystectomy is one of the most frequent elective surgical procedures and is relevant for evaluation of NOTES. The aim of the experimental study was to compare hybrid transrectal and laparoscopic cholecystectomy regarding feasibility and inflammatory response.

A total of 20 pigs weighing 26-56 kg were randomized to laparoscopic or NOTES group. Transrectal approach (15-18 cm from anal edge) was created by needle knife, followed by balloon dilatation and two-channel endoscope was introduced into the abdominal cavity. Cystic artery and duct were clipped and dissected. After extirpation of the gall bladder the colostomy was closed by occlusion loop-and-clip (King' closure) technique. In the laparoscopic group, cholecystectomy was performed by three-port access. Blood samples for evaluation of inflammatory response markers (leukocytes, CRP, interleukin 6) were taken 0, 2nd, 7th and 30th postoperative day, when the experiment ended and pig was euthanized.

Two pigs were excluded (1 died early postoperatively for pneumonia, 1 for the rectal closure impossibility after it's laceration during of the gall bladder extirpation). Other pigs survived without complications. Procedure time was significantly longer in NOTES group (134 +/- 27 minutes versus 60 +/- 22 minutes, p < 0.05). White blood cells count and CRP level increased significantly in both groups 2nd and 7th postoperative day and then normalized. Differences between groups were not significant in any of the measured laboratory markers. Sectional finding of exudate and adhesions was comparable in both groups and all transrectal closures were healed. Small subhepatal abscess was found in one pig from NOTES group.

Transrectal hybrid cholecystectomy is a safe and feasible method with comparable inflammatory responses and longer operating time compared to laparoscopy. A novel loop-and-clip technique was verified as a safe and simple rectal closure.