Natural orifice translumenal endoscopic surgery (NOTES): Dissection for the critical view of safety during transcolonic cholecystectomy

Background: Natural orifice translumenal endoscopic surgery (NOTES), an emerging field in minimally invasive surgery, is driving the development of new technology and techniques. The NOTES approach has several proposed benefits including potentially decreased abdominal pain, wound infections, and hernia formation [1-4]. Cholecystectomy is one of the most commonly performed NOTES procedures to date [5-7]. To perform a safe cholecystectomy and reduce potential bile duct injuries, the cystic duct and artery must first be identified. Establishing this critical view of safety before ligation and division has been shown to reduce bile duct injuries associated with laparoscopic cholecystectomy [8]. This video shows that the critical view of safety can be attained with endoscopic dissection. Methods: In the porcine model, transcolonic peritoneal access is gained using an endoscopic needleknife and balloon dilator. Once orientation is established, the gallbladder is retracted using percutaneous T-tags. The cystic duct and artery bundle are identified and then meticulously dissected using endoscopic graspers, hook cautery, biopsy forceps, and scissors. The individual cystic duct and artery are isolated and identified, establishing the critical view of safety. Endoscopic clip ligation and division are then performed, and the gallbladder is dissected free. Conclusions: Dissection of the critical view of safety can be performed in a completely endoscopic fashion using appropriate instrumentation. By achieving this critical view, the incidence of biliary injury during NOTES should be minimal and similar to the incidence of biliary injury during laparoscopic surgery. While completing this procedure, we identified several remaining technical limitations and deficiencies. Endoscopic retraction of tissue still is challenging with currently available instrumentation. Hemostatic endoscopic clips are not currently available for cystic artery and duct ligation. With the development of such instruments, cholecystectomy and other NOTES procedures will become technically more feasible.