经自然腔道内镜胆囊切除术的实验研究

Cholecystectomy via natural orifice transluminal endoscopic surgery

目的初步评价经自然腔道内镜胆囊切除术不同方法的可行性和优缺点。方法采用8只雌性猪模型平均分为4组。单镜手术均为经阴道途径的双管道内镜，双镜联合时再经胃插入一条普通内镜协助。分为单条内镜法、经阴道和经胃双镜联合法、腹腔镜抓钳辅助单条内镜法、单条带透明帽的内镜法4种不同方法进行胆囊切除术。先用针刀在管壁穿透切开，ERCP拉式切开刀扩大切口，再用扩张球囊扩大通道，将胃镜送入腹腔，内镜在腹腔内寻找胆囊并进行胆囊切除术。术后管壁切口用止血夹闭合。于术后1周处死解剖动物，观察腹腔内粘连，胆囊床，邻近脏器损伤及管壁切口闭合情况。结果使用单条内镜无法完成胆囊切除术；双镜联合及腹腔镜抓钳辅助有利于胆囊管及血管的分离，均只有1例成功，1例未能最终完成胆囊切除术；2例带透明帽的单条内镜法都成功完成了胆囊切除术。腹腔镜抓钳辅助出现1例出血，双镜联合出现1例胆囊破裂。结论经自然腔道内镜胆囊切除术是可行的，带透明帽的双管道内镜法是较理想的操作方法，专用新器械的开发是手术操作顺利进行和成功的关键。

Objective To evaluate the feasibility and relative merits of cholecystectomy via natural orifice transluminal endoscopic surgery （NOTES） in porcine model. Methods A total of 8 female pigs were divided into 4 groups to accept cholecystectomy via different NOTES approaches, which included single transvaginal dual-channel endoscopy, combination of trans-vaginal dual-channel endoscopy and trans-gastrie conventional endoscopy, laparoseopy assisted trans-vaginal dual-channel endoscopy, and single trans-vaginal dual-channel endoscopy with cap. An incision in the vaginal wall was made with a needle-knife, expanded with a cutting knife and enlarged with a dilating balloon, after which a dual-channel endoscope was advanced into the peritoneal cavity to locate and excise the gallbladder. The incision was closed with clips. Animals were sacrificed 1 week later to explore the changes in peritoneal cavity, including adhesion, injuries around the gallbladder and healing situation of the incisions. Results Cholecystectomy could not be accomplished with single endoscope technique, but was succeeded in 1 animal with combination technique and laparoscopy assisted technique, respectively, and was performed successfully in 2 pigs with cap assisted methods. Rupture of gallbladder occurred in combination group and bleeding occurred in laparoscnpy assisted group. Conclu- sion Cholecystectomy via NOTES is feasible, and cap assisted dual-channel endoscope with EMR-cap is the most desirable NOTES technique. Development of specialized instruments is the key of success.