Surgical Endoscopy

, Volume 21, Issue 12, pp 2308–2316 | Cite as

Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments

  • Daniel J. Scott
  • Shou-jiang Tang
  • Raul Fernandez
  • Richard Bergs
  • Mouza T. Goova
  • Ilia Zeltser
  • Farid J. Kehdy
  • Jeffrey A. Cadeddu



Natural orifice translumenal endoscopic surgery (NOTES) is an evolving field and suitable instruments are lacking. The purpose of this study was to perform transvaginal cholecystectomies using instruments incorporated into a magnetic anchoring and guidance system (MAGS).


Non-survival procedures were conducted in pigs (n = 4). Through a vaginotomy created under direct vision, a rigid access port was inserted into the peritoneal cavity and used to maintain a CO2 pneumoperitoneum. MAGS instruments were deployed through the port and held in place on the peritoneal surface using magnetic coupling via an external handheld magnet which was optionally exchanged for an 18ga percutaneous threaded needle anchor; instruments included a tissue retractor (a clip-fixated magnet or flexible graspers) and a cautery dissector. A gastroscope was used for visualization.


The first two procedures ended prematurely due to instrumentation shortcomings and inadvertent magnetic coupling between instruments; one case required a laparoscopic rescue. Three new forms of instrumentation were developed: (1) a longer access port (50 cm) which provided easier deployment of instruments and suitable reach, (2) a more robust cauterizer with a longer, more rigid, pneumatically deployed tip with better reach and sufficient torque to allow blunt dissection, and (3) a more versatile tissue retractor with bidirectional dual flexible graspers which provided excellent cephalad fundus retraction and inferiolateral infundibulum retraction. With these modifications, 100% of the cholecystectomy was completed in the third and fourth animals using only a NOTES/MAGS approach. Retrieval of the tissue retractor resulted in a rectal injury in the third animal but further procedural modifications resulted in a successful procedure in the fourth animal with no complications.


While still under development with more refinements needed, completely transvaginal cholecystectomy using MAGS instruments is feasible. By offering triangulation and rigidity, MAGS may facilitate a NOTES approach while alleviating shortcomings of a flexible platform.


NOTES Natural orifice translumenal endoscopic surgery Endoscopy Transvaginal surgery Cholecystectomy Magnetic instrumentation MAGS 



We gratefully acknowledge the equipment support provided by Olympus, Karl Storz Endoscopy, the US Surgical Corporation, and Valleylab.


  1. 1.
    Gettman MT, Lotan Y, Napper CA, Cadeddu JA (2002) Transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model. Urology 59:446–450CrossRefPubMedGoogle Scholar
  2. 2.
    Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117CrossRefPubMedGoogle Scholar
  3. 3.
    Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P (2005) Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 61:601–606CrossRefPubMedGoogle Scholar
  4. 4.
    Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SSC, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN (2005) Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 61:449–453CrossRefPubMedGoogle Scholar
  5. 5.
    Kantsevoy SV, Jagannath SB, Niiyama H, Vaughn CA, Chung SSC, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Barlow D, Shimonaka H, Kalloo AN (2005) Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 62:287–92CrossRefPubMedGoogle Scholar
  6. 6.
    Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SCC, Cotton PB, Gostout CJ, Hawes RJ, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN (2006) Per-oral transgastric endoscopic splenectomy: Is it possible? Surg Endosc 20:522–525CrossRefPubMedGoogle Scholar
  7. 7.
    Ikeda K, Fritscher-Ravens A, Mosse CA, Mills T, Tajiri H, Swain CP (2005) Endoscopic full-thickness resection with sutured closure in a porcine model. Gastrointest Endosc 62:122–129CrossRefPubMedGoogle Scholar
  8. 8.
    Wagh MS, Merrifield BF, Thompson CC (2006) Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model. Gastrointest Endosc 63:473–478CrossRefPubMedGoogle Scholar
  9. 9.
    Swanstrom LL, Kozarek R, Pasricha PJ, Gross S, Birkett D, Park PD, Saadat V, Ewers R, Swain P (2005) Development of a new access device for transgastric surgery. J Gastrointest Surg 9:1129–1137CrossRefPubMedGoogle Scholar
  10. 10.
    Fritscher-Ravens A, Mosse CA, Mukherjee D, Yazaki E, Park PO, Mills T, Swain P (2004) Transgastric gastropexy and hiatal hernia repair for GERD under EUS control: a porcine model. Gastrointest Endosc 59:89–95CrossRefPubMedGoogle Scholar
  11. 11.
    Bergstrom M, Ikeda K, Swain P, Park P (2006) Transgastric anastomosis by using flexible endoscopy in a porcine model. Gastrointest Endosc 63:307–312CrossRefPubMedGoogle Scholar
  12. 12.
    Pai RD, MD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006) Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 64:428–434Google Scholar
  13. 13.
    Lima E, Rolanda C, Pego JM, Henriques-Coelho T, Silva D, Carvalho JL, Correia-Pinto J (2006) Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery. J Urology 176:802–805CrossRefGoogle Scholar
  14. 14.
    Rattner D, Kalloo A (2006) SAGES/ASGE Working group on natural orifice translumenal endoscopic surgery. Surg Endosc 20:329–333CrossRefPubMedGoogle Scholar
  15. 15.
    Malik A, Mellinger JD, Hazey JW, Dunkin BJ, MacFadyen BV Jr (2006) Endoluminal and transluminal surgery: current status and future possibilities. Surg Endosc 20:1179–1192CrossRefPubMedGoogle Scholar
  16. 16.
    McGee MF, Rosen MD, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J (2006) A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Innov 13:86–93CrossRefPubMedGoogle Scholar
  17. 17.
    Kaehler G, Grobholz R, Langner C, Suchan K, Post S (2006) A new technique of endoscopic full-thickness resection using a flexible stapler. Endoscopy 38:86–89CrossRefPubMedGoogle Scholar
  18. 18.
    Cadeddu JA, Eberhart R, Fernandez R, Bergs R (2005) Transabdominal magnetic anchoring system for trocar-less laparoscopic surgery. J Urology 167:4 (abstract)Google Scholar
  19. 19.
    Park S, Bergs R, Eberhart R, Baker L, Fernandez R, Cadeddu JA (2007) Trocar-less laparoscopy: magnetic positioning of intra-abdominal camera and retractor. Ann Surg 245:379–384CrossRefPubMedGoogle Scholar
  20. 20.
    Zeltser IS, Bergs R, Fernandez R, Baker L, Eberhart R, Cadeddu JA (2007) Single trocar laparoscopic nephrectomy using magnetic anchoring and guidance system in the porcine model. J Urology 178:288–291CrossRefGoogle Scholar
  21. 21.
    Scott DJ, Tang SJ, Bergs R, Fernandez R (2006) Magnetically-Anchored Instruments for Transgastric Endoscopic Surgery, Presented at the SAGES Emerging Technologies Session, SAGES Annual Meeting, Dallas, TX April 29, 2006Google Scholar
  22. 22.
    Scott DJ, Tang SJ, Fernandez R, Bergs R, Cadeddu JA (2007) Transgastric, transcolonic, and transvaginal cholecystectomy using magnetically anchored instruments. Surg Endosc 21(Suppl):S474Google Scholar
  23. 23.
    Clayton RD (2006) Hysterectomy. Best Pract Res Clin Obstet Gynaecol 20:73–87CrossRefPubMedGoogle Scholar
  24. 24.
    Kovac SR (2000) Hysterectomy outcomes in patients with similar indications. Obstet Gynecol 95:787–793CrossRefPubMedGoogle Scholar
  25. 25.
    Khouri A, Magos A (2005) The cost of out-patient culdoscopy compared to in-patient laparoscopy in women with infertility. J Obstet Gynaecol 25:160–165CrossRefPubMedGoogle Scholar
  26. 26.
    Paulson JD, Ross JW, El-Sahwi S, Paulson JD, Ross JW, El-Sahwi S (1999) Development of flexible culdoscopy. J Am Assoc Gynecol Laparosc 6:487–490CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Daniel J. Scott
    • 1
  • Shou-jiang Tang
    • 2
  • Raul Fernandez
    • 4
  • Richard Bergs
    • 4
  • Mouza T. Goova
    • 1
  • Ilia Zeltser
    • 3
  • Farid J. Kehdy
    • 1
  • Jeffrey A. Cadeddu
    • 3
  1. 1.Southwestern Center for Minimally Invasive Surgery, Department of SurgeryUT Southwestern Medical CenterDallasUSA
  2. 2.Department of GastroenterologyUniversity of Texas Southwestern Medical CenterDallasUSA
  3. 3.Department of UrologyUniversity of Texas Southwestern Medical CenterDallasUSA
  4. 4.Texas Manufacturing Assistance Center, Automation and Robotics Research InstituteUniversity of TexasArlingtonUSA

Personalised recommendations