1. Transgastric Endoscopic Cholecystectomy of the porcine and canine models Institute for Digestive Research, Digestive Disease Center 1, Department of Surgery 2, College of Medicine, Soonchunhyang University Won Young Cho 1, Jin-Oh Kim 1, Hyun Gun Kim 1, Joo Young Cho 1, Young Koog Cheon 1, Young Deok Cho 1, Dong Ho Choi 2, Yong Jin Kim 2, Kyung Yul Hur 2, Jae Joon Kim 2

2. Backgrounds Transgastric endoscopic appendectomy (2002~06, Raddy, India, unofficial) Transgastric endoscopic liver biopsy (2004, Kalloo *, 1 st official) Papers about endoscopic procedures of the pig model : Ligation of fallopian tubes, Gastrojejunostomy and Hysterectomy (2005, Jagannath *, Kantsevoy *, Wagh * ) ASGE † /SAGES ‡ guideline for NOTES (2005) and NOSCAR § (2006~) Papers about new instruments, closing techniques, and Hybrid method (2007, Marks *, Symiyama *, Shih * ) EATS(European Association for Transluminal Surgery, 2007) Human applied NOTES : transvaginal (2007, Jaque ||, Fr.) * Published || Presented † ASGE : American Society of Gastrointestinal Endoscopy ‡ SAGES : Society of American Gastrointestinal and Endoscopic Surgeons § NOSCAR : Natural Orifice Surgery Consortium for Assessment and Research

3. Suggested Advantages Wound infection Adhesion Ileus Recovery Pain Abdominal wall hernia Cosmetic surgery Invasiveness

4. Materials Specimen –30kg, 2 female pigs –10Kg, 2 female dogs Instruments –1 Endoscope (QV10-GF ®, Olympus Optical Co., One channel) –Endoscopic Accessories (Endo Flex-knife ®, Injection needle, Clip, Snare) –5mm laparo port 1, EndoGrasper ® 1 for each Op., Veress Needle ® 1 90°s 135°

5. Methods Procedures –General anesthesia, Supine position OP team : Endoscopist Laparoscopic Surgeon 1.Endoscopic puncture of the stomach wall 2.Clipping of the cystic duct/vessels and resection 3.Separation of the GB from the liver bed 4.Extraction of the GB with endoscope 5.Endoscopic closure of punctured stomach

6. First trial to canine

7. Porcine model

8. Results Submucosal Injection Submucosal Injection Puncture of Stomach wall Puncture of Stomach wall Enter the peritoneal cavity Enter the peritoneal cavity Assist Lapa Port insert Assist Lapa Port insert Expose GB and Liver Expose GB and Liver First Clipping on Cystic duct First Clipping on Cystic duct Resection of Cystic duct Resection of Cystic duct GB dissection from liver bed GB dissection from liver bed GB capturing with Endo-Snare GB capturing with Endo-Snare GB extraction through oral cavity GB extraction through oral cavity Closing of punctured stomach wall Closing of punctured stomach wall 00:00 00:36 00:17 00:15 00:04 00:57 01:11 01:35 01:59 Pig 1 Pig 2 00:31

9. Discussion I Stomach puncture method  ‘ESD technique’ (Endoscopic Submucosal Dissection) –Easy opening and more safe closure Endoscopic clip –135° EndoClip ®, Olympus, CO. –Good for tubular structure, not good for plane structure 90°s

10. Discussion II Limitation of Instruments –One channel ? Two channel ? –Novel endoscope and accessories Necessity of assisted laparo-port : ‘Hybrid methods’ Maintenance and regulation of gas insufflation for each phases in NOTES Training program for NOTES (in the laparoscopic operation)