NOTES: transvaginal cholecystectomy with assisting articulating instruments

Abstract

Background Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques. Methods A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min. Results The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics. Conclusions The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach.

Patient preferences for surgical techniques: should we invest in new approaches?

“…The majority of the work done on NOTES has been based on animal models but some human cases have been reported [2][3][4], although some safety issues have been raised [6,7]. A number of challenges faced by NOTES were highlighted in a recent white paper [8].…”

Natural orifice translumenal endoscopic surgery (NOTES®): a technical review

“…Of these, 64 articles met the inclusion and exclusion criteria of the study and were chosen for further, detailed review. Detailed review of these articles revealed nine studies [6,10,13,16,34,57,58,60,66] reporting cases that were included in other series. These redundant cases were accounted for in the final analysis.…”

Natural orifice transluminal endoscopic surgery (NOTES): when a step forward may be a step too soon or too far

“…However, nowhere in the article were the potential hazards of this new procedure mentioned, nor the possibility of severe complications including bladder or rectal perforation, Douglas abscess, or postoperative vaginal bleeding. These potential risks were not mentioned in the case of transvaginal hybrid NOTES reported in the same issue by Horgan et al [3], who stated that the patient signed an informed consent. What is a truly informed consent for a surgical procedure that we, the surgeons, do not even know is safe?…”

“…Does another solution exist that may fit the male population? Moreover, they used a 5-mm transabdominal trocar, resulting in a hybrid NOTES procedure, as in most recent reports [3]. But is hybrid NOTES still NOTES?…”

“…In addition, the procedure described by Horgan et al [3] illustrates the recent NOTES trends. First the access was transvaginal, as in most reported cases to date due to the unsolved problems of transluminal access.…”