Update on Instrumentations for Cholecystectomies Performed via Transvaginal Route: State of the Art and Future Prospectives

Abstract

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an innovative approach in which a flexible endoscope enters the abdominal cavity via the transesophageal, transgastric, transcolonic, transvaginal or transvescical route, combining the technique of minimally invasive surgery with flexible endoscopy. Several groups have described different modifications by using flexible endoscopes with different levels of laparoscopic assistance. Transvaginal cholecystectomy (TVC) consists in accessing the abdominal cavity through a posterior colpotomy and using the vaginal incision as a visual or operative port. An increasing interest has arisen around the TVC; nevertheless, the most common and highlighted concern is about the lack of specific instruments dedicated to the vaginal access route. TVC should be distinguished between “pure”, in which the entire operation is performed through the transvaginal route, and “hybrid”, in which the colpotomy represents only a support to introduce instruments and the operation is performed mainly by the classic transabdominal-introduced instruments. Although this new technique seems very appealing for patients, on the other hand it is very challenging for the surgeon because of the difficulties related to the mode of access, the limited technology currently available and the risk of complications related to the organ utilized for access. In this brief review all the most recent advancements in the field of TVC's techniques and instrumentations are listed and discussed.

A Simple Approach to Specimen Retrieval via Posterior Colpotomy Incision

“…In the general surgery literature, Ghezzi et al reported no increase in infection rate for transvaginal removal of the appendix, and Pulvirenti et al similarly noted no increase in infection rate when removing the gallbladder transvaginally. 6 , 7 These findings were affirmed in the gynecologic literature: a 2012 review of transvaginal specimen retrieval for gynecologic procedures demonstrated no significant increase in infection rates or sexual dysfunction. 2 , 17 Furthermore, these findings are consistent with prior studies that have found no increased incidence in sexual dysfunction and dyspareunia after total hysterectomy, where a colpotomy incision is created, versus a supracervical hysterectomy.…”

“… 5 Prior case reports and case series have documented successful transvaginal retrieval of various organs, including the appendix, gallbladder, kidney, stomach, pancreas, and colon. 6 – 11 Studies comparing traditional laparoscopic approaches with transumbilical specimen retrieval versus transvaginal approaches have demonstrated decreased postoperative pain from using the transvaginal approach. 12 – 14 Furthermore, studies have demonstrated no increased risk of postoperative infection or incidence of sexual dysfunction or pelvic pain.…”

Laparoscopic-Assisted Transvaginal Cholecystectomy – the US Military Experience With Long-Term Follow Up

“…Operative instruments and endoscopes working in parallel create the possibility for interferences, hinders effective manipulation, and does not facilitate triangulation as movement is constrained to the long axis. 58,[94][95][96] This may significantly limit exposure, dissection, and field of view potentially increasing the risk of injury while instruments are out of sight. 97 In a task-analysis of CLC versus TVC, Nemani et al demonstrated increased errors in the TVC group due to instruments being out of sight whereas the CLC group had more errors due to lack of progress.…”

“…7,18,102 Some authors have described manual straightening of endoscopic clips to mitigate this issue and facilitate placement, however, while successful, this technique is inefficient and not ideal given that it requires modifying a manufactured product. 18,95 Prototype flexible clip appliers capable of complete occlusion have been described 103 including one with a zero-gap clip. 97 Of note, clip placement using this prototype took 9 minutes, significantly longer than laparoscopic clip placement.…”

Advances and Trends in Pediatric Minimally Invasive Surgery

“…Hybrid NOTES, with an additional port through the umbilicus, appeared to increase instrumentation and safety, as the entry through the vagina or stomach can be visually controlled. Several reports found hybrid NOTES to be applicable in general surgery, as for cholecystectomy and appendectomy and several technical reports on instrumentation for NOTES can be found ( Figures 3 and 4) [29,30]. The ENDOSAMURAI by Olympus is a platform with two arms fitted to the tip of an endoscope that includes forceps channels in addition to the endoscope itself and its two arms.…”