Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases with mid-term follow-up

Background and study aims: Natural orifice transluminal endoscopic surgery (NOTES) has been tested in the animal model for a multitude of procedures including cholecystectomy. Clinical experience using flexible endoscopes is, however, very limited. Transvaginal cholecystectomy has been shown to be the most feasible approach in which rigid instruments can be used. We report our experience in all patients treated over a 1-year period.

Patients and methods: Between June 2007 and June 2008, 68 patients (mean age 50 years) underwent transvaginal cholecystectomy with an additional 5-mm umbilical trocar using rigid laparoscopic instruments. Data about symptoms, operation, and postoperative course were prospectively collected, as were findings of a gynecological follow-up examination 1 week after surgery and the results of an interview at least 3 months after surgery.

Results: All 68 operations were finished successfully without conversion, with a mean operation time of 51 minutes; in three additional cases severe pelvic adhesions prevented further transvaginal progress. There were no intraoperative or immediately postoperative complications, but one patient presented with a Douglas pouch abscess 3 weeks after surgery. Gynecologic follow-up exams 1 week after surgery were unremarkable. All patients were interviewed 3 – 10 months after surgery and had no abdominal or gynecological complaints including in relation to sexual intercourse.

Conclusion: Transvaginal NOTES cholecystectomy with rigid instruments can be safely and effectively performed in daily routine.

References

• 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
• 2 Fong D G, Rai R D, Thompson C C. Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model.  Gastrointest Endosc. 2007;  65 312-318
• 3 Fong D G, Ryou M, Pai R D. et al . Transcolonic ventral hernia mesh fixation in a porcine model.  Endoscopy. 2007;  39 865-869
• 4 Fritscher-Ravens A, Mosse C A, Ikeda K, Swain P. Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance.  Gastrointest Endosc. 2006;  63 302-306
• 5 Jagannath S B, Kantesevoy S V, Vaughn C A. et al . Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in porcine model.  Gastrointest Endosc. 2005;  61 449-453
• 6 Kantsevoy S V, Hu B, Jagannath S B. et al . Transgastric endoscopic splenectomy. Is it possible?.  Surg Endosc. 2006;  20 522-525
• 7 Kantsevoy S V, Jagannath S B, Niiyama H. et al . Endoscopic gastrojejunostomy with survival in a porcine model.  Gastrointest Endosc. 2005;  62 287-292
• 8 Lima E, Henriques-Coelho T, Rolanda C. et al . Transvesical thoracoscopy: a natural orifice transluminal endoscopic approach for thoracic surgery.  Surg Endosc. 2007;  21 854-858
• 9 Matthes K, Yusuf T E, Willingham F F. et al . Feasibility of endoscopic transgastric distal pancreatectomy in the porcine animal model.  Gastrointest Endosc. 2007;  66 762-766
• 10 Pai R D, Fong D G, Bundga M E. et al . Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model.  Gastrointest Endosc. 2006;  64 428-434
• 11 Park P O, Bergström M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis.  Gastrointest Endosc. 2005;  61 601-606
• 12 Wagh M S, Merrifield B F, Thompson C C. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model.  Gastrointest Endosc. 2006;  63 473-478
• 13 Fritscher-Ravens A, Patel K, Ghanbari A. et al . Natural orifice endoscopic surgery (NOTES) in the mediastinum: long term survival animal experiments in transoesophageal access, including minor surgical procedures.  Endoscopy. 2007;  39 870-875
• 14 Sanchez-Margallo F M, Asencio J M, Tejonero M C. et al . Technical feasibility of totally natural orofice cholecystectomy in a swine model.  Minim Invasive Ther Allied Technol. 2008;  17 361-364
• 15 Bessler M, Stevens P D, Milone L. et al . Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery.  Gastrointest Endosc.. 2007;  66 1243-1245
• 16 Marescaux J, Dallemagne B, Peretta S. et al . Surgery without scars: report of transluminal cholecystectomy in a human being.  Arch Surg. 2007;  142 823-826
• 17 Zorrón R, Filgueiras M, Maggioni L C. et al . NOTES. Transvaginal cholecystectomy: report of the first case.  Surg Innov. 2007;  14 279-283
• 18 Branco F ilho, Noda R W, Kondo W. et al . Initial experience with hybrid transvaginal cholecystectomy.  Gastrointest Endosc. 2007;  66 1245-1248
• 19 Zorron R, Maggioni L C, Pombo L. et al . NOTES transvaginal cholecystectomy: preliminary clinical application.  Surg Endosc. 2008;  22 542-547
• 20 Palanivelu C, Rajan P S, Rangarajan M. et al . Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique.  Endoscopy. 2008;  40 428-431
• 21 Ramos A C, Zundel N, Neto M G, Maalouf M. Human hybrid NOTES transvaginal sleeve gastrectomy: initial experience.  Surg Obes Relat Dis. 2008;  4 660-663
• 22 Noguera J F, Dolz C, Cuadrado A. et al . Transvaginal liver resection (NOTES) combined with minilaparoscopy.  Rev Esp Enferm Dig. 2008;  100 411-415
• 23 Lacy A M, Delgado S, Rojas O A. et al . MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human.  Surg Endosc. 2008;  22 1717-1723
• 24 Bernhardt J, Gerber B, Schober H C. et al . NOTES, case report of a unidirectional flexible appendectomy.  Int J Colorectal Dis. 2008;  23 547-550
• 25 Zornig C, Emmermann A, v Waldenfels H A, Felixmüller C. Die Kolpotomie zur Präparatebergung in der laparokopischen Chirurgie [Colpotomy for removal of specimen in laparoscopic surgery] [English abstract].  Chirurg. 1994;  65 883-885
• 26 Zornig C, Mofid H, Emmermann A. et al . Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach.  Endoscopy. 2007;  39 913-915
• 27 Zornig C, Mofid H, Emmermann A. et al . Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients.  Surg Endosc. 2008;  22 1427-1429
• 28 Ramos A C, Murakami A, Galvao Neto M. et al . NOTES transvaginal video-assisted cholecystectomy: first series.  Endoscopy. 2008;  40 572-575
• 29 Johnson N, Barlow D, Lethaby A. et al . Surgical approach to hysterectomy for benign gynaecological disease.  Cochrane Database Syst Rev. 2006;  2 CD003677