Abstract
Background
Clinical applications of transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) are still limited in the literature, mostly case reports performed by hybrid procedures with laparoscopic assistance. Avoiding complications from incisions is the main goal for natural orifice surgery. This study reports on a technique developed at our institution that uses two endoscopes inserted into the vagina to perform a Totally NOTES (T-NOTES) transvaginal cholecystectomy, and describes preliminary results.
Methods
IRB approval was obtained at the institution for transvaginal NOTES clinical trials, and informed consent was obtained. The technique of T-NOTES transvaginal cholecystectomy was clinically applied in four female patients with symptomatic cholelithiasis, and data were prospectively documented. Transvaginal NOTES access was obtained by direct vaginal incision, and two endoscopes were simultaneously introduced in the abdominal cavity. Dissection was accomplished with available endoscopic instruments. Ligation of cystic duct and artery was performed using endoscopic clips. Vaginal closure was achieved using the direct-vision sutured technique.
Results
The technique was successfully performed in the four patients. Insufflation and spatial orientation was of good quality. Mean operative time was 210 min. There were no complications during the 30-day follow-up. Postoperative course was uneventful, and patients were released from the hospital on the first postoperative day.
Conclusion
Tranvaginal T-NOTES using two endoscopes provides a feasible method for natural orifice cholecystectomy using available technology. Large-series studies are needed to evaluate the results with respect to safety of the approach.
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References
Zorron R, Filgueiras M, Maggioni LC, Pombo L, Carvalho GL, Oliveira A (2007) NOTES transvaginal cholecystectomy: report of the first case. Surg Innov 14(4):279–283
Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M (2008) NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc 22(2):542–547
Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007) Report of transluminal cholecystectomy in a human being. Arch Surg 142:823–826
Branco Filho AJ, Noda RW, Kondo W, Kawahara N, Rangel M, Branco AW (2007) Initial experience with hybrid transvaginal cholecystectomy. Gastrointest Endosc 66(6):1245–1248
Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007) Transvaginal laparoscopically-assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 66(6):1243–1245
Zornig C, Emmerman A, von Waldenfels HA, Mofid H (2007) Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach. Endoscopy 39(10):913–915
Ramos AC, Murakami A, Galvão Neto M, Galvão MS, Silva AC, Canseco EG, Moyses Y (2008) NOTES transvaginal video-assisted cholecystectomy: first series. Endoscopy 40(7):572–575
DeCarli L, Zorron R, Branco A, Lima FC, Tang M, Pioneer SR, Zanin I Jr, Schulte AA, Bigolin AV, Gagner M (2008) Natural orifice transluminal endoscopic surgery (NOTES) transvaginal cholecystectomy in a morbidly obese patient. Obes Surg 18(7):886–889
Forgione A, Maggioni D, Sansonna F, Ferrari C, Di Lernia S, Citterio D, Magistro C, Frigerio L, Pugliese R (2008) Transvaginal endoscopic cholecystectomy in human beings: preliminary results. J Laparoendosc Adv Surg Tech A 18(3):345–351
Kalloo AN, Singh VK, Jagannath BS, 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(1):287–292
Kantsevoy SV, Jagannath BS, Niiyama H, Chung SSC, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN (2005) Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 62(2):287–292
Hochberger J, Lamadé W (2005) Transgastric surgery of the abdomen: the dawn of a new era? Gastrointest Endosc 62(2):293–295
Bergman S, Melvin WS (2008) Natural orifice transluminal endoscopic surgery. Surg Clin North Am 88(5):1131–1148
Sousa LH, Sousa Filho LH, Sousa VM, Sousa JAG, Tamura S, Chalela JRD (2007) Endoscopic cholecystectomy: proposal of a new technique—totally natural orifice transluminal surgery preliminary results of experimental study in pigs. Braz J Videoendosc Surg 5(2):90–102
Branco A, Filho AJ, Condo W, Noda RW, Kawahara N, Camargo AA, Stunitz LC, Valente J, Rangel M (2008) Hybrid transvaginal nephrectomy. Eur Urol 53:1290–1294
Zorron R, Soldan M, Filgueiras M, Maggioni LC, Pombo L, Oliveira A (2008) NOTES transvaginal for cancer diagnostic staging: preliminary clinical application. Surg Innov 15(3):161–165
Hazey JW, Narula VK, Renton DB, Reavis KM, Paul CM, Hinshaw KE, Muscarella P, Ellison EC, Melvin WS (2008) Natural orifice transgastric endoscopic peritoneoscopy in humans: initial clinical trial. Surg Endosc 22:16–20
Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES—world’s first report. Surg Endosc 22(5):1343–1347
Ramos AC, Zundel N, Neto MG, Maalouf M (2008) Human hybrid NOTES transvaginal sleeve gastrectomy: initial experience. Surg Obes Relat Dis 4(5):660–663
Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22(7):1717–1723
Zorron R, DeCarli L, Branco A, Filgueiras M, Lima FC, Tang M, Pioneer SR, Branco A, Noda RW, Gagner M, Schulte AA, Bigolin AV (2009) NOTES Transvaginal Cholecystectomy: prospective clinical comparative study with laparoscopy. Gastrointest Endosc
Rattner D, Kalloo A (2006) ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery. Surg Endosc 20:329–333
Kantsevoy SV (2008) Infection prevention in NOTES. Gastrointest Endosc Clin N Am 18:291–296
Narula VK, Hazey JW, Renton DB, Reavis KM, Paul CM, Hinshaw KE, Needleman BJ, Mikami DJ, Ellison EC, Melvin WS (2008) Transgastric instrumentation and bacterial contamination of the peritoneal cavity. Surg Endosc 22:605–611
Bingener J, Michalek J, Winston J, van Sickle K, Haines V, Schwesinger W, Lawrence V (2008) Randomized blinded trial comparing the cardiopulmonary effects of NOTES with standard laparoscopy in a porcine survival model. Surg Endosc 22:1430–1434
Bingener J, Michalek J, van Sickle K, Schwesinger W (2008) Randomized blinded trial shows relative thrombocytopenia in natural orifice transluminal endoscopic surgery compared with standard laparoscopy in a porcine survival model. Surg Endosc 22:2067–2071
Meirelles O, Kantsevoy SV, Kalloo AN, Jagannath SB, Giday SA, Magno P, Shih SP, Hanly EJ, Ko CW, Beitler DM, Marohn MR (2007) Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery. Surg Endosc 21:998–1001
Bergström M, Swain P, Park PO (2007) Measurements of intraperitoneal pressure and the development of a feedback control valve for regulating pressure during flexible transgastric surgery (NOTES). Gastrointest Endosc 66:174–178
McGee MF, Rosen MJ, Marks J, Chak A, Onders R, Faulx A, Ignagni A, Schomisch S, Ponsky J (2007) A reliable method for monitoring intraabdominal pressure during natural orifice transluminal endoscopic surgery. Surg Endosc 21(4):672–676
Mummadi RR, Pasricha PJ (2008) The eagle or the snake: platforms for NOTES and radical endoscopic therapy. Gastrointest Endosc Clin N Am 18:279–289
Verhoeven HC, Brosens I (2005) Transvaginal hydrolaparoscopy, its history and present indication. Minim Invasive Ther Allied Technol 14(3):175–180
Christian J, Barrier BF, Schust D, Miedema BW, Thaler K (2008) Culdoscopy: a foundation for natural orifice surgery—past, present and future. J Am Coll Surg 207(3):417–422
Bueno B (1949) Primer caso de apendicectomia por via vaginal. Tokoginec Pract (Madrid) 8:152–154
Reiner IJ (1980) Incidental appendectomy at the time of vaginal surgery. Texas Med 76(11):46–50
Delvaux G, Devroey P, De Waele B, Willems G (1993) Transvaginal removal of gallbladders with large stones after laparoscopic cholecystectomy. Surg Laparosc Endosc 3(4):307–309
Abrao MS, Sagae UE, Gonzales M, Podgaec S, Dias JA Jr (2005) Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy. Int J Gynaecol Obstet 91(1):27–31
Zornig C, Emmerman A, von Waldenfels HA, Felixmuller C (1994) Colpotomy for specimen removal in laparoscopic surgery. Chirurg 65(10):883–885
Gill IS, Cherullo EE, Meraney AM, Borsuk F, Murphy DP, Falcone T (2002) Vaginal extraction of the intact specimen following laparoscopic nephrectomy. J Urol 167(1):238–241
Tsin DA, Colombero L, Mahmood D, Padouvas J, Manolas P (2001) Operative culdolaparoscopy: a new approach combining operative culdoscopy and minilaparoscopy. J Am Assoc Gynecol Laparosc 8(3):438–441
Gordts S, Campo R, Rombauts L, Brosens I (1998) Transvaginal hydrolaparoscopy as an outpatient procedure for infertility investigation. Hum Reprod 13(1):99–103
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de Sousa, L.H., de Sousa, J.A.G., de Sousa Filho, L.H. et al. Totally NOTES (T-NOTES) transvaginal cholecystectomy using two endoscopes: preliminary report. Surg Endosc 23, 2550–2555 (2009). https://doi.org/10.1007/s00464-009-0453-z
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DOI: https://doi.org/10.1007/s00464-009-0453-z