NOTES Transvaginal Surgery: Dead or Alive in 2015? Results of a Survey

Alberto Raul Ferreres, MD, PhD, FACS, hon, Rosana Trapani, MD, Pablo Miguel, MD, Julieta Camelione, MD, Leandro Cardozo, MD, Paula Curvale, MD. University of Buenos Aires

Introduction: Laparoscopic cholecystectomy (LC) introduced in the late 80´s is currently the standard of care for the treatment of cholelithiasis. New approaches such as NOTES and SILS developed but did not catch the attraction of surgeons and patients. TV NOTES cholecystectomy appears in the surgical armamentarium around 2007 but recent adoption rates are very low, exception made of Germany. Our objective was to assess surgeons´ opinion regarding this approach and its validity.

Methods and Procedures: Between march and august 2015, this study surveyed 240 surgeons trained in TV cholecystectomy in our hands- on courses set up between 2008 and 2013 using an end point questionnaire designed to establish their opinion with respect to NOTES surgery in comparison to standard laparoscopic cholecystectomy. The statistical analysis was performed with the Mann Whitney U test, and a p-value of ≤ was considered to be statistically significant.

Results: The surveys were completed by 180 surgeons (75%), 157 (87%) were from Argentina, 20 (11%) from Latin American countries and 3 (2%) from the rest of the world (2 Europe, 1 Africa). 170 were males (94%) and the average age was 43.4 years (ranges 32-53). The number of courses was: 6 in 2008 and 6 in 2009; 4 in 2010 and 4 in 2011, 2 in 2012 and 1 in 2013. Each course hosted 10 participants each, with a required experience of more than 3 years or 130 cases of previous LC.

None of the surgeons with the exception of 2 (1%) are still performing NOTES TV cholecystectomy. These 2 surgeons performed less than 10 cases yearly and only under patients´ request. None of the 10 female surgeons would accept a TV performed on them. It was unanimous the opinion that NOTES TV cholecystectomy is not a valid alternative and 153 (85%) believe NOTES represents an unncessesary innovation, while the remaining 15% considered there is a place, both for transoral and transanal procedures. Reasons for abandonment of this technique are multiple.

Conclusions: After an initial upheaval with partial embracement, the situation regarding NOTES in 2015 seems to have changed. A significant skepticism is the rule in surgeons trained in this procedure. Standard laparoscopic cholecystectomy stills remains the accepted standard of care for the treatment of symptomatic gallbladder stones and NOTES remains to be an alternative to the access of both ends of the digestive tract.

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