Gynecologic Status After NOTES Transvaginal Cholecystectomy

Background: the development of NOTES procedures and its clinical application raise issues regarding the ways of access to the abdominal cavity. The transvaginal access through posterior colpotomy has been widely used by gynecologists for the treatment of several conditions and eliminates the disadvantages associated with other NOTES approaches ( transgastric, transrectal and trans-vesical).

Objective: assessment of the gynecological impact, both anatomical and functional, of the transvaginal NOTES access.

Methods and material: within a research protocol agreement between the Department of Surgery of the University of California, San Diego and the Department of Surgery of the University of Buenos Aires (Bocalandro Hospital) with IRB and approval of the Ethics Committe, 22 female patients were operated at this last institution between August 2007 and September 2008. The patients fulfilled the following requirements: a) symptomatic gallbladder stones, b) absence of common bile duct obstruction, c) previous pregnancy, d) negative pregnancy tests, e) mini- mental state evaluation of 14 or higher. The gynecologic screening included: a) thorough interrogation, b) examination including colposcopy, c) pelvic and transvaginal ultrasound.
A transvaginal NOTES cholecystectomy was attempted in the 22 patients with a hybrid technique: with laparoscopic control via a 5 mm umbilical trocar a 2 way trocar was inserted trough the right posterior vaginal cul de sac and endoscope, forceps and diverse instruments were inserted. Disecction of the cystic elements (duct and artery) and the Calot´s triangle was performed with electrocautery, scissors and Maryland forceps through the umbilical port, in a laparoscopic fashion. A 5 mm ligaclip instrument was introduced for placing titanium clips in the biliary and arterial structures. Once the gallbladder was divided from its attachments it was removed through the vagina. The access was closed with a running suture of absorbable vycril 2/0.
The postoperative follow up included gynecologic assessment at postoperative days 7, 30 and 60. The first 8 patients could resume normal sexual activity after 15 days and the remaining 14 have to wait 30 days. The evaluation included: guided questionnaire (patients´ satisfaction with the procedure, restart of sexual activity, spontaneous pain, dyspareunia), physical examination and colposcopy to assess healing, presence of anatomical injuries, vaginal secretion and other alterations.

Results: the operation with the NOTES hybrid technique could be completed in 21 of the 22 patients (95 %). In the remaining case the operation had to be performed laparoscopically due to pelvic adhesions (5 previous cesarean sections). One case ( # 6) required a minilaparotomy through a previous Pfannestiel incision for checking hemostasis of the vaginal cul de sac.
The systematic assessment prove adequate healing of the vaginal access with no local complications as well as absence of granulomas, hematomas, adhesions or retractions
Two patients restarted sexual relations before the 15 days prescribed, and the rest followed compliance with the indications. None of the patients refer or mention dyspareunia. Two patients got pregnant after the procedure and one underwent a normal birth delivery without complications.

Conclusions: the transvaginal NOTES access proves to be safe, with excellent outcomes, no complications and void of negative impact in the gynecologic and sexual aspects.

Session: Podium Presentation

Program Number: S078

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