Human Transvaginal Cholecystectomy using an IT-Knife

Background: NOTES is an evolving and controversial field of surgery on its beginning. Laparoscopic surgery and Endoscopy merges to fulfill it. Despite NOTES human experience had begin by the transgastric way with Rao in India, the transvaginal approach is taking place as a safer and easy way to achieve the upper abdomen. As on its beginning the lack of specifically designed instruments makes the procedures more difficult and we have to look for the endoscopic instruments we have and think on new ways to use it. One of these instruments is the IT-Knife (Olympus company®), originally designed for use on EMR that can be used as a useful tool on transvaginal NOTES cholecystectomy. It is a monopolar cautery that has a ceramic ball on its end not allowing the electricity to pass, cutting only on the expose wire. It prevents damage and improves safety
Aim: demonstrate in video the feasibility of a transvaginal cholecystectomy and the use of the IT-Knife instrument on this procedure
Method: Patient in semi-litotomy position under general anesthesia; closed pneumo-peritoneum with veress needle and passage of a 2-3mm trocar: colpotomy under laparoscopic guidance by means of a trocar passage in between the utero-sacral ligament: a double channel endoscope (Olympus GIF-2T160) is inserted under direct vision: the gallbladder is visualized and a 2-3mm grasper trough the umbilicus port mobilize it: a hot biopsy endoscopic grasper make a small open on the anterior and posterior peritoneal coverage of the pedicle and the IT-Knife starts dissecting until a complete exposure and individualization of the artery and cystic duct: once exposed, regular endoscopic metallic clips are applied proximally and distally to the on them: a endoscopic scissor is applied to cut the duct and artery: after cleared it, the IT-Knife is again used, now to dissect the gallbladder from the liver, making it easier with its capability of protecting the liver from being damaged by the cautery : after complete dissection, the gallbladder is grabbed with a polipectomy snare and removed by the vaginal route: the colpotomy is closed with suture.
Results: From July of 2007 our group have done 6 transvaginal cholecystectomy under IRB approval with this approach in a mean of 200min (130 to 240min), patient discharge in a mean of 5h, one intra-operative cystic artery lesion controlled with clips and no post-operative complication.
Conclusion: the transvaginal cholecystectomy as a NOTES procedures with an IT-Knife appears to be a safe and feasible procedure

Session: Podium Presentation

Program Number: V029