Jesse Bandle, MD, Gordon Wisbach, MD. Naval Medical Center San Diego
OBJECTIVES: We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution.
METHODS: Institutional Review Board approval was obtained to perform this prospective study. Ten women with an indication for cholecystectomy were enrolled. Inclusion criteria included ASA classification 1 as well as no previous abdominal surgery or gynecology disorders. All patients were examined by gynecology prior to operation. Our technique involved initial placement of a infra-umbilical 5mm port for visual exploration followed by a posterior colpotomy to accommodate a single-site working port. The laparoscope and a retracting grasper were placed through the colpotomy port site to facilitate the dissection of Calot’s triangle and mobilization of the gall bladder. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture.
RESULTS: Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy and one operation included an intra-operative cholangiogram. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 132 mins (95-180) and median blood loss was 20 ml (5-400). There were no conversions to traditional laparoscopic or open cholecystectomy and average length of stay was 11.4 hrs (2.4-28.8). Pain (scale 1-10) on post-operative day three was minimal (mean 2.3) and was related only to the infra-umbilical incision. On average patients returned to work by post-operative day seven and resumed normal daily activities at eight days. Complications included one patient with post-operative urinary retention requiring bladder catheterization.
CONCLUSION: Application of the NOTES technique to cholecystectomy can be safely and effectively performed. Military benefits may include earlier return to work for the service member and therefore improved operational readiness.
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