NOTES Transvaginal Hybrid Cholecystectomy: Early Experience of a New Approach

Shohan Shetty, MD, Amir H Shariff, MD, Andrew J Duffy, MD, Robert L Bell, MD, Kurt E Roberts, MD. Yale University School of Medicine, New Haven, CT, Saint Mary’s Hospital, Waterbury, CT

Background
Natural orifice translumenal endoscopic surgery (NOTES) is an innovative approach in minimally invasive surgery that has been found to be a practical and safe alternative to laparoscopic cholecystectomy. Initial reports have suggested faster recovery and less pain with NOTES cholecystectomy when compared to a traditional 4-port laparoscopic cholecystectomy. We describe the results of the first series of NOTES transvaginal hybrid cholecystectomy within the United States.
Methods
Through a 5 mm vertical transumbilical incision, a 5-mm trochar was placed using the Veress technique. A 12-mm trochar was introduced through the posterior vagina into the cul-de sac under direct visualization. An endoscope was then introduced through the vaginal port to visualize the gallbladder. Two extracorporeal stay sutures were utilized to provide retraction of the gallbladder. The hilum of the gallbladder was dissected and the cystic duct and artery were clipped and divided using standard laparoscopic instruments through the umbilical port. The gallbladder specimen was removed through the vaginal port. Patient demographic data, operative time, length of stay, surgical pathology and complications were recorded.
Results
This prospective study was conducted at Yale-New Haven Hospital between August 2009 and September 2010. Fifteen patients underwent a successful NOTES transvaginal hybrid cholecystectomy. The average age was 33.8 years (21-55 years) and the average BMI was 29 kg/m² (18.3-38.1 kg/m²). The mean operative time was 67 min (45-94 min). There was no requirement for additional trocar placement, conversion to 4-port laparoscopic or open cholecystectomy. All patients were discharged on the same day of the operation. No complications were observed. All patients were very pleased with their outcomes.
Conclusion
NOTES transvaginal hybrid cholecystectomy is a safe and feasible alternative to 4-port laparoscopic cholecystectomy with excellent cosmetic results and high patient satisfaction. Randomized controlled trials are necessary to confirm our promising early results.

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