Rigid Transvaginal Retraction in Hybrid NOTES Cholecystectomy

Introduction: As techniques of natural orifice translumenal endoscopic surgery (NOTES) improve, the safe performance of totally translumenal surgery is becoming more feasible. In a previous report of a hybrid approach to natural orifice transvaginal cholecsytectomy we noted difficulty with gallbladder retraction and could only accomplish this transabdominally.
We present a novel technique and instrument that allows for safe and effective transvaginal gallbladder retraction.
Methods: A 35 year-old woman with a past surgical history of tubal ligation presented with symptoms consistent with biliary colic. After informed consent for participation in an IRB approved study transvaginal cholecystectomy was performed. Transvaginal access was obtained using a 15 mm trocar trough the posterior fornix of the vagina after insufflation with a Verres needle. A dual channel therapeutic gastroscope (Karl Storz, Germany) was inserted through the trocar. A purpose built long curved retractor (Aesculap, Tuttlingen, Germany) was passed transvaginally, alongside the endoscope, into the abdomen and used to retract the gallbladder. A single 5 mm trocar was placed at the umbilicus to ensure the safety of the vaginal entry and for placement of clips.
Results: The retractor was safely passed into the abdomen transvaginally. Adequate retraction of the gallbladder and good exposure were obtained. Attempts at endoscopic clip placement with 2 types of clips (Olympus, USA; Inscope, USA) were felt to be inadequate and the cystic structures were both controlled with laparoscopic clips. The patient did well, was discharged on the day of surgery and used no postoperative pain medication.
Conclusion: Rigid transvaginal gallbladder retraction allowed for elimination of a transabdominal port. Use of rigid instrumentation is another potential advantage of the transvaginal approach for NOTES. As experience with NOTES continues and purpose-designed instrumentation is developed, a safe totally translumenal approach to cholecystectomy and other procedures will be possible.

Session: Podium Presentation

Program Number: V011

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