Transvaginal Insertion of Internal Retractor for Hybrid Notes (natural Orifice Translumenal Endoscopic Surgery) Transvaginal Cholecystectomy.

Since the introduction of hybrid NOTES transvaginal (TV) cholecystectomy, retraction of the gallbladder has been described with magnets, percutaneos sutures and flexible long grasper. The need for adequate instrumentation gives room for improvement and development of new instrumentation. Here in we describe a novel technique for internal retraction of the gallbladder.

Non-survival Hybrid Transvaginal NOTES Cholecystectomies were performed in swines. For insertion of the TV port and the internal retractor a 5mm 30 degree laparoscope was used. The retractor consisted of a modified bulldog clamp, the Cinch Organ Retractor System (Aesculap, Tuttlingen, Germany). It was introduced through the transvaginal port and deployed in the gallbladder fundus using an Applier grasper of 75-cm in length. The retraction system was then attached to the parietal peritoneum of the right hemidiaphragm. To carry out the dissection, a double-channel endoscope, an endoscopic grasper and a laparoscopic flexible-tip “L” hook cautery were used. Regular 5-mm laparoscopic clips were used. The specimen was extracted transvaginally along with the retraction clip.

Between August 2010 and February 2011, 10 hybrid NOTES cholecystectomies were succesfully performed. Operative time was 100±20 minutes. Estimated blood loss was minimal. No intraoperative complications or conversions were documented.

TV hybrid cholecystectomy is a safe and feasible technique. The use of this novel retraction mechanism improved surgical exposure and demonstrated also to be safe. In addition can be introduced and removed transvaginally along with the specimen therefore not increasing invasiveness. The concept of internal retraction can potentially broaden the range of procedures that can be performed an eventually allow for pure NOTES procedures in the future.



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