Transvaginal Notes Cholecystectomy: Key Technical Points

Lucian Panait, MD, Stephanie G Wood, MD, Robert L Bell, MD, Andrew J Duffy, MD, Kurt E Roberts, MD. Yale School of Medicine


Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) is gaining increasing acceptance, equally among physicians and patients. Randomized trials are in progress to better assess the safety and efficacy of these procedures.
Methods: Sixty transvaginal NOTES cholecystectomies were performed at our institution to date. The greatest part of the operation is achieved with a laparoscopic camera positioned through a 12 mm vaginal port, and a working 5 mm port at the umbilicus. We exclusively use straight standard laparoscopic instruments for the intraabdominal part of the procedure. Transabdominal sutures are placed through the gallbladder fundus and infundibulum to facilitate retraction of the gallbladder and expose the cystic triangle area. Dissection of the cystic duct and artery is performed similarly to the standard laparoscopic technique.
Results: Some key elements of the procedure need to be taken into account in order to minimize the chances of iatrogenic injuries. Vaginal access is achieved on the posterior vaginal wall, with a Veres needle attached to a dilator sheath. The abdominal cavity should be entered under direct vision provided by a laparoscope placed at the umbilicus, and with the uterus anteverted. The right hepatic artery is more clearly visualized in the NOTES cholecystectomy. Given the low position of the transvaginal camera, the critical view of safety is different from the standard laparoscopic technique: the cystic duct and artery present at a different angle, forming a configuration similar to the letter “V”. However, different angulation of the camera allows visualization of these elements from the right side, thus achieving a “reverse critical view”. This right side visualization of the duct and artery is rarely possible with the standard technique, given the position of the camera at the umbilicus. Lastly, some challenges are present when placing the gallbladder in a specimen retrieval bag inserted through the vaginal port.
Conclusion: Transvaginal NOTES cholecystectomy is an attractive alternative to laparoscopy in female patients. With adequate precautions and mastery of the surgical technique, the procedures are safe, have good postoperative outcomes and improved cosmesis when compared with laparoscopy.

Session Number: SS25 – Videos: NOTES / Flexible Endoscopy
Program Number: V066

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