NOTES hybrid transvaginal cholecystectomy with a flexible endoscope

This video shows a stepwise approach for a NOTES transvaginal cholecystectomy. The advantages of the hybrid technique are approached.

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NOTES hybrid transvaginal cholecystectomy with a flexible endoscope

Authors

D Mutter, B Dallemagne, S Perretta, J Marescaux

Abstract

This video shows a stepwise approach for a NOTES transvaginal cholecystectomy. The advantages of the hybrid technique are approached.

Keywords

NOTES hybrid transvaginal cholecystectomy, flexible endoscope

Media type

Surgical video

Duration

03'35''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2413.htm

NOTES hybrid transvaginal cholecystectomy with a flexible endoscope

1. Clinical case presentation 00'11''

Presented in this video are the steps necessary to perform a laparoscopic-assisted cholecystectomy via a trans-umbilical incision in a 53-year-old woman with symptomatic cholelithiasis.

2. Transabdominal approach 00'25''

Under general anesthesia, an exploratory laparoscopy was carried out via a 5mm umbilical trocar to assess the feasibility of transvaginal cholecystectomy. The placement of this 5mm trocar was mandatory to insufflate CO2, to monitor the pneumoperitoneum and to allow the use of a 5mm laparoscopic clip applier at a later stage of the procedure.

3. Transvaginal approach 00'51''

Once the feasibility of transvaginal cholecystectomy was assessed, a double channel standard endoscope was introduced through a posterior vaginal colpotomy. An extra long rigid atraumatic laparoscopic grasper was advanced alongside the scope to retract the infundibulum of the gallbladder cephalad. Both the transvaginal access to the peritoneal cavity and the introduction of the double channel gastroscope and the grasper were performed under laparoscopic control using a 5mm optic. Now to the cholecystectomy. While the view was provided by the endoscope, CO2 insufflation was accomplished by the 5mm port at the umbilicus, which also served to alternatively expose, isolate, and clip the cystic duct and artery and dissect the gallbladder free from the liver bed using standard 5mm laparoscopic grasper, hook and clip applier.

4. Calot’s triangle identification 01'44''

The elements of Calot’s triangle were clearly identified and dissected with excellent visualization of the cystic duct and artery, which were clipped twice on patient side and once on gallbladder side and divided; The use of a rigid laparoscopic 5mm clip applier was utilized to improve the safety of this procedure. The surgeon and the assistant who holds the endoscope stand between the patient’s legs.

5. Gallbladder extraction 02'50''

The gallbladder was dissected away from the intrahepatic fossa using the hook and upon complete dissection placed in a specimen retrieval bag prior to removal through the vagina; the operative site was checked to ensure hemostasis and rule out any inadvertent injury to the adjacent organs. No bleeding or bile leak occurred during the procedure. The patient had no postoperative pain, “no visible scars” and was discharged on the second postoperative day. At 2 months\' follow-up, the patient was doing fine; there were no postoperative complications. A true NOTES procedure without the use of any abdominal port(s) is still under investigation with many potential obstacles. Advantages of this hybrid technique include the ability to use conventional laparoscopic clips rather than flexible endoscopic clips, which expose, in our opinion, to the potential risk of bleeding and bile leaks. The operation was performed by a multidisciplinary team, which included a gynecologist who performed and closed the colpotomy. The use of only a single laparoscopic incision greatly simplifies the technique, shortens the operative time and learning curve at the cost of no visible abdominal scars.