Transvaginal hybrid NOTES cholecystectomy using an internal retractor

Under general anesthesia with the patient supine in lithotomy position, a pelvic exam is performed. A first 5mm umbilical trocar is placed and an exploratory laparoscopy is performed to ascertain the feasibility of a NOTES cholecystectomy. The patient is then tilted in steep Trendelenburg. The posterior vaginal vault is carefully examined before gaining access to the peritoneal cavity. A linear cold blade scalpel incision is made in the cul-de-sac, well posterior in the fold between the uterosacral ligaments, 1cm below the uterine os.

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Transvaginal   hybrid   NOTES   cholecystectomy   using   an   internal   retractor

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
Under general anesthesia with the patient supine in lithotomy position, a pelvic exam is performed. A first 5mm umbilical trocar is placed and an exploratory laparoscopy is performed to ascertain the feasibility of a NOTES cholecystectomy. The patient is then tilted in steep Trendelenburg. The posterior vaginal vault is carefully examined before gaining access to the peritoneal cavity. A linear cold blade scalpel incision is made in the cul-de-sac, well posterior in the fold between the uterosacral ligaments, 1cm below the uterine os.
Keywords
Transvaginal hybrid NOTES cholecystectomy, EndoGrab™, internal retractor
Media type
Duration
04'45''
Publication
2010-02
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E-publication
WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2892.htm

Transvaginal   hybrid   NOTES   cholecystectomy   using   an   internal   retractor

1. Case description 00'10''
Under general anesthesia with the patient supine in lithotomy position, a pelvic exam is performed. A first 5mm umbilical trocar is placed and an exploratory laparoscopy is performed to ascertain the feasibility of a NOTES cholecystectomy. The patient is then tilted in steep Trendelenburg. The posterior vaginal vault is carefully examined before gaining access to the peritoneal cavity. A linear cold blade scalpel incision is made in the cul-de-sac, well posterior in the fold between the uterosacral ligaments, 1cm below the uterine os. The fascia is pushed downward, displacing the rectum and exposing a wide area of thin peritoneum. The peritoneum is then carefully opened in safe window without danger of injury to the bowel, between the uterosacral ligaments. A double channel endoscope together with a 60cm long laparoscopic grasper are introduced transvaginally. The gallbladder is exposed using the transvaginal long laparoscopic grasper and the dissection started with scissors. In order to improve the exposure, an internally anchored, hands-free retracting device “the EndoGrab™” is introduced. The EndoGrab™ is brought in by the 5mm port by means of a dedicated applier, which is first attached to the gallbladder and then anchored to the abdominal wall, thereby exposing the operative field. The introducer is then removed and the port is free for the laparoscopic hook to continue the dissection. This way, the elements of Calot’s triangle could be 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. A combination of altered lighting, fish eye vision and lack of haptic feedback can create an optical illusion during NOTES cholecystectomy. It is therefore mandatory to achieve correct exposure and opening of the triangle of Calot’s as was done in this case thanks to the EndoGrab™. The gallbladder was dissected away from the intrahepatic fossa with the hook and 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. The colpotomy was then closed with 3/0 Vicryl sutures.