Abstract
Background
Natural orifice translumenal endoscopic surgery (NOTES) is an emerging concept in the recent literature that could lead to potential benefits in clinical applications. Restricted to animal experiments, however, human procedures have not yet been published. Because of the technical and ethical challenges involved in perforation and closure of a healthy organ—as is also seen in operating via the transgastric route—and because of the lack of understanding of the physiopathology and infection risk with these approaches, they have not been applied in the clinical setting. Thus the present study, based on previous animal experiments, describes preliminary clinical application in four cases of transvaginal NOTES cholecystectomy, and discusses safety, feasibility, and potential benefits of the method.
Methods
Preliminary acute and survival animal experiments developed by the NOTES Research Group at our institution solved such technical problems for transvaginal NOTES as spatial orientation, insufflation, and instrumentation, making possible the introduction of NOTES as a clinical application. The trials were approved by ethics committee of our institution, and informed consent was obtained from all patients. Since 13 March 2007, four female patients with elective surgical indication for cholecystectomy have undergone transvaginal NOTES cholecystectomy. All intraoperative and postoperative parameters were documented. Vaginal access was achieved under direct vision with conventional instruments, and a 2-channel colonoscope was inserted into the abdominal cavity. After endoscopic insufflation to achieve pneumoperitoneum with CO2, instruments were inserted through and alongside a colonoscope, allowing successful NOTES cholecystectomy in all patients, with vaginal extraction of the gallbladder. The vaginal wound was closed by direct vision using conventional instruments.
Results
The procedure was successful in all patients, with operative time of 45–115 min. Patients experienced low need for postoperative analgesia. Free oral intake was permitted 2 h after the procedure. There were no postoperative complications, and patients were discharged, according to the study protocol, 48 h after the procedure.
Conclusions
Preliminary results showed the feasibility and safety of the transvaginal NOTES method in this small initial study population. The technique, developed in our institution, and not transgastric NOTES, may be the preferred approach to serve as the basis for clinical studies.
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References
Abrao MS, Sagae UE, Gonzales M, Podgaec S, Dias JA Jr (2005) Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy. Int J Gynaecol Obstet 91:27–31
Beger H, Schwartz A, Bergmann U (2003) Progress in gastrointestinal tract surgery: the impact of gastrointestinal endoscopy. Surg Endosc 17:342–350
Bergström M, Ikeda K, Swain P, Park PO (2006) Transgastric anastomosis by using flexible endoscopy in a porcine model. Gastrointest Endosc 63:307–312
Brasil inova e retira vesicula de paciente pela vagina. Estado de São Paulo, 23th March (2007). http://www.estadao.com.br/ciencia/noticias/2007/mar/23/4.htm
Bueno B (1949) Primer caso de apendicectomia por via vaginal [in Spanish]. Tokoginec Pract (Madrid) 8:152–154
Delvaux G, Devroey P, De Waele B, Willems G (1993) Transvaginal removal of gallbladders with large stones after laparoscopic cholecystectomy. Surg Laparosc Endosc 3:307–309
Equipo medico brasileño retira la vesicula de un paciente pela vagina. Madrid Reporter Digital, 23rd March (2007). http://www.reporterodigital.com/madrid/ciencia/object.php?o=605699
Fischer-Havens A, Moses A, Ikeda K, Swain P (2006) Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance. Gastrointest Endosc 63:302–306
Gill IS, Cherullo EE, Meraney AM, Borsuk F, Murphy DP, Falcone T (2002) Vaginal extraction of the intact specimen following laparoscopic nephrectomy. J Urol 167:238–241
Harrell AG, Heniford T (2005) Minimally invasive abdominal surgery: lux et vertitas past, present, and future. Am J Surg 190:239–243
Hochberger J, Lamadé W (2005) Transgastric surgery of the abdomen: the dawn of a new era? Gastrointest Endosc 62:293–295
Jagannath BS, Kantsevoy SV, Vaughn CA, Chung SSC, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN (2006) Peroral transgastric endoscopic ligation of fallopian tubes with long term survival in a porcine model. Gastrointest Endosc 61:449–453
Kalloo AN, Singh VK, Jagannath BS, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:287–292
Kantsevoy SV, Jagannath BS, Niiyama H, Chung SSC, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN (2005) Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 62:287–292
Kantsevoy SV, Hu B, Jagannath BS, Vaughn CA, Beitler DM, Chung SSC, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN (2006) Transgastric endoscopic splenectomy. Is it possible? Surg Endosc 20:522–525
Ko CW, Kalloo A (2006) Per-oral transgastric abdominal surgery. Chin J Dig Dis 7:67–70
Lamadé W, Hochberger J (2006) Transgastric surgery: avoiding pitfalls in the development of a new technique. Gastrointest Endosc 63:698–700
Malik A, Mellinger JD, Hazey JW, Dunkin BJ, MacFadyen BV Jr (2006) Endoluminal and transluminal surgery: current status and future possibilities. Surg Endosc 20:1179–1192
McGee MF, Rosen MJ, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J (2006) A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Innov 13:86–93
Merrifield BF, Wagh MS, Thompson CC (2006) Peroral transgastric organ resection: a feasibility study in pigs. Gastrointest Endosc 63:693–697
Park PO, Bergström M, Ikeda K, Fritscher-Ravens A, Swain P (2006) Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 61:601–606
Ponsky JL (2005) Gastroenterologists as surgeons: what they need to know. Gastrointest Endosc 61:454
Rattner D, Kalloo A (2006) ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. Surg Endosc 20:329–333
Reiner IJ (1980) Incidental appendectomy at the time of vaginal surgery. Texas Med 76:46–50
Sclabas GM, Swain P, Swanstrom LL (2006) Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES). Surg Innov 13:23–30
Seifert H, Wehrmann T, Schmit T, Zeuzem S, Caspary WF (2000) Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 19:653–655
Swanstrom L, Kozarek R, Pasricha PF, Gross S, Birkett D, Park PO, Saadat V, Ewers R, Swain P (2005) Development of a new access device for transgastric surgery. J Gastrointest Surg 9:1129–1137
Targarona EM (2006) Cirurgía endoscópica transgástrica: delirio tecnológico o advance potencial [in Spanish]. Cir Esp 80:1–2
Tsin DA, Sequeria RJ, Giannikas G (2003) Culdolaparoscopic cholecystectomy during vaginal hysterectomy. JSLS 7:171–172
Vitale GC, Davis BR, Tran TC (2005) The advancing art and science of endoscopy. Am J Surg 190:228–233
Wagh MS, Merrifield BF, Thompson CC (2005) Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model. Clin Gastroenterol 3:892–896
Wagh MS, Merrifield BF, Thompson CC (2006) Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model. Gastrointest Endosc 63:473–478
Zornig C, Emmerman A, von Waldenfels HA, Felixmuller C (1994) Colpotomy for specimen removal in laparoscopic surgery. Chirurg 65:883–885
Zorrón R, Fang HL, Soldan M, Costa M, Oliveira AL, Rios M, Elia CSC (2007) Transvaginal NOTES para colecistectomia: estudo experimental. Rev Bras Videocirurgia - (in press)
Acknowledgments
The authors are grateful to Richard Wolf GmbH, Germany; e Tyco Healthcare, Auto Suture Brazil; Fujinon, Japan; and Labormed, Brazil, for technical support for experimental and clinical NOTES studies.
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Zorron, R., Maggioni, L.C., Pombo, L. et al. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc 22, 542–547 (2008). https://doi.org/10.1007/s00464-007-9646-5
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DOI: https://doi.org/10.1007/s00464-007-9646-5