Transvaginal Cholecystectomy

From the first open cholecystectomy performed in 1882 by Langenbuch[1] to the first laparoscopic cholecystectomy performed by Mühe in 1985[2] to the culdolaparoscopic cholecystectomy performed by Tsin et al in 1999[3] to the transvaginal cholecystectomy performed by Zorrón et al in 2007,[4] the treatment of symptomatic gallbladder disease has come a long way.

Kalloo et al are credited with the first description of a natural orifice transluminal endoscopic surgery (NOTES) procedure in 2004,[5] in which they described its safety and feasibility in a porcine model. Since then, multiple NOTES procedures have been performed, and this technique has been steadily increasing in popularity. At present, the most commonly performed NOTES procedure is transvaginal cholecystectomy.[6, 7]

Laparoscopic cholecystectomy currently is the most commonly performed surgical procedure for symptomatic gallbladder disease. Given the rapidly changing face of surgery today, NOTES cholecystectomy may be the wave of the future. The transition from open to laparoscopic and then to minimally invasive single-port surgery has been associated with a marked reduction in the degree of invasiveness, and NOTES surgery represents the next step in the evolution of surgical technique.[8, 9]

With the instrumentation currently available, pure NOTES transvaginal cholecystectomies can be cumbersome, which is why a hybrid transvaginal NOTES procedure is described in this article.

Indications for transvaginal cholecystectomy include the following:

• Symptomatic cholelithiasis
• Biliary dyskinesia
• Gallstone ileus with cholecystoduodenal fistula - A few reports of treatment with hybrid NOTES technique are available in the literature ^[10]

Absolute contraindications for transvaginal cholecystectomy include the following:

• Evidence of gangrenous cholecystitis
• Pregnancy
• Inflammatory bowel disease
• American Society of Anesthesiologists (ASA) classification 3 or 4

Relative contraindications include a history of pelvic inflammatory disease, endometriosis, retroflexed uterus, or previous abdominal surgery.

Patients with such contraindications should be excluded, and a conventional laparoscopic cholecystectomy should be performed.

These contraindications are likely to evolve as cholecystectomy via NOTES advances and gains momentum and surgeon expertise increases.

Anatomy

The gallbladder is a pear-shaped organ situated on the undersurface of the liver in a fossa corresponding to segments 4 and 5 and at the lower limit of the Cantlie line (an imaginary line running from the middle of the gallbladder anteriorly to the inferior vena cava posteriorly). It occupies a variable position in relation to the liver, and so it may be partially or completely embedded within the liver parenchyma (the so-called intrahepatic gallbladder); this may create difficulties in dissection and may increase the risk of intraoperative liver injury.

Large portal and hepatic venous branches traverse the liver at a depth of around 1 cm from the gallbladder; thus, a deep liver tear during the dissection of the gallbladder off its fossa can occasionally bleed profusely. Therefore, it is important to err on the side of the gallbladder rather than the liver parenchyma during dissection.

The gallbladder is divided into a fundus, a body, and a neck or infundibulum. The Hartmann pouch, an outpouching of the wall in the region of the neck, varies in size; a large Hartmann pouch may obscure the cystic duct and the Calot triangle. If a small cystic duct is hidden in this way and traction is placed on the gallbladder, the common bile duct (CBD) may be mistaken for the cystic duct, which can result in disastrous consequences.

The cystic duct joins the gallbladder to the CBD. It generally ranges from 2 to 4 cm in length; however, its length may be highly variable, and it may run a straight or a fairly convoluted course. It is usually 2-3 mm wide but may be dilated in the presence of pathology (stones or passed stones). The normal bile duct is also around 5 mm and hence can look like a mildly dilated cystic duct. It is therefore of utmost importance to properly identify both structures.

The cystic artery is a branch of the right hepatic artery (RHA) that is usually given off in the Calot triangle and enters the gallbladder in the neck or body area. The course and length of the cystic artery in the Calot triangle vary. Although the artery typically traverses the triangle almost in its center, it can occasionally be very close or even lower than the cystic duct.

The RHA normally courses behind the bile duct. It may come very close to the gallbladder and the cystic duct in the form of the “caterpillar” or “Moynihan” hump. In this case, the cystic artery is usually short. In this situation, the RHA is liable to be mistakenly identified as the cystic artery or torn in an attempt to ligate the cystic artery.

The Calot triangle was originally described by Calot in 1891 as being bound by the cystic duct, the common hepatic duct, and the cystic artery. However, in its present interpretation, the upper border is formed by the inferior surface of the liver, with the other two boundaries being the cystic duct (lateral) and the CBD (medial). Its contents usually include the RHA, the cystic artery, the cystic lymph node (Calot node), connective tissue, and lymphatics. In some cases, it contains accessory hepatic ducts and arteries.

It is this triangular space that is dissected during cholecystectomy to identify the cystic artery and cystic duct before ligation and division. In reality, it may be a small potential space rather than a large triangle.

Best practices

If intraoperative complications arise during a transvaginal cholecystectomy, understanding when to convert to a conventional laparoscopic technique is of utmost importance and shows good surgical judgment.

Transvaginal cholecystectomy reduces postoperative pain, eliminates skin infections and incisional hernias, and improves cosmesis, allowing a faster return to daily activities, faster return to work, and overall decreased health care cost.

One of the main advantages of transvaginal cholecystectomy is decreased postoperative pain. The authors of this article have observed this benefit in their patients, and transvaginal hysterectomies compare favorably to abdominal hysterectomies regarding pain in the gynecologic literature.[11, 12]

The absence of a skin incision prevents all complications associated with skin incisions. In addition to preventing pain, the elimination of skin infections, abdominal wall hernias, and aesthetic deformities is also a potential advantage.

Patients who undergo NOTES procedures also have a faster return to daily activities, faster return to work, and reduced health care costs compared to the laparoscopic technique.[13]

There are reports demonstrating no significant difference in safety between NOTES cholecystectomy and laparoscopic cholecystectomy.[14, 15, 16] Despite good reported results, there are reports of apprehension about performing transvaginal cholecystectomy, attributable to limited awareness of the procedure.[17]

The following equipment is used for transvaginal cholecystectomy:

• Port (5 mm) for the umbilical site
• Port (12 mm)
• Extracorporeal sutures
• Maryland dissector
• Scissors
• Clip applier
• Electrocautery
• Gallbladder retrieval bag

Anesthesia

General anesthesia is required because of the need to insufflate the abdominal cavity to ensure adequate visualization.

Positioning

The patient is placed in the low lithotomy position with stirrups (see the image below). After Veress needle insufflation of the abdominal cavity through the umbilical site, the patient is placed in a steep Trendelenburg position.

Transvaginal cholecystectomy. Position of patient.

Patients are recommended to refrain from sexual intercourse for a period of 2 weeks, as recommended by the gynecologists in the authors’ institution.

After a surgical timeout, the patient is positioned, prepared, and draped. The Veress needle is placed through the 5-mm incision made within the umbilicus into the peritoneum, and the abdominal cavity is insufflated to achieve an intra-abdominal pressure of approximately 15 mm Hg. The patient is then placed in a steep Trendelenburg position.

A scope is inserted through the umbilical port and the cul-de-sac visualized. A weighted speculum is introduced into the vagina, which allows visualization of the cervix and exposure of the posterior vaginal fornix.

The fornix is grasped with a single-toothed tenaculum on the posterior cervical lip, and the posterior vaginal fornix is thus brought into the operative field (see the image below).

Transvaginal cholecystectomy. Incision for entry into cul-de-sac.

A 12-mm port is introduced via the Veress system through the posterior fornix into the cul-de-sac, with direct visualization through the umbilical port.

The patient in placed in the reverse Trendelenburg position to allow adequate visualization of the upper abdomen through the transvaginal port with an extra-long 45° angle.

A 2-0 glycolide-lactide suture is passed on a Keith needle intracorporeally through the right upper quadrant close to the lowest rib and through the midbody of the gallbladder for cephalad retraction. Similarly, a second 2-0 glycolide-lactide suture is passed on a Keith needle intracorporeally and through the infundibulum of the gallbladder for lateral retraction.

The hilum of the gallbladder is dissected with a Maryland dissector so as to expose the cystic duct and cystic artery. The cystic duct and cystic artery are then clipped with 5-mm clips (see the first image below) and divided with scissors through the umbilical port (see the second image below).

Transvaginal cholecystectomy. Clips on cystic artery.

Transvaginal cholecystectomy. Division of cystic artery between clips.

The hook electrocautery is used to dissect the gallbladder off the gallbladder fossa (see the image below).

Transvaginal cholecystectomy. Dissection of gallbladder off gallbladder fossa.

A gallbladder retrieval bag is inserted through the vaginal port, and the gallbladder is removed through this port.

Adequate hemostasis is ensured. The culdotomy is closed with a running absorbable suture (see the image below).

Transvaginal cholecystectomy. Closure of culdotomy.

Any cholecystectomy, regardless of technique (open, laparoscopic, or natural orifice transluminal endoscopic surgery [NOTES]), can cause the following complications:

• Hemorrhage - Potential bleeding sources include the liver bed, the hepatic artery and its branches, and the porta hepatis
• Bile duct injuries - These may result in biliary leaks, biliary strictures, and cholangitis; biliary leaks may also result from clips slipping off the cystic duct; however, the most common cause of a bile leak after cholecystectomy is transection of the ducts of Luschka

Potential complications specific to the NOTES procedure may be extrapolated from the complications of culdoscopy (accessing the abdominal cavity through the posterior fornix) described in the gynecology literature. One potential complication described in the culdoscopy literature is bowel or rectal injury, which occurs in approximately 0.25% of cases.[18]

Other potential adverse effects from the gynecologic perspective include the formation of adhesions and spread of preexisting endometriosis.

Although the potential for infertility or dyspareunia was once a concern, the uterus is only passed by and uninjured on the way to the posterior fornix, and therefore any effect on potential childbearing is unlikely.

Also extrapolated from the gynecologic literature on transvaginal access for hysterectomy, preservation of sexual function is similar to that associated with transabdominal access.[19, 20] However, patients are recommended to refrain from sexual intercourse for a period of 2 weeks.