Hybrid Transvaginal NOTES Cholecystectomy
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).
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).
The hook electrocautery is used to dissect the gallbladder off the gallbladder fossa (see the image below).
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).
Complications
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.
-
Transvaginal cholecystectomy. Position of patient.
-
Transvaginal cholecystectomy. Incision for entry into cul-de-sac.
-
Transvaginal cholecystectomy. Clips on cystic artery.
-
Transvaginal cholecystectomy. Division of cystic artery between clips.
-
Transvaginal cholecystectomy. Dissection of gallbladder off gallbladder fossa.
-
Transvaginal cholecystectomy. Closure of culdotomy.
