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Meadows and Chamberlain

surgery (intensive care patients) may have NOTES performed as a bedside procedure in the future, this seems fanciful and would be limited to diagnostic NOTES peritoneoscopy rather than a therapeutic procedure.36

Patient acceptance of NOTES approaches to cholecystectomy

Although physicians and surgeons are intrigued by the notion of “incisionless” surgery, whether patients will consent to these investigational procedures is not certain. Among 100 patients questioned on their feeling about NOTES, 78% stated that they would prefer NOTES to a traditional laparoscopic cholecystectomy.37 The most common reason for preferring NOTES was to avoid incisional pain and scar- ring, however the extent of post-procedural pain has yet to be quantified in a NOTES study comparing it to traditional laparoscopic cholecystectomy. Over 97% of the patients sur- veyed stated that they would consent to a NOTES approach only if the risk of complications were equal to or lower than a laparoscopic approach. Interestingly, both men (92%) and women (87%) preferred an oral route of access over trans- vaginal and transrectal approaches. Eighty-two percent of the surveyed group who preferred laparoscopic cholecystectomy over NOTES stated that they considered the complication risks and the proven safety and efficacy of the procedure the most important factors in selecting this procedure. When the complication rates of NOTES were described to the entire group as potentially higher than a traditional laparoscopic cholecystectomy, overall interest decreased to less than 15%.

Transitioning to NOTES: the “hybrid” NOTES and SILS approaches

While awaiting engineering and technical solutions to many challenges surrounding NOTES, many surgeons have devel- oped “hybrid” techniques in an effort to transition us towards “incisionless” surgery. “Hybrid” NOTES involves making one or several incision(s) on the abdominal wall and inserting a trocar(s) for aid in overcoming current barriers such as permitting the use of rigid laparoscopic instrumentation for retraction of surrounding tissue and direct visualization of the transluminal incision. A large number of “hybrid” techniques have been described which involve placement of needles or ports through the abdominal wall for a variety of reasons including: (1) gaining optic connection, (2) use of rigid instrumentation, (3) stable retraction, (4) visualization


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of the colpotomy or gastrotomy, and (5) safe closure of organ incision.10,35,38–48 These approaches are detailed in Table 3. Echoing comments by many, Zornig et al have rhetorically asked whether these hybrid techniques should be termed “laparoscopically assisted transvaginal surgery” or “transvaginally assisted laparoscopic surgery” rather than “hybrid” NOTES.35

Parallel to the development of NOTES, has been the emergence of single incision laparoscopic surgery or SILS, as a means to bridge the current technological gap between stan- dard laparoscopy and NOTES. A variety of procedures has been described which involve a single umbilical skin incision followed by insertion of a 3- or 4-port trocar or placement of multiple trocars through the same SILS incision.7 Navarra et al reported the first SILS cholecystectomy in 1997 using two 10-mm trocars and three transabdominal stay sutures to facilitate gallbladder retraction.49 A substantial number of human trials and large case reports have emerged to con- firm the feasibility and safety of SILS (see Table 4).31,49–61 However, as with NOTES, whether SILS provides for any non-cosmetic advantages versus traditional laparoscopic cholecystectomy is unclear. Moreover, whether SILS will result in increased risk of hernia and wound complications is also an unanswered concern.

The remainder of this review will focus on published reports of human NOTES cholecystectomy. “Hybrid” NOTES procedures will be defined as any NOTES proce- dure that involves transabdominal needles or laparoscopic instruments, whereas procedures done entirely with only transluminally placed instrumentation will be referred to as a “pure” NOTES procedure.

Published reports of human NOTES cholecystectomy Transvaginal approach to NOTeS cholecystectomy

One hundred and seventy-four of the 186 (93.5%) NOTES cholecystectomies reported in humans have been per- formed via a transvaginal route. In general, the ability to use current rigid instrumentation and familiarity with transvaginal surgery for performing other procedures such as hysterectomies has provided a “comfort level” for more rapid maturation of this access method. In a recent survey of 181 Chairmen of Obstetrics and Gynecology, 69% reported that the transvaginal approach was an ethi- cal and sound approach for the advancement of NOTES, while only 31% considered it experimental.33,62 In addition,

Open Access Surgery 2010:3

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