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Peritoneal access

Number of incisions

Size of trocars

Location of trocars Right hypochodrium

Transvaginal

0

2-mm needle port

Transvaginal

1

5-mm

Umbilicus

Transvaginal

1

5-mm

Umbilicus

Transvaginal

1

5-mm

Umbilicus

Transvaginal

1

5-mm

Umbilicus

Transvaginal

1

3-mm

Umbilicus

Transvaginal

1

3-mm

Right hypochodrium

Transvaginal

1

2- or 3-mm

Right hypochodrium

Transvaginal

1

3-mmb

Left upper quadrant

Transvaginal

2

5-mm and 2-mm

Umbilicus and right hypochodrium, respectively

Transvaginal

2

5-mm and 3-mm

Umbilicus and right upper quadrant, respectively Umbilicus

Transvaginal

2

3-mm × 2

Transgastric

1a

5-mm

Umbilicus

Transgastric

1a

5-mm

Umbilicus

Additional dissection port using rigid instrumentation Laparoscopic visualization, retraction, primary port for utilization of 5-mm endoclips Laparoscopic visualization

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Table 3 All published reports of transvaginal “hybrid” NOTeS cholecystectomy

Techniques and challenges of NOTeS cholecystectomy

Purpose

Insufflation, laparoscopic visualization, and retraction

Maintain insufflation, mobilization of gallbladder Insufflation, laparoscopic visualization, additional dissection port using rigid instrumentation, mobilization of gallbladder Insufflation, laparoscopic visualization, additional dissection port using rigid instrumentation Insufflation, laparoscopic visualization, retraction, primary port for dissection using rigid instrumentation Laparoscopic visualization, retraction Retraction

Retraction

Laparoscopic visualization, insufflation 5-mm: laparoscopic visualization, primary port for dissection and clipping 2-mm: retraction 5-mm: laparoscopic visualization 3-mm: retraction

Decarli et al (2009)65 Dallemagne et al (2009)44

Asakuma et al (2009)45

Authors

Zornig et al (2009)35

(2007)47 Zornig et al (2007)41

Navarra et al (2009)38

Marescaux et al (2007)10

Branco Filho et al

Palanivelu et al (2009)43 Zorrón et al (2007)40 Zorrón et al (2008)39 Forgione et al (2008)42 Ramos et al (2008)48

Noguera et al (2009)46

Notes: “Hybrid” NOTeS was created to overcome current technological barriers which exist in NOTeS such as (1) gaining optic connection, (2) use of rigid instrumentation, (3) stable retraction, (4) visualization of the colpotomy or gastrotomy, and (5) safe closure of organ incision. “Hybrid” NOTeS involves the placement of transabdominal needles or laparoscopic instruments to assist transluminal instrumentation. aAn addition 2- or 3-mm grasper in the umbilicus or 3-mm trocar in the right hypochondrium were used liberally based on individual cases; bMade into a 5-mm trocar for utilization of 5-mm endoclips.

the distance from incision to the target organ is shorter and more direct via a transvaginal approach compared to a transgastric approach, and the ability to triangulate for optical correctness transvaginally makes dissection easier than via a transgastric method.35

Zornig et al have the largest published experience with transvaginal “hybrid” NOTES cholecystectomies involving 68 patients.35 Initially, patients considered for NOTES must have had a BMI , 35, no prior surgery and no symptoms of acute cholecystitis. As their experience grew, the investigators evolved their criteria to exclude

only patients that had undergone prior pelvic surgery or radiation, had a BMI . 35, a history of endometriosis or when severe adhesions were anticipated. All 68 procedures were successfully completed without the need for traditional laparoscopic conversion. There were no perioperative or immediate postoperative complications, however one patient (1.47%) did present with a pelvic abscess three weeks postoperatively. All 68 patients were interviewed between 3 and 10 months postoperatively, and reported no procedural complaints. Forty-eight (70.6%) of the patients reported having sexual intercourse within 6 weeks after the

Open Access Surgery 2010:3

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