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operation. The mean operating time for all 68 procedures was 51 minutes (range 30–100).

The surgical technique utilized by these authors involved placing the patient in the lithotomy position followed by perineal and abdominal prep with transvaginal iodopovi- done. A 5-mm incision was made in the umbilicus through which a pneumoperitoneum was created and maintained.The patient was then placed in the steep Trendelenberg position to reduce the risk of accidental injury to the small bowel and to expose the pouch of Douglas.33,38 A 5-mm mandarin was inserted into the posterior fornix of the vagina under laparoscopic guidance via the 5-mm umbilical port site and then replaced with a 5-mm extra-long dissector which was used for retraction of the gallbladder. Alongside this dissector, a 10-mm trocar was placed and an extra-long 45° 10-mm camera was inserted and utilized for the remainder of the operation. The dissection of the gallbladder includ- ing clipping and dividing the cystic duct and artery, and removal of the gallbladder from the underside of the liver with cautery was completed through the 5-mm umbilical port site. Once the gallbladder was fully mobilized, the umbilical dissector was exchanged with the original 5-mm camera and the specimen retrieval bag was placed through the 10-mm vaginal trocar. The vaginal defects were closed with interrupted absorbable sutures in standard fashion.

Palanivelu et al have described a variation of this “hybrid” NOTES technique that was performed on 8 patients.43 Two patients (25%) were converted to a traditional laparoscopic procedure due to either severe adhesions or a wide cystic duct that could not be completely occluded by endoclips. One patient (12.5%) developed a bile leak due to a partially slipped endoclip. In the fourth week another patient (12.5%) complained of dyspareunia whereby vaginal inflammation was observed.This patient subsequently recovered after treat- ment with antibiotics. The mean operative time for all eight procedures was 149 minutes (range 115–182). These authors placed a 3-mm umbilical trocar through which a 3-mm camera was inserted and used to help guide a double-channel endoscope from the vaginal incision to the gallbladder. The 3-mm camera was replaced with a 3-mm toothed grasper to help retract the gallbladder superiorly. A biopsy forceps was then inserted into the left working channel of the double- channel endoscope to hold the infundibulum. In the right channel, a hot biopsy forceps with diathermy was used for dissection. The remainder of the operation was similar to that used by Zornig et al discussed above.

Gumbs et al was the first to report a “pure” NOTES cholecystectomy in June 2009.33 This report included

Open Access Surgery 2010:3

Techniques and challenges of NOTeS cholecystectomy

four patients; the first three patients underwent a “hybrid” NOTES procedure similar to that described by Zornig et al while the fourth patient had a “pure” NOTES transvaginal cholecystectomy. Patients were excluded for consider- ation if they had acute cholecystitis, choledocholithiasis, gallstone pancreatitis, prior pelvic or abdominal surgery, a history of endometriosis, or pelvic inflammatory diseases. No complications were noted with this procedure; however the “pure” NOTES patient reported a higher pain score immediately postoperatively (7/10) than the other 3 “hybrid”.

NOTES patients (mean score = 4). At 2- and 4-week follow-up all patients were pain-free, with no reported com- plications. This “pure” NOTES procedure took 185 minutes to complete.

The technique used for the “pure” NOTES procedure involved placing the patient in lithotomy and in a steep Trendelenberg position.The cervix was grasped and retracted upwards, and a 1-cm incision was created in the posterior fornix with a bovie electrocautery knife followed by blunt dis- section.A 15-mm trocar was inserted followed by abdominal insufflation. A 12-mm double-channel gastroscope was then inserted and retroflexed to inspect surrounding areas for inad- vertent injury. An adjacent laterally placed colpotomy was then made and a 5-mm trocar was inserted to permit a rigid curved 5-mm extra long reticulating retractor to be positioned in the right upper quadrant and used to retract the gallbladder. Skeletonization and dissection was completed through the working channels of the dual-chamber gastroscope with an endoscopic hook knife and a grasping biopsy forceps. The endoscopic clips were manually modified with 2 needle hold- ers to straighten the tips, since there are no FDA-approved clips for ligation of the cystic duct and artery currently avail- able. The gallbladder was dissected off the liver fossa with an endoscopic ball-tipped bovie electrocautery knife. After removal of the gallbladder, both colpotomies were closed in standard fashion.

Among the published NOTES cholecystectomy studies, 4 of 174 cases (2.29%) were converted to traditional lap- aroscopy when severe adhesions or anatomic variants were encountered based upon the surgeons comfort level.26,35

Transgastric approach to NOTeS cholecystectomy

Given the applicability to both genders, a transgastric approach to access the peritoneal cavity is the most promising route for NOTES.62 However, the technological, procedural and ethical issues surrounding transgastric approaches are

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