Introduction: A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC).
Methods: Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.).
Results: Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively.
Conclusions: This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.