Abstract
Abstract
Background:
Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have been proposed as different solutions to further minimize the invasiveness of laparoscopy. In this article, we present our experience with NOTES and SILS over the last few years, trying to focus on identifying which technique should be offered to which patients at the beginning of 2010.
Patients and Methods:
Between January 2009 and January 2010, 100 patients were diagnosed with symptomatic cholelithiasis at our department. Considering our positive previous experiences with NOTES and SILS, we offered the hybrid NOTES approach to women over 40 years with no previous pelvic surgery or history of inflammatory pelvic disease and SILS to male patients and women excluded from the hybrid NOTES approach, with previous surgery in the upper right quadrant and gallbladder empyema being the main contraindications.
Results:
Twenty-six patients accepted the SILS or NOTES approach instead of standard laparoscopic cholecystectomy (LC). Seventy-four patients underwent standard LC via four trocars. In the hybrid NOTES transvaginal cholecystectomy, there were no problems or complications related to the culdotomy, trocar, or stay suture placement. There were no conversions, and all the procedures were performed as planned without complications. In the SILS cholecystectomy, there were no problems or complications related to the trocar or stay sutures placement. All the procedure were completed without complications.
Conclusions:
NOTES and SILS are promising techniques that need new, dedicated instrumentations to reduce technical limitations. Randomized studies comparing SILS/NOTES and traditional laparoscopy are necessary to evaluate safety, efficacy, and potential benefits.
Introduction
Patients and Methods
Between January 2009 and January 2010, 100 patients were diagnosed with symptomatic cholelithiasis at our department. A surgical procedure to remove the gallbladder was proposed to all of them. Considering our positive previous experiences2,3 with NOTES and SILS, we offered the hybrid NOTES approach to women over 40 years with no previous pelvic surgery or history of inflammatory pelvic disease and SILS to male patients and women excluded from the Hybrid NOTES approach, with previous surgery in the upper right quadrant and gallbladder empyema being the main contraindications. Twenty-six patients accepted the SILS or NOTES approach instead of standard LC. Seventy-four patients underwent standard LC via four trocars (technical details of conventional LC are not described).
Hybrid transvaginal cholecystectomy
Nine female patients fulfilled the inclusion criteria, but 3 patients refused the hybrid NOTES approach because of concerns about the safety of the procedure and potential for infectious complications related to the transvaginal approach. As a consequence, 6 patients (33.3%) underwent hybrid NOTES transvaginal cholecystectomy. Average age was 52 years (range, 46–65), with an average body mass index (BMI) of 31 (range, 29–37). The technique has already been described. 2 Briefly, after creating the pneumoperitoneum with a Verres needle, a 5-mm port was introduced into the umbilicus, followed by a 5-mm 30-degree scope. After placing the patient in a steep Trendelenburg position, a culdotomy was performed under direct, laparoscopic view. The flexible endoscope was inserted into the pelvis through the vagina and advanced to expose the gallbladder. The laparoscope was replaced with a 5-mm grasper. Three or more transabdominal sutures were placed through the gallbladder wall for retraction. Cholecystectomy was then performed, using conventional 5-mm laparoscopic instruments through the 5-mm umbilical port. Finally, stay sutures were removed and the specimen was retrieved through the vagina.
Single-incision LC
Twenty patients (12 females and 8 males) underwent single-incision LC because of cholelithiasis. In 5 cases, patients were admitted because of acute cholecystitis. Average age was 45 years (range, 28–65), with an average BMI of 27 (range, 23–36). The technique has been described elsewhere.3–5 Briefly, skin and subcutaneous tissue were incised horizontally within the confines of the umbilical scar. The pneumoperitoneum was induced by means of a Verres needle, and two 5-mm trocars were inserted 1 cm apart. A 5-mm 30-degree laparoscope and different operating instruments were used. Three sutures on a straight needle were passed through the abdominal wall in the right-upper quadrant, through the gallbladder wall (at the fundus and medial and lateral aspect of the infudibulum), then out through the abdominal wall again to raise the gallbladder and expose Calot's triangle. Cholecystectomy was then performed, using conventional laparoscopic instruments through the 5-mm umbilical port. The gallbladder was withdrawn after the little bridge of fascia between the two incisions was cut, thereby creating a single wound, which was then sutured.
Results
Hybrid NOTES transvaginal cholecystectomy
There were no problems or complications related to the culdotomy, trocar, or stay suture placement. There were no conversions, and all the procedures were performed as planned without complications within an average of 65 minutes (range, 45–75). None of the patients required postoperative analgesia and all but 1 were discharged the day after surgery. No complications or readmissions were reported after a minimum follow-up of 45 days (Table 1).
Statistically, analysis is not applicable due to the difference in the number of cases treated.
Wong Baker Faces Pain Rating Scale.
SILS, single-incision laparoscopic surgery; NOTES, natural orifice transluminal endoscopic surgery.
SILS cholecystectomy
There were no problems or complications related to the trocar or stay suture placement. In 2 patients admitted because of cholelithiasis and common bile duct stones who underwent an endoscopic retrograde cholangiography (ERCP) and stone extraction preoperatively, a 3-mm trocar was inserted within the umbilical scar, laterally to the other two 5-mm trocars already in place, to help the placement of an endoloop to secure a large cystic duct. All the procedures were completed without complications within an average of 53 minutes (range, 25–75). In 1 case of acute cholecystitis, intraoperative bile spillage occurred. The procedures took an average of 15 minutes longer in the presence of acute inflammation. All but 4 patients were discharged the day after surgery. No complications or readmissions were reported after a minimum follow-up of 45 days (Table 1).
Standard four-trocar LC
There were no problems or complications related to trocar placement. Ten patients admitted because of cholelithiasis and common bile duct stones underwent ERCP and stone extraction preoperatively. All the procedures were completed without complications within an average of 40 minutes (range, 25–60). One case of acute cholecystitis was converted to open due to massive adhesions. All but 20 patients were discharged the day after surgery. No complications or readmissions were reported (Table 1).
Discussion
NOTES and SILS represent the surgeon's attempt to reduce invasiveness and body-image trauma perception and improve cosmesis, in comparison to conventional laparoscopic surgery. Several NOTES6,7 and SILS3–5,8–12 procedures have been described. However, NOTES, even if it is going to represent the future, is still experimental. Waiting for a new generation of flexible endoscopes and instrumentation born specifically for NOTES, hybrid transvaginal approach, and SILS seem the most reasonable techniques to assure most of the advantages of NOTES in cases of basic procedures, such as the cholecystectomy. We have already published our experience with single-incision hybrid transvaginal cholecystectomy and single-incision LC.2–5 In both techniques, traction is assured by at least three transabdominal stay sutures passed through the fundus and both medial and lateral aspects of the infundibulum in order to retract, stabilize, and flag the gallbladder laterally or medially and expose Calot's triangle, while the operating instrument (i.e., scissor, dissector, clip-applier, and hook) is inserted through a 5-mm trocar placed at the umbilicus. The only difference between the two approaches is that vision is given by an endoscope inserted through the vagina in the hybrid NOTES technique and by a 30-degree-angled, 5-mm laparoscope inserted through the umbilical scar in the SILS approach. Since the beginning of our NOTES and SILS experience, we have tried to tailor the type of cholecystectomy to patients in identifying which technique to offer which patient.
The transvaginal approach has been utilized widely in gynecology for different procedures and, expecially, hysterectomy. Reports comparing vaginal with transabdominal or laparoscopic hysterectomy, in terms of infection complications, are contradictory, while there has been reported no significant difference in patients' sexual function between the vaginal and conventional laparoscopic approach.13–15 However, since no definitive information on the impact of the transvaginal approach on subsequent fertility or sexual discomfort exists, we excluded from offering the hybrid NOTES approach to young fertile women. Moreover, very rare, but potentially catastrophic, complications can follow NOTES transvaginal cholecystectomy, such as pelvic infections or inflammations, intestinal injuries, and hernias, particularly in patients who previously underwent pelvic surgery. 16 Consequently, patients with previous pelvic surgery and history of major inflammatory pelvic disease or acute cholecystectomy were also excluded from the hybrid NOTES approach. So, we started offering the hybrid NOTES approach to women over 40 with no previous pelvic surgery or history of inflammatory pelvic disease. SILS was offered to male patients and women excluded from the hybrid NOTES approach, with previous surgery in the upper right quadrant and gallbladder emphiema being the main contraindications.
Nine female patients met the inclusion criteria to undergo hybrid transvaginal cholecystectomy. However, 3 preferred the SILS approach because of concerns about the safety of the NOTES technique and the potential for infectious complications related to the transvaginal approach. Peterson et al. 17 surveyed 100 women who were given a written description of MIS and NOTES surgery, along with a 10-question survey exploring their concerns and opinions regarding transvaginal surgery. The women had a positive perception of transvaginal procedures and would want such procedures if they were found to be equivalent to laparoscopic surgeries; but, infectious concerns were a major concern for women who would not want transvaginal surgery, as shown in our limited experience.
Among the twenty-six cholecystecomies included in the present study, all procedures were successfully performed. Only in 2 cases of the SILS approach was a 3-mm trocar inserted together with the other two 5-mm trocars into the umbilical scar to help in the placing of an endoloop around the cystic duct stump. Operating times were, on average, under 1 hour. No intra- or postoperative complications were recorded. Acute cholecystitis can be approached in SILS, but operative times are expected to be longer and conversion to conventional laparoscopy higher than when approaching cases without acute inflammation.
Conclusions
In conclusion, NOTES and SILS are promising techniques that need new, dedicated instrumentations to reduce technical limitations. Randomized studies comparing SILS/NOTES and traditional laparoscopy are necessary to evaluate safety, efficacy, and potential benefits.
Footnotes
Disclosure Statement
No competing financial interests exist.