Abstract
Pollard et al. 1 have attempted to answer this question by reviewing the published literature on this subject. The short answer to this question is “yes.” However, the field of minimally invasive surgery is moving forward rapidly; hence the answers to some of these questions change over time. What was not feasible yesterday can be done now since gallbladder disease is the same but the technology to access the gall bladder has evolved rapidly. Accessing and removing the gall bladder depends on available technology and surgeon's skills. The basic surgical principles and operative steps to remove the diseased organ are the same.
Standard four-port laparoscopic cholecystectomy (LC), in experienced hands, is safe. Current technology permits excellent views with a 5-mm camera. The length of stay is close to a day, and complications are minimal. SIS for cholecystectomy is in some ways similar to LC because the view is familiar, instruments are similar, and ergonomics are superior to NOTES but as good as what is obtained from LC. The downside is wound-related problems from traction and instruments rubbing against each other. Resident and fellow teaching is compromised as the operator is working through a single access device that limits triangulation.
NOTES cholecystectomy, compared with LC and SIS, is a spectrum of procedures that includes transvaginal (commonest), transgastric, transesophageal, transcolonic, and transvesical routes to access the offending organ. Variations in technique, therefore, are natural. The overarching question is whether it is a safer, comparable procedure with similar cost, complications, and associated morbidity and mortality. Unfortunately, we have not answered this question as yet.
In a recent report on a prospective randomized controlled trial comparing LC with SIS by Phillips et al., 2 SIS was shown to be safe with a biliary complication profile that was similar to that of LC. However, pain scores and wound complication rates were higher with SIS compared with LC. SIS, however, gave better cosmetic results.
There is, therefore, a need for a prospective randomized controlled trial comparing LC with SIS and NOTES, either transvaginal or transgastric (which can be performed on both sexes). This is important because most authors carefully select their NOTES patients, and a prospective randomized controlled trial will eliminate this bias.
NOTES is currently associated with longer operating room time, limited views and movement, ergonomic challenges, visceral injuries, chronic dyspareunia, operator distress, and compromised hands-on teaching of residents and fellows. The good news is that it provides excellent cosmesis and is scarless (technically speaking). Another plus in favor of NOTES is the rapidly advancing technology that is promptly circumventing these challenges associated with NOTES, addressed in reviews by Huang et al. 3 and Moreira-Pinto et al. 4 This includes introduction of mechanical platforms like EndoSamurai™ (Olympus, Tokyo, Japan), the Direct Drive Endoscopic System (Boston Scientific, Natick, MA), and the EndoSurgical Operating System™ (EOS) (USGI Medical, San Clemente, CA), computer-assisted platforms like the da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA), and custom-paired magnetic intraluminal devices like a magnetic anchoring guidance system.
Patient safety is paramount; hence until these devices have been established as safe, surgeons practicing NOTES have advocated a hybrid and a safe approach like using a transumbilical port that could supplement pneumoperitoneum introduced by endoscopic insufflation and also supplement better visualization with a 5-mm camera. 5
One thing, however, is certain. NOTES is here to stay. Technology and surgical expertise will quickly catch up. So will patient acceptance of this as improved cosmesis is complemented by reduced operating time and morbidity profile better or comparable to that of LC.