Natural Orifice Transluminal Endoscopic Surgery Cholecystectomy Research Articles

An Observational Study Comparing Hybrid Transvaginal Notes and Four-Port Laparoscopic Cholecystectomy.

Recently, a great interest has arisen in hybrid natural orifice transluminal endoscopic surgery-cholecystectomy (NOTES-C). It has the potential to causeless postoperative pain and may offer better cosmesis over conventional laparoscopic cholecystectomy (CLC). A total of 112 females who underwent conventional cholecystectomy were compared with 108 patients of hybrid transvaginal NOTES-cholecystectomy (TV NOTES-C). We compared intraoperative factors, postoperative pain, the analgesic requirement at different intervals, duration of hospital stay, and time to return to normal activities. In addition, cosmesis and patient satisfaction were assessed at four weeks. Postoperative pain and analgesic requirement were less in the hybrid TV NOTES-C group (p<0.001 at 95% CI). Hybrid TV NOTES-C patients were discharged more frequently within 12 hours (27.5% versus 1.8%; p<0.001) and returned faster (2.22 versus 4.62 days; p<0.001) to normal activities.Cosmetic results and short-term quality of life as assessed by the patient and observer scar assessment scale (POSAS) and short form-36 (SF-36) scores, respectively, were better in the hybrid TV NOTES-C group (p<0.001 at 95% CI). Hybrid TV NOTES-C is associated with reduced postoperative analgesic requirements, faster return to normal activities, better cosmesis, and patient satisfaction compared to conventional four-port cholecystectomy.

Women's Perception of Transgastric and Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) - Impact of Medical Education, Stage of Life and Cross-Cultural Aspects.

Despite that NOTES produces at least matchable clinical long-term results when compared to laparoscopy, still a restraint within the medical community and among patients is evident. Consequently, it might be meaningful to evaluate factors of patient's NOTES perception to promote its acceptance. NOTES is still quite novel and questionnaires regarding its perception by the public is still lacking even so in the Middle East. Aim of our survey is to investigate the viewpoint of female healthcare staff on NOTES. A total of 350 questionnaires along with written information about Minimally Invasive Surgery and NOTES were distributed among the female staff in a Tertiary-care Hospital in Abu Dhabi, 257 were returned completely anonymously and voluntarily and entered into a database with a response rate of 73%. We surveyed factors like religion, medical background, age as well as history of previous laparoscopy, endoscopy, birth and other aspects that may impact a woman's perception of both transgastric and transvaginal NOTES for cholecystectomy and ovariectomy, respectively. Univariate analyses revealed the majority of Muslim women to be more receptive to NOTES as a choice of surgical technique for cholecystectomy and for ovariectomy, respectively, when compared to Christians and Hindus. However, when compared to Muslims, Christian and Hindu groups had a larger share of medical professions. Women with a medical background would opt significantly less for NOTES. Among younger women, NOTES cholecystectomy was refused due to anxiety concerning future pregnancies and sexual dysfunction. Multinomial logistic regression analysis determined medical background and with independent predictive value for the overall choice of interventional technique (p<0.001). Marital status played a significant role only in the comparison of laparoscopy vs transgastric NOTES when performing cholecystectomy and ovariectomy (p<0.01). In this first study emanating from the Middle East, medical education and partly life stage rather than cross-cultural differences seem to influence NOTES perception in women.

Does a prior hysterectomy complicate transvaginal/transumbilical hybrid NOTES cholecystectomy?\u2014a comparative analysis of prospectively collected data

PurposeHysterectomy alters the anatomy of the posterior vaginal vault used as access for transvaginal/transumbilical hybrid NOTES cholecystectomy (NC), creating potential consequences for the feasibility and complication rate of the procedure. Therefore, the aim of our retrospective analysis of prospectively collected data was to analyze the postoperative course after NC in previously hysterectomized (PH) patients compared with patients who had not undergone hysterectomy (NH).MethodsA total of 126 NH patients and 50 PH patients aged over 42 who had an NC from 12/2008 to 04/2021 were compared regarding age, body mass index (BMI), ASA classification, number of percutaneous trocars, need for intraoperative urinary bladder catheterization, length of procedure, conversion rate, and intraoperative and postoperative complication rate according to the Clavien/Dindo classification, Comprehensive Complication Index (CCI), mortality, and hospital length of stay.ResultsPH patients were older than NH patients (63.0 vs 51.5 years; P < 0.001) but did not differ significantly in ASA classification (P = 0.595) and BMI (26.8 vs 27.9 kg/m2; P = 0.480). They required more percutaneous trocars (P = 0.047) and longer procedure time (66.0 vs. 58.5 min; P = 0.039). Out of all 287 scheduled NC only one had to be “converted” to traditional laparoscopic cholecystectomy. Intraoperative and postoperative complication rates, Clavien/Dindo classification, CCI, need for intraoperative urinary bladder catheterization, and length of stay did not differ significantly.ConclusionOur results indicate an increased degree of difficulty of NC in PH patients, although there is no major impact on intraoperative and postoperative complication rates. Urinary bladder perforation is a specific access-related complication in PH patients.

Comparative analysis of postoperative pain after transvaginal hybrid NOTES versus traditional laparoscopic cholecystectomy in obese patients

PurposeEven though obesity is a known risk factor for needing cholecystectomy, most research excludes patients with higher degrees of obesity. The aim of this retrospective study was to compare postoperative pain and analgesic consumption in obese patients, who underwent either transvaginal hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy (NC) or traditional laparoscopic cholecystectomy (LC).MethodsBetween 12/2008 and 01/2017, 237 NC were performed, of which 35 (14.8%) showed a body mass index (BMI) of 35 kg/m2 or more (obesity II and III according to the World Health Organization). Of these, procedural time, postoperative pain, analgesic requirements, and other early postoperative parameters were collected and compared with 35 matched LC patients from the same time period.ResultsThere were no differences in the baseline characteristics between the two groups, but we found significant benefits for the hybrid NOTES technique in terms of less pain (P = 0.006), coherent with significantly less intake of peripheral (paracetamol; P = 0.005), and of centrally acting analgesics (piritramide; P = 0.047) within the first two-day post-surgery. We also found that those in the NC group had shorter hospital stays (P < 0.001). The postoperative complication rates and the procedural time did not differ between the two groups.ConclusionWith regard to postoperative pain and analgesic requirements and without an increase in postoperative complications, obese patients experience short-term benefits from the hybrid NOTES technique compared to traditional laparoscopic cholecystectomy.

The use of single incision laparoscopic surgery techniques and natural orifice transluminal endoscopic surgery – a nationwide survey

Abstract Objective Since the first report of transgastric peritoneoscopic surgery in 2004, minimal invasive surgery (MIS) including conventional laparoscopy, natural orifice transluminal endoscopic surgery (NOTES), single incision laparoscopic surgery (SILS), and robotic surgery have gained traction in general and visceral surgery. While laparoscopic surgery is now the gold standard in many institutions, other MIS approaches lag behind in spite of the enthusiasm of few promoters. The present study investigates the current role of NOTES and SILS in Switzerland. Methods All Swiss surgical departments where queried. Heads of department were asked to complete a detailed questionnaire regarding the use of NOTES and SILS techniques, reminders were sent twice. Results Of 93 departments queried, 63 (68%) answered the survey and most were public hospitals (92%). One third of general surgery departments and 46% of visceral surgery departments had the highest accreditation level A and V1, respectively. While up to 27% of the responding hospitals had performed NOTES in the past, only about 9% still use the technique today. Since January 2019, only two departments performed NOTES cholecystectomy, one department NOTES colectomy and three departments NOTES total mesorectal excision. The main reasons for not performing NOTES anymore were lack of perceived benefits, higher costs, increased morbidity in routine procedures, no patient demand, and the lack of surgical expertise. A similar picture was found regarding the use of SILS, with 37% of hospitals having past experience with SILS and only 13% still performing SILS procedures. Yet, significantly more institutions performed a broader range of SILS procedures today: SILS appendectomy (n = 2), SILS cholecystectomy (n = 4), SILS thyroidectomy (n = 1), SILS small bowel resection (n = 2), SILS colonic resection (n = 5), and SILS rectal resection (n = 2). The main reasons for not performing routinely SILS were similar to the rationale against NOTES. Conclusion Due to technical limitations and lack of perceptible benefits, NOTES and SILS are less frequently performed nowadays than they were in the past. Only a minority of departments are still performing NOTES and SILS, including cholecystectomies, appendectomies, thyroidectomies, and bowel resections. Whether the rise in use of robotic techniques correlates with the decrease of NOTES and SILS needs further investigation.

Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies.

Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

A snare-assisted pure NOTES retrograde cholecystectomy using a single channel flexible endoscope: a pilot experiment in a porcine model.

Natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy is an emerging technology. Interest is ongoing and developments have been rapid but NOTES cholecystectomy has failed to gain traction. Here, we share our experience of snare-assisted pure NOTES retrograde cholecystectomy using porcine models. Under general anesthesia, an incision was created on the posterior vagina wall and an endoscope with a snare attached to the transparent cap was introduced into the pelvic cavity and then upward into peritoneal cavity. After locating the liver and gallbladder, the fundic wall of gallbladder was grasped using a biopsy forceps and the snare was released to ligate the fundus. The gallbladder was then carefully dissected from the gallbladder bed using hook/IT knives with the assistance of the snare. The cystic duct and cystic artery were identified, clipped twice and isolated from the gallbladder using the hook knife to cut between the clips. The specimen was then removed through the vagina using the snare. This procedure was successfully performed in 8 consecutive pigs. The average procedure time was 53min (range 40-60min). No severe bleeding or other complication was observed either during or after the procedure. Normal diets were given on the same day of the procedure. All animals recovered uneventfully. We successfully performed snare-assisted pure NOTES retrograde cholecystectomy in pigs using standard endoscopic instruments. In our experience, pure NOTES cholecystectomy using the retrograde approach performed with a single channel flexible endoscope proved safe and feasible with a short procedure time and quick recovery. The translation of this technique to human subjects seems straight forward and provides a new fitting path to pure NOTES.

Robotic-Assisted Transrectal Cholecystectomy in a Porcine Model.

Background. With increasing experience and technological advancement in surgical instruments, surgeons have explored the feasibility of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). These techniques aim to further reduce surgical trauma, but are not popular due to their inherent pitfalls including clashing of instruments, lack of counter traction, lengthy operating time, and so on. A novel surgical robotic system was designed to overcome the limitations of the existing technologies. Animal trials were conducted to demonstrate its feasibility in performing robotic-assisted transrectal cholecystectomy in a porcine model. Method. The Novel surgical robotic system is a high dexterity, single access port surgical robotic system that enables surgeons to carry out single-port surgical procedure or NOTES. The proposed system's main features include the ability to perform intraabdominal and pelvic surgeries via natural orifices like the vagina or rectum. The system is equipped with multiple miniaturized (16 mm diameter) internally motorized robotic arms, each with a minimum of 7 degrees of freedom, a dual in vivo camera system, a cannula, and an external swivel system. Results. Robotic-assisted transrectal cholecystectomy was successfully performed in 3 adult male pigs. The estimated blood loss was <10 mL in all 3 cases. There were no intraoperative complications. The system provided good dexterity and clear vision. Conclusions. The trial demonstrated that the system can provide the surgeon a stable platform with adequate spacing for the transrectal insertion of robotic arms, 3-dimensional vision, and enhanced dexterity in performing NOTES cholecystectomy.

Transvaginal Hybrid NOTES Cholecystectomy: A Single-Centre Long-Term Experience on Sexual Function.

Transvaginal hybrid NOTES cholecystectomy is an alternative approach to the traditional laparoscopic technique. Despite increasing data regarding clinical outcomes following transvaginal hybrid NOTES cholecystectomy, there is still a lack of long-term results, particularly with regard to sexual function. Therefore, the aim of this study was to evaluate long-term outcome of a series of transvaginal hybrid cholecystectomy. Female patients with symptomatic cholecystolithiasis who underwent transvaginal hybrid NOTES cholecystectomy were retrospectively analysed regarding clinical and surgical outcome parameters. Furthermore, all patients received a 17-question survey postoperative with questions about sexual intercourse, the domains satisfaction and pain of the German Female Sexual Function Index. Overall, 47 of 80 patients were included in the study with a completed survey responses (return rate 58.6%), with a mean age of 48years, mean body mass index of 29 and mean operative time of 47min. The median follow-up was 40months. There were no intra- or postoperative complications and no conversion to a laparoscopic or open approach. No significant differences were found for postoperative sexual function (painful intercourse, inability to achieve orgasm), although sexual intercourse was less frequent postoperatively (p=0.022). Forty-four patients (93.7%) were satisfied with the aesthetic and the overall postoperative result, and 40 patients (85.1%) would recommend the applied surgical technique to friends and family. The findings show that transvaginal hybrid NOTES cholecystectomy is a safe procedure for female patients, particularly with regard to sexual function.

Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study.

The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment. Twenty pigs were randomized to trCCE (n=10) or lapCCE (n=10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination. Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p=0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p=1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0±2.7 vs. 14.6±2.3; p=0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114±32 vs. 111±27min; p=0.921) did not differ, but wound closure took longer for trCCE (31.5±19 vs. 13±5min; p=0.002). After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.

Natural orifice transluminal endoscopic surgery (hybrid) cholecystectomy: The Dhillon technique.

INTRODUCTION:This study presents a novel technique to perform cholecystectomy and assess its outcome and feasibility.PATIENTS AND METHODS:This study presents the novel Dhillon technique and experience of hybrid natural orifice transluminal endoscopic surgery (NOTES) technique, that is, laparoscopic-assisted transvaginal cholecystectomy. We have evaluated the outcomes in terms of cosmesis, post-operative recovery and analgesic requirement. The study included 257 patients who underwent hybrid NOTES cholecystectomy at single tertiary hospital. The biographical data, surgical time, pain score on day 1 and 2, need of analgesia, intra- and post-operative complication and aesthetic assessment on day 7 were recorded.RESULTS:Out of a total of 1100 cases of laparoscopic cholecystectomy 257 had hybrid NOTES cholecystectomy. Only two of these cases were converted to standard laparoscopic cholecystectomy. The mean operative time was 31.5 ± 5.1 (25–40) min. None of the patients had any complication or biliary leakage. The mean pain score on day 1 and 2 was 3.6 ± 0.4 (3–4) and 1.0 ± 0.06 (1–2), respectively. The mean paracetamol (analgesic) dose requirement was 6.1 ± 0.6 (4–6.9) g. The aesthetic score was excellent in all the cases.CONCLUSIONS:Using the present technique of hybrid NOTES is beneficial in terms of cosmetic results, lesser need of analgesic and shorter hospital stay.

Safety Outcomes of NOTES Cholecystectomy Versus Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis.

Objective:Natural orifice transluminal endoscopic surgery (NOTES) is an endoscopic technique whereby surgical interventions can be performed with a flexible endoscope passed through a natural orifice (mouth, vulva, urethra, anus) then through a transluminal opening of the stomach, vagina, bladder, or colon. Although in the early stage of research and development, NOTES has been clinically applied across the globe, above all the transvaginal cholecystectomy is among the most frequently performed procedures. In the existing 2 types of transvaginal routes, the hybrid NOTES cholecystectomy (NC) is more likely to be accepted. However, there has been controversy regarding the safety outcomes of hybrid NC in comparison with classical laparoscopic cholecystectomy (LC). The primary objective of this meta-analysis is to compare the characteristics between NC and classical LC.Materials and Methods:A meta-analysis of eligible studies comparing NC with classical LC was performed to evaluate the safety outcomes including wound complications, other postoperative complications and intraoperative conversion between the 2 groups.Results:Pooling 3 randomized controlled trials (n=157) and 7 nonrandomized trial (n=593) demonstrated that the rates of wound complications and other postoperative complications in NC group did not significantly differ from those of classical LC group [wound complications: ratio difference (RD)=−0.02, 95% confidence interval (CI) −0.04to 0.01, P=0.23; other postoperative complication: RD=−0.01; 95% CI, −0.03 to 0.02; P=0.6]. The intraoperative conversion rate in NC groups was higher than that of LC groups (RD=0.03; 95% CI, 0.01-0.06; P=0.02).Conclusions:There is no significate difference between the safety of NC and laparoscope cholecystectomy. NC is associated with a higher rate of intraoperative conversion when compared with LC. It is worthy of further promotion and validation in clinical settings.

New device for transrectal trocar placement and rectal sealing for NOTES: a porcine in vivo and human cadaver study.

To date, hybrid NOTES, combining transvaginal and laparoscopic access, represents the most popular clinically applied NOTES approach enabling surgical handling comparable to laparoscopic surgery. The transrectal route could be used in a similar way; however, suitable devices facilitating feasible transrectal access and rectal sealing are lacking. In collaboration with Karl Storz GmbH, we tailored a rectoscope and trocars to facilitate transrectal trocar placement and rectal sealing for hybrid NOTES procedures using rigid instruments. Five German Landrace pigs underwent transrectal hybrid NOTES cholecystectomy using the new devices. In a second experiment, the transferability to human anatomy was assessed in a human cadaver. Using the new devices, transrectal trocar placement and rectal sealing proved to be feasible in both experiments. Transrectal hybrid NOTES cholecystectomy could be performed without complications. The presented devices provide a tailored operating platform allowing precise transrectal trocar insertion and feasible sealing of the rectotomy. Consequently, these new instruments may pave the way for transrectal hybrid NOTES procedures and could succeed to clinical use in future.

Scarless surgery: a vision becoming reality?

As minimal invasive abdominal surgery became established in the last decades, further minimization of the surgical access is in the focus now. Although laparoscopic instruments and camera systems become diminished in size there is still a need for a minilaparotomy for extraction and anastomosis of organs. NOTES (Natural orifice transluminal endoscopic surgery) aims to avoid this minilaparotomy. Consequently, laparoscopic-assisted procedures become pure laparoscopic surgery. The transvaginal access is the most common performed NOTES procedure. The acceptance in women is high. The feasibility of NOTES cholecystectomy is scientifically proofed. The procedure is associated with less pain than the common four-port laparoscopic surgery and does not interfere with the sexual well-being. There are no access-related infections; the abdominal wound infection and incisional hernia rate are low. In left sided colonic resection the transrectal access makes NOTES available for both genders.

Modifications of Laparoscopic Cholecystectomy

Aims: More than 30 different ways of performing laparoscopic cholecystectomy (LC) are described in the literature. These were developed by surgeons with the aim to improve postoperative and esthetic outcome following LC. The modifications included reduction in port size and/or number than what is used in standard LC. The aim of this literature review was to evaluate the technical feasibility of the modifications of LC without compromising safety and the benefits associated with these modifications in terms of safety, postoperative pain, cosmesis, early recovery, and patient satisfaction. Materials and methods: Literature review was performed on articles describing different techniques of LC, variations in port number and size, and their advantages over one another. The search was made by using search engines like Google, PubMed, Springer link, and HighWire Press. Observation: Reduction in number of ports and port size especially in epigastric site gave advantages in terms of decreased postoperative pain score and esthesis. There was an increase in the number of transumbilical single-site surgery (TUSS) being performed in recent years with advantages like decreased postoperative pain and increased patient acceptance being documented in various studies. Hybrid technique of using additional ports during single-site laparoscopic surgery (SSLS) may be used as a bridge to single-site surgery while the surgeon is in a learning curve from a multiport surgery to SSLS. Currently NOTES cholecystectomy is under evaluation and not routinely performed. But current literature does not provide enough evidence of any clear benefit of any of these modifications over standard LC. Conclusion: This literature review showed that even though there are some advantages in postoperative pain score, esthetic outcome, and patient acceptance while doing the different types of LC in selected patients, there is no evidence of any clear benefit over conventional LC. It is not acceptable to compromise the vision and increase the risk of bile duct injury to the patient while doing LC. Hence, modified LC may be performed by surgeons only after gaining enough experience and in selected group of patients without violating the basic principles of laparoscopic surgery.

Endolumenal colon occlusion reduces peritoneal contamination during a transrectal NOTES procedure: a controlled porcine survival study.

To enable an efficient and enduring decontamination of the rectal mucosa during transanal endosocopic procedures, we developed a device for reversible endolumenal colon occlusion (ColoShield). The aim of this study was to assess the value of ColoShield in reducing peritoneal contamination during a transrectal procedure. Sixteen pigs underwent transrectal hybrid NOTES cholecystectomy after standardized disinfective rectal washout either with endolumenal colon occlusion using ColoShield (N=8) or without colon occlusion (N=8). Rectal swab samples were taken before and after rectal washout and at the end of the procedure. Peritoneal biopsies for microbiological evaluation were obtained at the end of the procedure and at necropsy 7days after surgery. Peritoneal contamination at the end of surgery was significantly lower using ColoShield compared to not using colon occlusion [13 (1/8) vs. 75% (6/8); P=0.012]. No significant differences were found regarding contamination of rectal swabs and peritoneal contamination at necropsy. The application of ColoShield may increase the safety of transrectal NOTES and transanal endoscopic procedures by reducing peritoneal contamination and consecutive infectious complications.

New minimally invasive approaches for cholecystectomy: Review of literature.

Laparoscopic cholecystectomy is the most commonly performed abdominal intervention in Western countries. In an attempt to reduce the invasiveness of the procedure, surgeons have developed single-incision laparoscopic cholecystectomy (SILC), minilaparoscopic cholecystectomy (MLC) and natural orifice transluminal endoscopic surgery (NOTES). The aim of this review was to determine the role of these new minimally invasive approaches for elective laparoscopic cholecystectomy in the treatment of gallstone related disease. Current literature remains insufficient for the correct assessment of emerging techniques for laparoscopic cholecystectomy. None of these procedures has demonstrated clear benefits over conventional laparoscopic cholecystectomy. SILC cannot be currently recommended as it can be associated with an increased risk of bile duct injury and incisional hernia incidence. NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice. As it is standardized and almost identical to the standard laparoscopic technique, MLC could lead to limited benefits without exposing patients to increased postoperative complications, being therefore adoptable for routine elective cholecystectomy. Technical challenges of SILC and NOTES cholecystectomy could be addressed with the evolution of new surgical tools that need to catch up with the innovative minds of surgeons. Regardless the place of these approaches in the future, robotization may be necessary to impose them as standard treatment.

Safety of transvaginal hybrid NOTES cholecystectomy: a systematic review and meta-analysis.

Despite increasing data regarding clinical outcomes following transvaginal hybrid NOTES cholecystectomy (TVC), a consensus regarding safety based on comparative studies has yet to be reached. The aim of this systematic review and meta-analysis was to compare safety and clinical outcomes of TVC with conventional laparoscopic cholecystectomy (CLC) for the treatment of benign gallstone disease. A comprehensive search for published studies comparing TVC and CLC was performed. Review of each study was conducted and data were extracted. All pooled outcome measures were determined using random-effects models. Data were retrieved from 14 studies describing 1,145 patients. There was no difference in total complications (POR = 0.68; 95 % CI 0.40-1.14; P = 0.14), incidence of bile duct injury (POR = 1.33; 95 % CI 0.31-5.66; P = 0.70), Clavien-Dindo Grade II (POR = 0.48; 95 % CI 0.14-1.60; P = 0.23) or Grade III (POR = 0.63; 95 % CI 0.24-1.65; P = 0.34) complications between TCV and CLC. Time of return to normal activities was significantly reduced in the TVC group (WMD = -4.86 days; 95 % CI -9.33 to -0.39; P = 0.03), and there was a non-significant reduction in postoperative pain on days 1 (WMD = -0.80; 95 % CI -1.60 to 0.01; P = 0.05) and 3 (WMD = -0.89; 95 % CI -1.77 to -0.01; P = 0.05). TVC is safe when performed by appropriately trained surgeons and may be associated with a faster return to normal activities and decreased postoperative pain.

Hybrid NOTES cholecystectomy - A safe and economic innovation

Background: Minimally invasive techniques have revolutionized surgery, making great impact in terms of reduced postoperative morbidity and shorter hospital stay by reducing abdominal wall trauma. Recent introduction of single incision laparoscopic surgery has introduced another debate. After establishing safety profile at the local level, we now present another modification of single incision cholecystectomy. Findings: These procedures were performed on two female patients diagnosed with gallstone disease and scheduled to undergo elective single incision laparoscopic surgery (SILS). Standard laparoscopic ports, straight laparoscopic instruments and 5mm 30° scopes were used. The scope was inserted per vaginum using a long 5mm laparoscopic port. The operation was performed using two instruments introduced through the umbilicus using two standard 5mm laparoscopic ports. The 5mm umbilical fascial defects did not require formal closure. No intra-operative or postoperative complication was reported. Operation was made technically easy because this modification provided greater flexibility of movement for operating instruments by decreasing crowding at the umbilical port without compromising on postoperative recovery or cosmetics. Conclusion: The use of laparoscope through vagina is a viable and safe modification of single incision laparoscopic surgery.

Perception of preference and risk-taking in laparoscopy, transgastric, and rigid-hybrid transvaginal NOTES for cholecystectomy

Few data are available regarding patients' perceptions of new cholecystectomy (CC) techniques, in the context of the patients' risk behaviours. We investigated patients' preferences for transgastric pure natural orifice translumenal endoscopic surgery (NOTES; transgastric NCC) and rigid-hybrid transvaginal NOTES CC (tvNCC) compared with the standard laparoscopic CC (SL-CC), and patients' risk behaviours. A total of 140 inpatients scheduled for elective laparoscopic CC were enrolled in this prospective single-centre study, from January 2009 to January 2010. Patients judged the potential advantages and disadvantages of transgastric NCC and tvNCC compared with SL-CC. The individual's risk behaviour was analysed by means of the validated 40-item Domain-Specific Risk Attitude Scale (DOSPERT). Of the 140 recruited patients, 57 (65% females; mean age 51.5 years) were analysed. Twenty-five percent of males opted for transgastric NCC and 75% opted for SL-CC. Among females, 10.8%, 37.8% and 51.4% opted for transgastric NCC, tvNCC and SL-CC, respectively. Faster convalescence was graded as the primary potential advantage of transgastric NCC, whereas the potential risk of long-term stomach injuries was considered a primary disadvantage. Females graded the reduction of hospital-acquired morbidity as the primary advantage of tvNCC. The risk assessment showed significantly more risk-taking behaviour in the recreational domain of life among patients who opted for innovative surgical techniques than among those opting for conventional surgery. Transgastric NCC is rarely accepted by females but accepted by a quarter of males. Females consider rigid-hybrid tvNCC and SL-CC similarly attractive. Despite promising new techniques, three-quarters of male and one half of female patients still prefer the standard laparoscopic CC.