title: Hybrid NOTES transvaginal cholecystectomy: operative and long-term results after 18 cases.
abstract: OBJECTIVE
  Natural orifice transluminal endoscopic surgery (NOTES) is a novel technique that aims at reducing or abolishing skin incisions and potentially also postoperative pain. The purpose of this study was to analyse operative and long-term results of a series of hybrid transvaginal cholecystectomy.
  
  
  METHODS
  Between July 2007 and May 2009, transvaginal NOTES cholecystectomy for symptomatic cholelithiasis was performed by a hybrid technique in 18 women (mean age 54 years), including four women with a body mass index >30 kg/m(2). Dissection was conducted in the first four cases by a round-tip unipolar electrode (UE) introduced through the operative channel of the endoscope coming from the vagina and in the last 14 cases by a ultrasonic scalpel (US) introduced through a 5-mm abdominal port. The short-term outcomes and the long-term results of the two methods were compared.
  
  
  RESULTS
  The transvaginal approach entailed no intraoperative complication and no conversion. The overall mean duration of procedures was 75 min (range 40-190). In the first four cases (UE), the operating time was 148 min (range 140-190), whilst in the last 14 (US), it was considerably shorter, 53 min (range 40-60, p < 0.01). We experienced one biliary leak in the UE group, whilst morbidity with US was nil (p < 0.005). The biliary leak healed in 7 days with nasobiliary drainage. No other complications were encountered in either group. The mean follow-up was 12 months (range 1-22), and none of the patients has complained of dyspareunia or other colpotomy-related complications so far.
  
  
  CONCLUSIONS
  Until specifically designed endoscopic tools are available for NOTES, the hybrid technique with US dissection conducted through a 5-mm port should be preferred in transvaginal cholecystectomy in order to shorten the duration of surgery and make this approach effective, safe and reproducible. After a mean follow-up of 1 year, none of our patients has complained of any problem related to transvaginal approach.
authors: General Surgery and Videolaparoscopy Unit, AIMS, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162, Milan, Italy. raffaele.pugliese@ospedaleniguarda.it
authors: Raffaele
authors: R
authors: Pugliese
authors: Antonello
authors: A
authors: Forgione
authors: Fabio
authors: F
authors: Sansonna
authors: Giovanni Carlo
authors: GC
authors: Ferrari
authors: Stefano
authors: S
authors: Di Lernia
authors: Carmelo
authors: C
authors: Magistro
mesh_terms: D002763:Cholecystectomy / Q000379:methods*; D002769:Cholelithiasis / Q000601:surgery*; D004724:Endoscopy; D005260:Female; D006801:Humans; D008875:Middle Aged; D016896:Treatment Outcome; D014621:Vagina