title: Video. Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy.
abstract: Enthusiasm for natural orifice transluminal endoscopic surgery (NOTES) has been partly tempered by the reality that most NOTES procedures to date have been laparoscopically assisted. After safely performing transvaginal cholecystectomy in an IACUC-approved porcine model, the authors embarked on an institution review board (IRB)-approved protocol for ultimate performance of pure NOTES cholecystectomy in humans. They describe their experience performing a true NOTES transvaginal cholecystectomy after safely accomplishing three laparoscopically assisted or hybrid procedures in humans. One of the patients was a 35-year-old woman presenting with symptoms of biliary colic. Ultrasound confirmed gallstones, and her liver enzymes were normal. Pneumoperitoneum to 15 mmHg was obtained via a transvaginal trocar placed through a colpotomy made under direct vision. A double-channel endoscope then was advanced into the abdomen. To overcome the retracting limitations of currently available endoscopes, the authors used an extra-long 5-mm articulating retractor placed into the abdomen via a separate colpotomy made under direct vision using the flexible endoscope in a retroflexed position. Endoscopically placed clips were used for control of both the cystic duct and the artery. These techniques obviated the need for any transabdominally placed instruments or needles. This patient was the first to undergo a completely NOTES cholecystectomy at the authors' institution, and to their knowledge, in the United States. She was discharged on the day of surgery and at this writing has not experienced any complication after 1 month of follow-up evaluation. Performance of NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe for humans. Additional experience with this technique are required before studies comparing it with standard laparoscopy and hybrid techniques are appropriate.
authors.affiliation: Department of Surgery, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, Herbert Irving Pavilion, New York, NY10032, USA. mb28@columbia.edu
authors.forename: Marc
authors.initials: M
authors.lastname: Bessler
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Gumbs
authors.forename: Luca
authors.initials: L
authors.lastname: Milone
authors.forename: John C
authors.initials: JC
authors.lastname: Evanko
authors.forename: Peter
authors.initials: P
authors.lastname: Stevens
authors.forename: Dennis
authors.initials: D
authors.lastname: Fowler
mesh_terms: D000328:Adult; D002763:Cholecystectomy / Q000379:methods*; D005260:Female; D042882:Gallstones / Q000601:surgery*; D006801:Humans; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D018084:Ultrasonography, Interventional; D014621:Vagina / Q000601:surgery