Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1127_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
Figure 10.10 View of the transgastric peritoneoscopy: retrofl ex
panoramic view of the peritoneal cavity showing small intestine.
Figure 10.11 View of the transgastric peritoneoscopy: intra -abdominal
adhesions between the greater omentum and the abdominal wall.
Figure 10.12 View of the transgastric peritoneoscopy: liver, stomach,
and omentum.
114
Figure 10.13 Transgastric endoscopic visualization is limited due to
intra-abdominal adhesions.
CHAPTER 10 NOTES for Peritoneal Exploration
https://t.me/med1917
(a)
(b)
Figure 10.14 Endoscopic adhesiolysis is performed by the ESD
technique.
Figure 10.15 A small nodule located in the stomach is biopsied to rule
out cancer metastasis.
Figure 10.16 The mucosal entry site after completion of transgastric
endoscopic peritoneoscopy.
115
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
Figure 10.17 Closure of the mucosal incision site.
Figure 10.18 Gastric closure is completed with endoclips.
Future direction
Clinical experience of NOTES for peritoneal exploration is
limited. However, review of the experimental evidence and
the preliminary clinical experience to date suggests that
NOTES peritoneoscopy with existing clinical equipment is
feasible and safe, although additional refi nements to the
technique and development of tools better adapted to the
task appear warranted. To permit safe introduction of NOTES
for peritoneal exploration without the need for laparoscopic
assistance, a modifi ed fl exible translumenal endoscopic platform, a more reliable technique and endoscopic stapler for
secure access site closure, endoscopic forceps for vigorous
retraction and grasping, and hemostatic devices are critical
[45–47]. Moreover, further clinical studies to clarify the real
benefi ts of NOTES peritoneoscopy compared with laparoscopic exploration are required.
Conclusion
NOTES for peritoneal exploration could be a useful alternative for pre -operative cancer staging or identifi cation of true
intra-abdominal pathology and it may not be long before
NOTES peritoneoscopy can be translated into clinical practice [48–50]. Establishing the simple technique of NOTES
peritoneoscopy will contribute to further expansion of the
use of other NOTES procedures in future interventions.
Chapter video clip
Video 10.1 Transgastric peritoneoscopy.
References
1 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural
Orifi ce Translumenal Endoscopic Surgery White Paper October
2005. Surg Endosc 2006;20(2):329–33.
2 Hawes R. ASGE/SAGES Working Group on Natural Orifi ce
Translumenal Endoscopic Surgery White Paper October 2005 .
Gastrointest Endosc 2006;63:199–203.
3 Kitano S, Tajiri H, Yasuda K, et al. Current status and activity
regarding natural orifi ce translumenal endoscopic surgery
(NOTES) in Japan . Asian J Endosc Surg 2008;1:7–10.
4 Baron TH. Natural orifi ce translumenal endoscopic surgery . Br J
Surg 2007;94:1–2.
5 Swain P. A justifi cation for NOTES – natural orifi ce translumenal
endosurgery . Gastrointest Endosc 2007;65:514–16.
6 De la Fuente SG, DeMaria EJ, Reynolds JD, et al. New develop-
ments in surgery: natural orifi ce transluminal endoscopic
surgery (NOTES) . Arch Surg 2007;142:295–7.
7 Allori AC, Leitman IM, Heitman E. Natural orifi ce transluminal
endoscopic surgery: lessons learned from the laparoscopic revolution. Arch Surg 2008;143:333–4.
8 Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric
peritoneoscopy: a novel approach to diagnostic and therapeutic
interventions in the peritoneal cavity . Gastrointest Endosc 2005;60:
114–17.
116
CHAPTER 10 NOTES for Peritoneal Exploration
https://t.me/med1917
9 Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of
transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos) . Gastrointest Endosc 2005;61:
601–6.
10 Pai RD, Fong DG, Bundga ME et al. Transcolonic endoscopic
cholecystectomy: a NOTES survival study in a porcine model
(video). Gastrointest Endosc 2006;64: 428–34.
11 Jagannath SB, Kantsevoy SV , Vaughn CA et al. Peroral transgas-
tric endoscopic ligation of fallopian tubes with long -term survival in a porcine model . Gastrointest Endosc 2005;61:449–53.
12 Wagh MS, Merrifi eld BF , Thompson CC. Survival studies after
endoscopic transgastric oophorectomy and tubectomy in a
porcine model . Gastrointest Endosc 2006;63:473–8.
13 Kantsevoy SV , Jagannath SB, Niiyama H et al. Endoscopic gas-
trojejunostomy with survival in a porcine model . Gastrointest
Endosc 2005;62:287–92.
14 Marescaux J, Dallemagne B, Perretta S, et al. Surgery without
scars: report of transluminal cholecystectomy in a human being .
Arch Surg 2007;142:823–7.
15 Bessler M, Stevens PD, Milone L, et al. Transvaginal laparoscopi-
cally assisted endoscopic cholecystectomy: a hybrid approach to
natural orifi ce surgery . Gastrointest Endosc 2007;66:1243–5.
16 Rao GV , Reddy DN, Banerjee R. NOTES: human experience .
Gastrointest Endosc Clin N Am 2008;18:361–70.
17 Horgan S, Mintz Y, Jacobsen GR, et al. Video. NOTES: transvagi-
nal cholecystectomy with assisting articulating instruments . Surg
Endosc 2009;23:1900.
18 Gumbs AA, Fowler D, Milone L, et al. Transvaginal natural
orifi ce translumenal endoscopic surgery cholecystectomy: early
evolution of the technique . Ann Surg 2009;249:908–12.
19 Zornig C, Mofi d H, Siemssen L, et al. Transvaginal NOTES hybrid
cholecystectomy: feasibility results in 68 cases with mid -term
follow-up. Endoscopy 2009;41:391–4.
20 Wagh MS, Merrifi eld BF , Thompson CC. Endoscopic transgastric
abdominal exploration and organ resection: initial experience in
a porcine model . Clin Gastroenterol Hepatol 2005;3:892–6.
21 Sumiyama K, Gostout CJ, Rajan E, et al. Submucosal endoscopy
with mucosal fl ap safety valve . Gastrointest Endosc 2007;65:
688–94.
22 Pauli EM, Moyer MT , Haluck RS, et al. Self-approximating trans-
luminal access technique for natural orifi ce transluminal endoscopic surgery: a porcine survival study (with video) . Gastrointest
Endosc 2008;67:690–97.
23 Yoshizumi F, Yasuda K, Kawaguchi K, et al. Submucosal tun-
neling using endoscopic submucosal dissection for peritoneal
access and closure in natural orifi ce transluminal endoscopic
surgery: a porcine survival study . Endoscopy 2009;41:707–11.
24 Trunzo JA, Poulose BK, McGee MF , et al. The diagnostic effi cacy
of natural orifi ce transluminal endoscopic surgery: is there a role
in the intensive care unit? Surg Endosc 2010;24:2485–91.
25 Fong DG, Pai RD, Thompson CC. Transcolonic endoscopic
abdominal exploration: a NOTES survival study in a porcine
model. Gastrointest Endosc 2007;65:312–18.
26 Wilhelm D, Meining A, von Delius S, et al. An innovative, safe
and sterile sigmoid access (ISSA) for NOTES . Endoscopy 2007;39:
401–6.
27 Ramamoorthy SL, Fisher LJ, Jacobsen G, et al. Transrectal endo-
scopic retrorectal access (TERA): a novel NOTES approach to the
peritoneal cavity . J Laparoendosc Adv Surg Tech 2009;19:603–6.
28 Lima E, Roland C, Pego JM, et al. Transvesical endoscopic peri-
toneoscopy: a novel 5 mm port for intra -abdominal scarless
surgery . J Urol 2006;176:802–5.
29 Branco F, Pini G, Osorio L, et al. Transvesical peritoneoscopy
with rigid scope: feasibility study in human male cadaver . Surg
Endosc 2011;25(6):2015–19.
30 Gettman MT , Blute ML. Transvesical peritoneoscopy: initial
clinical evaluation of the bladder as a portal for natural orifi ce
translumenal endoscopic surgery . Mayo Clin Proc 2007;82:
843–5.
31 Kitano S, Yasuda K, Shibata K, et al. Natural orifi ce translumenal
endoscopic surgery for preoperative staging in a pancreatic
cancer patient . Dig Endosc 2008;20:198–202.
32 Zorron R, Soldan M, Filgueiras M, et al. NOTES: transvaginal for
cancer diagnostic staging: preliminary clinical application . Surg
Innov 2008;15:161–5.
33 Hazey JW , Narula VK, Renton DB, et al. Natural-orifi ce trans-
gastric endoscopic peritoneoscopy in humans: initial clinical
trial. Surg Endosc 2008;22:16–20.
34 Steele K, Schweitzer MA, Lyn -Sue J, et al. Flexible transgastric
peritoneoscopy and liver biopsy: a feasibility study in human
beings (with video) . Gastrointest Endosc 2008;68:61–6.
35 Hyder Q, Zahid MA, Wagar SH, et al. Diagnostic transgastric
fl exible peritoneoscopy: is pure natural orifi ce transluminal
endoscopic surgery a fantasy? Singapore Med J 2008;49:375–81.
36 Narula VK, Happel LC, Volt K, et al. Transgastric endoscopic
peritoneoscopy does not require decontamination of the stomach
in humans . Surg Endosc 2009;23:1331–6.
37 Nau P, Anderson J, Yuh B, et al. Diagnostic transgastric endo-
scopic peritoneoscopy: extension of the initial human trial for
staging of pancreatic head masses . Surg Endosc 2010;24:
1440–46.
38 Nikfarjam M, McGee MF , Trunzo JA, et al. Transgastric natural -
orifi ce transluminal endoscopic surgery peritoneoscopy in
humans: a pilot study in effi cacy and gastrotomy site selection
by using a hybrid technique . Gastrointest Endosc 2010;72:
279–83.
39 Nau P, Anderson J, Happel L, et al. Safe alternative transgastric
peritoneal access in humans: NOTES . Surgery 2011;149:
147–52.
40 Memark VC, Anderson JB, Nau PN, et al. Transgastric endo-
scopic peritoneoscopy does not lead to increased risk of infectious complications . Surg Endosc 2011;25(7):2186–91.
41 Yasuda K, Kitano S. Lymph node navigation for pancreatic and
hepatobiliary malignancy by NOTES . J Hepatobiliary Pancreat Sci
2010;17:617–21.
42 Yoshizumi F, Yasuda K, Suzuki K, et al. Feasibility of fi brin glue
versus endoclips to close the transgastric peritoneal access site
in natural orifi ce translumenal endoscopic surgery in a survival
porcine study . Asian J Endosc Surg 2011;4(2): 73–7.
43 Moyer MT , Pauli EM, Haluck RS, et al. A self -approximating
transluminal access technique for potential use in NOTES: an ex
vivo porcine model (with video) . Gastrointest Endosc 2007;66:
974–8.
44 Sumiyama K, Gostout CJ, Rajan E, et al. Transesophageal medi-
astinoscopy by submucosal endoscopy with mucosal fl ap safety
valve technique . Gastrointest Endosc 2007;65:679–83.
45 Flora ED, Wilson TG, Martin IJ, et al. A review of natural orifi ce
translumenal endoscopic surgery (NOTES) for intra -abdominal
117
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
surgery: experimental models, techniques, and applicability to
the clinical setting . Ann Surg 2008;247:583–602.
46 Shaikh SN, Thompson CC. Natural orifi ce translumenal surgery:
fl exible platform review. World J Gastrointest Surg 2010;27:
210–16.
47 Dallemagne B, Marescaux J. NOTES: past, present and future .
Asian J Endosc Surg 2010;3:115–21.
48 Zorron R, Palanivelu C, Neto G, et al. International multicenter
trial on clinical natural orifi ce surgery: NOTES IMTN study:
preliminary results of 362 patients . Surg Innov 2010;17:
142–58.
49 Chukwumah C, Zorron R, Marks JM, et al. Current status of
natural orifi ce translumenal endoscopic surgery (NOTES) . Curr
Probl Surg 2010;47:630–68.
50 Khashab MA, Kalloo AN. Natural orifi ce translumenal endo-
scopic surgery . Curr Opin Gastroenterol 2010;26:471–7.
118
11
https://t.me/med1917
NOTES Cholecystectomy
Bernard Dallemagne & Jacques Marescaux
University Hospital of Strasbourg, IRCAD (Research Institute against Digestive Cancer), Strasbourg, France
Introduction
Given its frequency and that it makes up nearly one -third
of the work in many general surgeons ’ practices, cholecystectomy is recurrently chosen as a model when a new treatment modality is being evaluated. It is also closely scrutinized,
as its incidence facilitates benchmarking with validated
procedures.
Although severely criticized at the fi rst description in
1882, Langenbuch ’s open cholecystectomy remained the
gold standard for symptomatic cholelithiasis for over a
century. In the late 1980s, after the fi rst report of minimal
access cholecystectomy with a modifi ed laparoscope by
Mühe in Germany, Mouret, from France, performed the fi rst
laparoscopic cholecystectomy with an approach that would
become the standard technique: one optical trocar and three
other trocars for instruments. The world of general surgery
was soon divided in two: a small group of enthusiastic surgeons, convinced by the superiority of laparoscopic over
conventional cholecystectomy, and a second very large
group of surgeons with varying opinions, ranging from
curiosity to frank condemnation. Even if surgeons were
reluctant to acknowledge this shift in treatment, patients
applauded this new minimally invasive surgery. If at all
possible, patients would ask for a surgical procedure that
leaves no outside scarring and results in no postoperative
pain. The adoption rate of this technology was unprecedented. In 1992, the National Institutes of Health (NIH)
organized a consensus development conference entitled
“Gallstones and Laparoscopic Cholecystectomy ” [1]. At the
conclusion of the conference, it was determined that “laparoscopic cholecystectomy provides distinct advantages over
open cholecystectomy. ”
After Kalloo and colleagues ’ fi rst report in 2004 on transgastric peritoneoscopy in a porcine model, the interest in
natural orifi ce translumenal endoscopic surgery (NOTES)
has blossomed [2]. Theoretically the same operation performed laparoscopically could be carried out through natural
orifi ces without any abdominal incision, avoiding pain and
scarring. The majority of medical and surgical teams chose
cholecystectomy as the target for the development of the
technique and technology. The justifi cation of this technique
are: the reduction or absence of postoperative pain, ease of
access to some organs, the absence of trauma to the abdominal wall, ideal cosmetic results, and the psychological advantages of eliminating the trauma caused by transabdominal
surgery. Both transvaginal and transgastric cholecystectomy
have recently been translated from research to clinical application, but, two decades after the introduction of the laparoscopic approach, the bar has been set high for outcomes of
cholecystectomy. At this point of evaluation of NOTES, it is
absolutely necessary to respect the surgical rules that established the effi ciency and safety of cholecystectomy, whether
open or laparoscopic. Prevention of injury remains an
unbreakable rule, relying on accurate exposure and visualization of the critical view of safety. This requires retraction
of the gallbladder and exposure of the triangle of Calot.
Secure sealing of the cystic duct and artery must rely on
approved and validated technology. The alternative route for
extracting the gallbladder from the body should not be
ignored [3].
Transgastric cholecystectomy
Unlike the transvaginal route supported by many years of
experience, the transgastric route raises contentious issues
of getting access to the peritoneal cavity, controlling contamination and safe closure of the stomach [4]. An additional challenge is to obtain adequate spatial orientation and
retraction with the endoscope in a retrofl exed position when
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
119
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
the image is upside down and off -axis manipulation is
required. Although some of this spatial incongruity is likely
to be overcome with experience, exposure, interpretation of
the anatomy, and identifi cation of the structural landmarks
proved demanding. Initial excitement has been somewhat
tempered by the reality that a NOTES cholecystectomy
without laparoscopic or needle -scopic assistance has not
been performed by most groups. Swanstrom performed the
fi rst transgastric cholecystectomy (TGC) in 2007. To date,
fewer than fi fty TGCS have been reported in the literature
[5–8]. In a large multicenter trial, TGC was reported in 29
of 362 patients [9], a proportion that highlights the low
impact of the procedure.
Techniques
Several methods of transgastric entry into the peritoneum
have been described in the experimental setting, all of which
require blind puncture through the gastrointestinal wall,
with the inherent risk of injury to adjacent extramural structures. In the clinical setting, no specifi c gastric preparation,
besides cessation of proton pump inhibitors, if applicable, or
lavage with antibiotics is used.
Per Institutional Review Board (IRB) protocol, peritoneal
access and closures are performed under laparoscopic visualization [5–8].
A conventional double -channel endoscope or dedicated
NOTES endoscopic platform is used.
After induction of pneumoperitoneum using a Veress
needle, a single 3 –5 mm transparietal port is placed at the
umbilicus to allow peritoneoscopy and ascertain the feasibility of TGC. An endoscopic monopolar needle -knife is used
to create a 0.5 cm gastrotomy on the anterior gastric wall in
the antrum of the stomach. A guidewire is passed through
the gastrotomy to guide an 18 mm balloon dilator, which
expands the gastrotomy and allows for the passage of the
endoscope (Video 11.1). Salinas et al. used a direct PEG -like
access after gaining access under laparoscopic guidance in
the fi rst 10 patients. Swanstrom fi rst creates a gastric valve
by placing two sutures on the mid anterior gastric wall with
the g -Prox™ (USGI, San Capistrano, CA,) to create an
infolded gastric bridge on which the gastric incision is
made [8]. This infolded bridge reduces the risk of injury to
the surrounding structures associated with the blind creation of the gastrotomy. It also works as a valve and maintains
the pneumogastrium at the time of fi nal closure of the
gastrotomy.
Once the double -channel endoscope has entered the peritoneal cavity, the laparoscopic optic is switched to a 5 mm
standard laparoscopic grasper. With this single trocar set -up
used to retract the gallbladder, the procedure can be carried
out exclusively using current fl exible instruments, grasper
and blunt -tipped electrode, inserted via the two working
channels of the endoscope [6] (Video 11.2). The operating
time can be dramatically improved by the use of standard
Figure 11.1 Hybrid transgastric cholecystectomy: dissection with
laparoscopic hook introduced in a 5 mm umbilical trocar and gallbladder
retraction with a percutaneous 2 mm grasper (endoscopic view).
endoscopic instruments such as the hook inserted through
the umbilical port. In this condition, one additional transparietal laparoscopic instrument provides retraction (Figure
11.1). Swanstrom and Soper ’s groups use the Transport ™
NOTES endoscope (USGI, San Capistrano, CA, USA) and
specifi c endoscopic instrumentation throughout the procedure. One or two additional transparietal laparoscopic
instruments provide retraction.
Once suffi ciently skeletonized, the cystic duct and artery
are clipped using a laparoscopic clip applicator through the
umbilical port, or ligated with suture or endoloop. After
division of these elements, the gallbladder is dissected from
its fossa.
A polypectomy snare or grasper is used to grab the gallbladder, after having been emptied by puncture, and the
organ is retrieved through the gastrotomy, esophagus, and
mouth.
The gastrotomy is closed with extracorporeal interrupted
absorbable stitches by means of a 2 mm laparoscope and a
3 mm needle holder that were inserted side by side into the
5 mm umbilical port [6,7], or a running two -layer suture [7],
or with the g -Prox™. Soper ’s group adds additional laparoscopic sutures to the g -Prox™ intra -gastric stitches [10].
Results
Auyang et al. reported the technique of hybrid TGC in two
patients [10]. No operative complications were observed.
Dallemagne et al. performed TGC in 11 patients (7 men and
4 women) with a mean age of 48.5 years (range 28 –65
years) and a mean BMI of 23.3 (range: 21 –31) [5]. Transgastric peritoneal access was achieved without complication
120
CHAPTER 11 NOTES Cholecystectomy
https://t.me/med1917
or injury to adjacent organs. The site chosen for the creation
of the gastrotomy was the gastric antrum in all patients to
facilitate access to the right hypochondrium and the gallbladder. All procedures were completed using a hybrid
approach with a 5 mm umbilical trocar. In one patient, there
was a need to switch to a laparoscopic procedure because
of lack of exposure of the triangle of Calot. Additional
transparietal assistance was mandatory in all patients to
retract the gallbladder and to achieve a safe exposure
of Calot ’s triangle. Dissection of the gallbladder was completely achieved with fl exible endoscopic instruments in two
patients while a combination with laparoscopic hook dissector was used in the other patients.
A 5 mm laparoscopic clip applier was systematically used
to secure the cystic pedicle. Single -port gastric closure was
successfully achieved in 10 of 11 patients. One patient
required an additional 5 mm trocar because of technical
failure of the instrumentation. No trauma, vascular, or
biliary injury to the adjacent organs occurred during the
procedure. The mean operative time was 132 min (range
90–180 min). All patients recovered promptly. Postoperative
pain evaluated using the Visual Analog Scale (VAS), a tool
that allows pain intensity to be objectifi ed on a 0 –10 scale
(0 being no pain, 10 being extreme pain), was 2/10 at 24 h
and 0/10 at 48 h under usual immediate postoperative analgesia with paracetamol. One patient required additional
analgesia with morphine on day 1. They were allowed fl uids
the very evening of the procedure and resumed a normal
diet on the fi rst postoperative day. No gastric or biliary leaks
occurred. Mean hospital stay was 2 days (range 2 –3 days).
The bacteriological analysis of the peritoneal aspirates
showed no signifi cant contamination of the peritoneal cavity
for both aerobic and non -aerobic species. One patient was
readmitted 8 days after the operation for epigastric pain.
Workup, including gastroscopy, did not reveal any
complications.
Salinas et al. recently published their experience of TGC
in 27 patients [7]. Mean operative time was 137 minutes,
and the patients were discharged 3 hours after the procedure. Mortality rate was zero. Morbidity rate was 18%.
Complications included gastric hematoma (conversion
to open surgery), esophageal laceration and perforation,
abdominal sepsis, and biliary leakage from the cystic duct.
Esophageal perforation was caused by the per -oral retrieval
of a gallbladder containing a 3 cm gallstone. This complication was treated by thoracoscopic lavage -drainage and endoscopic stenting. Abdominal sepsis and biliary leakage were
managed successfully laparoscopically.
Transvaginal cholecystectomy
Transvaginal abdominal access has a longer track record of
safety in the fi eld of gynecology so, not surprisingly, it has
been the leading access for NOTES. After the fi rst reports of
transvaginal cholecystectomy from Marescaux and Bessler
in 2007, the use of this route largely surpassed the transgastric access [11,12]. The transvaginal route has the advantages of an established method of access and closure of the
entry point, direct line of vision toward the gallbladder, and
the ability to introduce rigid laparoscopic instruments that
could assist in different steps of the procedure. The most
obvious limitation of this route is, of course, that it is applicable to only half of the population.
Transvaginal access is performed surgically, through a
horizontal 2 cm posterior incision, 1 cm below the uterine os
between the utero -sacral ligaments, or with a laparoscopic
trocar. In hybrid procedures, access is obtained under laparoscopic control through a trocar inserted in the umbilicus.
Techniques
Pure NOTES technique
After posterior colpotomy under direct vision, a fl exible
endoscope is introduced in the peritoneal cavity. Additional
laparoscopic instruments, rigid or semi -fl exible, introduced
through the same or an additional colpotomy, provide
retraction of the gallbladder, exposure, and clipping. Dissection is performed with the laparoscopic vaginal instruments
or with fl exible instruments passed in the working channels
of the endoscope [13]. Specifi c trocars that group the endoscope, the instruments, and an insuffl ation port were developed. Davila et al. use long laparoscopic optic and instruments
and retract the gallbladder with percutaneous stitches [14].
De Souza et al. described a technique in which retraction of
the gallbladder is provided by a second single -channel endoscope introduced through the same colpotomy. Clipping of
the cystic pedicle is achieved with endoscopic clips [15].
Hybrid technique with a fl exible endoscope
By defi nition, a hybrid technique involves the use of at least
one laparoscopic trocar. A surgical colpotomy and introduction of the fl exible endoscope is performed under laparoscopic guidance. Some authors use a laparoscopic trocar
introduced in the vaginal cul -de-sac.
In the fi rst report of transvaginal cholecystectomy, a
double-channel endoscope and fl exible instruments were
used, including a fl exible clip applier [11]. A 2 mm needle port inserted in the right hypochondrium provided
laparoscopic guidance of the colpotomy, retraction of the
gallbladder, and CO
insuffl ation and pressure monitoring.
2
Thereafter, a safer and quicker technique has been developed [16]. A fl exible endoscope together with a 60 cm long
laparoscopic grasper is introduced transvaginally under
vision. The laparoscope is retrieved and operative vision is
switched to the fl exible endoscope. The long transvaginal
laparoscopic grasper can provide retraction of the gallbladder and cholecystectomy is accomplished using alternatively
fl exible instruments introduced via the endoscope and 5 mm
121
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
Figure 11.2 Hybrid transvaginal cholecystectomy: a long transvaginal
grasper provides exposure of the gallbladder (laparoscopic view).
laparoscopic instruments via the umbilical port (Figure
11.2). Problems in getting the critical view of safety are
frequently observed due to the lack of good traction on the
neck of the gallbladder. Now, an internally anchored hands free retracting device, the EndoGrab ™ (Virtual Port, Israel),
is used to retract the gallbladder. The long transvaginal
laparoscopic grasper is used to retract the neck of the gallbladder and expose properly the Calot ’s triangle (Video
11.3). Cholecystectomy is accomplished using a laparoscopic
hook dissector with cautery and clip applier introduced in
the 5 mm umbilical port, which provides CO
insuffl ation
2
and pressure monitoring. The gallbladder is retrieved in an
endoscopic extraction bag through the vagina. The colpotomy is closed by separate absorbable stitches. Variations in
the number of abdominal trocars and technique of retraction
of the gallbladder, with magnets [17] or transparietal stitches
[18], have been reported.
Hybrid technique with rigid
laparoscopic instruments
The majority of NOTES cholecystectomies in Europe have
been performed by a rigid hybrid technique either by a
modifi ed TEM instrumentation or using laparoscopic rigid
instrumentation as described by Zornig in 2007 [19]. His
technique became popular compared to the use of fl exible
endoscopes, as it relies on known laparoscopic skills and
instrumentation over less familiar endoscopic techniques
and less effective tools.
Transvaginal access is performed under direct vision of a
5 mm optic at the umbilicus. A 5 mm dissector and an extra
long 10 mm 45 ° optic are inserted with the patient in a steep
anti-Trendelenburg position in the posterior fornix of the
vagina. Another dissector replaces the optic in the umbilicus.
The gallbladder is retracted with the instrument positioned
through the vagina, and is then dissected via the umbilicus.
When the cystic duct and the cystic artery are identifi ed,
they are clipped through the umbilicus with a 5 mm clip
applier. The gallbladder is then mobilized with an electric
hook. For removal, the 5 mm optic from the umbilicus is
used again. A removal bag can be used through the 10 mm
vaginal trocar.
Results
Pure NOTES technique
The clinical experience with this approach is limited to fi ve
reported patients [15,20] and no conclusions can be drawn,
besides feasibility and operative time ranging from 180 to
240 minutes.
Hybrid technique with a fl exible endoscope
To date, no randomized trial has been reported.
In our institution, this hybrid technique was performed in
19 patients. All operations were performed using standard
dual-channel endoscopes (Karl Storz Endoskope, Tuttlingen,
Germany) with at least one 5 mm laparoscopic port for
assistance. Transvaginal peritoneal access was achieved
without complication or injury to adjacent organs. Cholecystectomy was performed using solely fl exible instruments
in two patients. There were no intraoperative complications.
No vascular or biliary injury to the adjacent organs occurred
during the procedure. Operative times ranged between 20
and 270 minutes. The routine use of additional retraction
via a transvaginal grasper and an internal retraction system
clearly simplifi ed the procedure and improved the critical
view of the triangle of Calot, with a consequent dramatic
reduction of the mean cholecystectomy time to 25 minutes
(range 20 –30). No patients complained of pelvic pain. In one
patient a postoperative hematoma due to oozing from the
cystic artery occurred, requiring longer hospital stay. The
artery had been clipped using endoscopic clips. As a result
we are now routinely securing the artery and duct with
standard laparoscopic clips.
No infectious complications or biliary leaks were noted at
30-day follow -up. Mean postoperative hospital stay was 2.8
days (range 1 –11 days). All 19 women who underwent
transvaginal cholecystectomy healed successfully with no
complications, were able to resume sexual activity without
pain following the recommended recovery period of 4
weeks, and reported no change in sexual desire and function
at a mean follow -up of 13.2 ± 4.8 months. None of the
patients reported infection or abnormal vaginal discharge.
Postoperative gynecologic assessment showed a soft well healed cervix and vaginal vault in all patients.
In the clinical series including a minimum of fi ve patients,
very few complications were reported. Individual center
experiences are listed in Table 11.1. Two biliary leaks were
treated using endoscopic methods. One colon injury during
the closure of the colpotomy was reported, which is the only
complication related to the access.
122
CHAPTER 11 NOTES Cholecystectomy
https://t.me/med1917
Table 11.1 Hybrid technique with a fl exible endoscope.
Author Year N Technique Complications
Niu [27] 2011 43 Endoscope + 1 trocar 0
Horgan et al. [8] 2011 4 Transport ™ + 1 trocar 0
Cuadrado [37] 2011 25 Endoscope + 2 trocars 0
Salinas et al. [7] 2010 12 Endoscope + 3 trocars Colon injury
Pugliese et al. [28] 2009 18 Endoscope + 1 trocar Bile leak
Decarli et al. [29] 2009 12 Endoscope
Asakuma et al. [16] 2009 9 Endoscope + 1 trocar Intraperitoneal hematoma
Horgan et al. [30] 2009 9 Endoscope + 1 trocar 0
Palanivelu et al. [31] 2009 8 Endoscope + 1 trocar Bile leak
Navarra et al. [18] 2009 6 Endoscope +1 trocar 0
Noguera [32] 2009 15 Endoscope + 2 trocars 0
Table 11.2 Hybrid technique with rigid laparoscopic instruments.
Author Year N Technique Complications
+ 2 trocars 0
Kilian et al. [33] 2011 15 Laparoscope + 1 trocar Bile leak
Hensel et al. [34] 2011 80 Laparoscope + 1 trocar Bladder injury, bleeding
Zornig et al. [21] 2010 108 Laparoscope + 1 trocar 0
Linke et al. [23] 2010 102 Laparoscope + 1 trocar Trocar hernia, stroke
Federlein et al. [35] 2010 115 Laparoscope + 1 trocar Bladder injury, vaginal bleeding, rectal injury, bile duct injury
Ramos et al. [36] 2008 32 Laparoscope
Hybrid technique with rigid
laparoscopic instruments
Individual center experiences are listed in Table 11.2. To
date, no randomized trial has been reported. Zornig reported
a matched -pair analysis comparing the transvaginal hybrid
approach to conventional laparoscopic technique in a series
of 100 patients [21]. In this study the two techniques
appeared similar in terms of re -operations, wound infection,
postoperative pain, hospital stay, and sick leave. The operative time was signifi cantly longer for the transvaginal
approach (52 versus 35 minutes, p < 0.001). Indications
were mainly symptomatic gallstones, although cholecystitis
was found pathologically in a small subset of patients.
Obesity (BMI ≥25) and older age ( ≥65 years) were associated
with longer operative times and higher likelihood of conversion. Sexual function was reported to be unchanged although
it was not assessed with a validated questionnaire. The popularity of this “rigid” translumenal technique was recently
highlighted by the recent report from the German Society
of General and Visceral Surgery (Deutsche Gesellschaft
für Allgemein - und Viszeralchirurgie) [22]. More than 488
+ 2 trocars 0
NOTES cholecystectomies have been performed in the
country, almost all using the technique described by Zornig
et al. [19]. According to the German registry, the mean
number of abdominal trocars used was 1.2 ± 0.5 (1 –4) with
an overall reported conversion rate to laparoscopy of 4.9%.
Of all conversions 44% were related to technical problems
concerning either transvaginal access or intraoperative fi ndings. Complication occurred in 3% and included bladder
injury, uterine perforation, rectal injury requiring a Hartmann procedure, postoperative vaginal bleeding, abscess,
and vaginal infection. Institutional case volume was associated with shorter operative times and fewer additional
trocars.
Another European group has recently published on rigid
hybrid transvaginal cholecystectomy on a series of 102 consecutive patients [23]. The authors included all patients
older than 18 years who were candidates for laparoscopic
cholecystectomy without restriction on BMI or clinical presentation. They treated symptomatic cholelythiasis (74) and
cholecystitis (28) with an overall operative time of 62 ± 21.9
minutes. An additional assisting trocar was required in 19
123
Соседние файлы в папке Библиотека им академика М.И. Перельмана