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194
D.N. Reddy et al.
26. Silberhumer GR, et al. Design and instrumentation of new devices for performing appendec-
tomy at colonoscopy (with video). Gastrointest Endosc. 2008;68(1):139–45.
27. Tsin DA, et al. Minilaparoscopy-assisted natural ori fi ce surgery. JSLS. 2007;11(1):24–9.
28. Zorron R, et al. NOTES transvaginal cholecystectomy: preliminary clinical application. Surg
Endosc. 2008;22(2):542–7.
29. Bessler M, et al. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid
approach to natural ori fi ce surgery. Gastrointest Endosc. 2007;66(6):1243–5.
30. Swanstrom LL, Whiteford M, Khajanchee Y. Developing essential tools to enable transgastric
surgery. Surg Endosc. 2008;22(3):600–4.
31. Sclabas GM, Swain P, Swanstrom LL. Endoluminal methods for gastrotomy closure in natural
ori fi ce transenteric surgery (NOTES). Surg Innov. 2006;13(1):23–30.
32. Jayaraman S, Schlachta CM. Transgastric and transperineal natural ori fi ce translumenal endo-
scopic surgery (NOTES) in an appendectomy test bed. Surg Innov. 2009;16(3):223–7.
33. Buunen M, et al. Stress response to laparoscopic surgery: a review. Surg Endosc.
2004;18(7):1022–8.
195
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_15, © Springer-Verlag London 2013
Keywords Training • NOTES • Transluminal surgery • Simulation • Web-based
education
Introduction
Recent decades have seen remarkable progress in medicine as minimally invasive
procedures have replaced radical surgical resections. Natural ori fi ce translumenal
endoscopic surgery (NOTES) is an evolving minimally invasive technique that has
the potential to break the physical barrier between incisions and surgery. The pres-
ent-day concept of NOTES was articulated by Kalloo et al. in 2004, who challenged
surgeons and endoscopists to focus research on fi nding the best translumenal endo-
scopic access to the peritoneal cavity, with the utmost attention to safety, including
the reliable closure of the entry point [ 1 ] . The justi fi cations for this technique are as
follows: the reduction or absence of postoperative pain; the 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 sur-
gery. Both transvaginal and transgastric cholecystectomies have been translated
from research into clinical applications, attracting an explosion of interest [ 2, 3 ] .
Since the fi rst report from Marescaux et al. [ 3 ] and Bessler et al. [ 2 ] in 2007, over
500 NOTES cholecystectomies have been reported in Europe, mostly using a hybrid
approach between NOTES and laparoscopy. With the goal of tracking the evolution
of new techniques, a global European NOTES activity registry, the Euro-NOTES
S. Perretta , M.D. • J. Marescaux , M.D. (Hon), FRCS, FACS (Hon), JSES (*)
Department of Digestive and Endocrine Surgery ,
University Hospital of Strasbourg ,
1 Place de l’Hopital , Strasbourg 67091, France
e-mail: silvana.perretta@ircad.fr ; jacques.marescaux@ircad.fr
Chapter 15
NOTES: Cholecystectomy
(European Experience)
Silvana Perretta and Jacques Marescaux
196
S. Perretta and J. Marescaux
Registry ( www.euronotes.world.it ), was created among ten centers. An independent
nationwide German registry was also established as an outcome database to allow
the monitoring and safe introduction of NOTES [ 4 ] . Both registries invite surgeons
who performed NOTES procedures to voluntarily contribute. Despite the fact that
NOTES has just recently been introduced, the technique has already gained consid-
erable clinical application in Europe, and it appears to be well accepted by patients
[
5 ] . According to the registries, cholecystectomies account for 89 % of all NOTES
procedures in Europe. NOTES cholecystectomies have been described in Europe
using the transvaginal approach with rigid in-line instruments, and through both the
transvaginal and transgastric approaches with a fl exible platform.
NOTES: Cholecystectomy (European Experience)
Transvaginal abdominal access has a longer track record of safety in the fi eld of
gynecology, and so, not surprisingly, it has been the leading access for NOTES.
Transvaginal access for abdominal surgery is not new, with the fi rst transvaginal
appendectomy at the time of vaginal hysterectomy reported by Bueno in 1949 [ 6 ] .
This fi rst case report was followed soon after by the successful report of 12 and 8
cases from Pelosi and McGowan, respectively [ 7, 8 ] . The procedures were described
as simple, quick, and safe. Posterior colpotomy as a route for specimen retrieval was
described as early as 1896 when Howard Kelly [ 9 ] reported ten cases of ectopic
pregnancies managed surgically through the vaginal route. NOTES has revisited the
established concept of posterior colpotomy as a port to the abdomen. The experi-
ence by gynecologists performing transvaginal procedures has demonstrated safety
in terms of pelvic infection. Data from transvaginal hysterectomies report an infec-
tion rate of 3.9 %, and fertiloscopy is associated with an extremely low infection
rate (0.1 %) [ 10 ] . The transvaginal route was the access chosen for the fi rst human
NOTES cholecystectomies due to the bene fi ts of (1) an established method of access
and closure of the entry point, (2) a direct line of vision toward the gallbladder, and
(3) the ability to introduce rigid laparoscopic instruments that could assist in differ-
ent steps of the procedure. The most obvious limitation of this route is, of course,
that it is applicable to only half of the population. Additionally, a major long-term
concern is postoperative sexual function. Validated sexual function questionnaires
exist, as sexual function can be dif fi cult to characterize and track.
In contrast to the transvaginal route, only 12 transgastric cholecystectomies have
been reported to date [ 11 ] . The use of a transgastric route to perform surgical proce-
dures is not particularly new either. The fi rst transgastric procedure dates back to
percutaneous endoscopic gastrostomy (PEG) feeding tube placement reported in
1980 [ 12 ] . PEG is today a common, well-standardized transgastric procedure, with
a low complication rate. In 1998, the Apollo group led by Kalloo brought new fuel
and an innovative prospective to this approach. Many experts believe that the trans-
gastric route will be the one to dominate NOTES in the future; today signi fi cant
challenges remain for this approach before it becomes widespread. Unlike the
197
15 NOTES: Cholecystectomy (European Experience)
transvaginal route supported by many years of experience, the transgastric route
raises contentious issues of controlling contamination and safe closure of the stom-
ach. J. Hazey investigated the bacterial load and contamination patients experience
during laparoscopic Roux-en-Y gastric bypass while having their gastrotomy for
gastrojejunostomy [
13 ] . Of the 50 patients enrolled, only 5 patients demonstrated
cross-contamination of bacterial loads from the stomach to the abdomen. None of
these cross-contaminants resulted in signi fi cant infection. Thus, these fi ndings sup-
port the hypothesis that while transgastric instrumentation does contaminate the
abdominal cavity, the pathogens introduced are unlikely to cause a clinically
signi fi cant infection.
The majority of NOTES cholecystectomies in Europe have been performed by a
rigid hybrid technique either by a modi fi ed TEM instrumentation or using laparo-
scopic rigid instrumentation as described by Zornig in 2007 [
14 ] . 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. In short, transvaginal access is performed under direct vision
of a 5-mm optic at the umbilicus. A 5-mm mandarin is introduced in the posterior
vaginal fornix and subsequently replaced by an extra-long dissector. A 10-mm tro-
car is inserted alongside the dissector to introduce an extra-long 10-mm 45° scope
(Olympus, Hamburg, Germany). The optic at the umbilicus is then replaced by
another dissector. In his initial series of 68 patients with uncomplicated cholelithia-
sis, Zornig described an acceptance rate of 23 % with an intention to treat feasibility
of 98 %. The mean operative time was 53 min, with the need for an additional trocar
in three cases, and no intraoperative complications [ 14 ] . One major complication of
an abscess in the pouch of Douglas requiring laparoscopic drainage was reported
3 weeks after surgery. Recently, the same group reported a matched-pair analysis
[ 15 ] comparing the transvaginal hybrid approach to the conventional laparoscopic
technique in a series of 100 patients. In this study, the two techniques appeared simi-
lar in terms of reoperations, wound infection, postoperative pain, hospital stay, and
sick leave. The operative time was signi fi cantly longer for the transvaginal approach
(52 vs. 35 min, p < 0.001). Indications were mainly symptomatic gallstones, although
cholecystitis was found pathologically in a small subset of patients. Obesity
(BMI ³ 25) and older age ( ³ 65 years) were associated with longer operative times
and a higher likelihood of conversion. Sexual function was reported to be unchanged
although it was not assessed with a validated questionnaire [ 4 ] .
The popularity of this “rigid” transluminal technique was recently highlighted by
the recent report from the German Society of General and Visceral Surgery (Deutsche
Gesellschaft für Allgemein- und Viszeralchirurgie). More than 488 NOTES chole-
cystectomies have been performed in the country, almost all using the technique
described by Zornig [
14 ] . According to the German registry, the mean number of
abdominal trocars used was 1.2 ± 0.5 (1-4 trocars) with an overall reported conver-
sion rate to laparoscopy of 4.9 %. Of all conversions, 44 % were related to technical
problems concerning either transvaginal access or intraoperative fi ndings. In the
rigid approach, complications occurred in 3 % and included bladder injury, uterine
perforation, rectal injury requiring a Hartmann procedure, postoperative vaginal
198
S. Perretta and J. Marescaux
bleeding, abscess, and vaginal infection. The institutional case volume was associ-
ated with shorter operative times and fewer additional trocars.
Another European group recently published on rigid hybrid transvaginal chole-
cystectomy in a series of 102 consecutive patients [
5 ] . 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
cholelithiasis (74) and cholecystitis (28) with an overall operative time of
62 ± 21.9 min. An additional assisting trocar was required in 19 patients, 11 of
whom had cholecystitis. Two major complications (one stroke and one trocar her-
niation) and 13 minor complications were reported (12.7 %). Among the gyneco-
logical complications, infection and dehiscence of the colpotomy closure were
reported. Postoperative sexual function was assessed using the gastrointestinal qual-
ity-of-life questionnaire (GIQLI) and one additional question related to dyspare-
unia. Using these measures, the authors reported an improvement in sexual life after
surgery that they attributed to the amelioration of the overall quality of life occur-
ring after cholecystectomy.
With appropriate training, experience, and patient selection, the use of a hybrid
transvaginal rigid instrument technique seems feasible and applicable to routine
clinical use. Nevertheless, it is important to note that new and unexpected complica-
tions unique to these techniques even distant from the targeted organ are possible,
including rectal and uterine injury.
The performance of cholecystectomy using a fl exible platform with endo-
scopic instruments is more technically challenging and has therefore remained
less popular. Dif fi culty derives from the endoscopic skills required and the lim-
ited capabilities of fl exible instruments. All the cholecystectomy techniques
reported in the literature with a “ fl exible” technique highlighted the limitations
related to the inadequacy of the current instrumentation, with the resulting lack
of exposure, fi ne dissection, and safe cystic duct ligation. One or several transab-
dominal laparoscopic trocars, transcutaneous suspension sutures, internal retrac-
tors, or transvaginal laparoscopic graspers are currently used to reach satisfactory
exposure and visualization of Calot’s triangle and to allow the use of standard
laparoscopic instruments, such as a clip applier and energy-driven dissection
tools.
Another limiting factor is related to instrument sterility and the absence of a
de fi nitive consensus on a standardization of “surgical” endoscope processing.
Whereas there is general agreement that a high-level disinfection is mandatory for
endoscopes used for NOTES, the need for sterilization with ethylene oxide is
unclear.
As a consequence, in Europe, the use of fl exible endoscopes for transvaginal and
transgastric NOTES procedures in humans is still very limited and is performed
only in highly specialized centers.
At our institution, we choose to approach cholecystectomy using a fl exible endo-
scopic operating platform for both the transgastric and transvaginal approaches.
While technically challenging, it conforms more to the core principles of NOTES,
as it enables interventions throughout the abdomen, it can be performed without
199
15 NOTES: Cholecystectomy (European Experience)
abdominal trocars, and when applied transgastrically, it is applicable to all
patients.
The transgastric and transvaginal routes were evaluated for ease of access to the
peritoneal cavity, quality of exposure of the gallbladder, and manipulation of the
endoscopic instruments before proceeding to clinical application. Between 2005
and 2007, over 400 procedures were performed in animal and ex vivo models.
After a few changes of the technique in the early learning curve, we have now
developed a standardized hybrid approach for fl exible endoscopic transvaginal
cholecystectomy including both steps and instruments. With the patient placed in a
modi fi ed Lloyd–Davies position, the operation begins with the introduction of a
5-mm trocar necessary for insuf fl ation and monitoring of the pneumoperitoneum,
and to introduce a 5-mm laparoscopic clip applier. The patient position is then
changed to a steep Trendelenburg tilt to better expose the pelvis. Transvaginal access
is obtained under laparoscopic control. The vagina is scrubbed with betadine and
the posterior lip of the cervix is grasped with a Pozzi forceps and traction main-
tained in the direction of the symphysis pubis. A horizontal 2-cm cold blade poste-
rior incision, 1 cm below the uterine os, is performed between the uterosacral
ligaments. Two stay sutures are placed at the distal edges of the colpotomy to pre-
vent tearing of tissue and to facilitate closure. A double-channel endoscope (Karl
Storz Endoskope, Tuttlingen, Germany) together with a 60-cm-long laparoscopic
grasper is introduced transvaginally under vision. In order to improve the exposure,
an internally anchored, hands-free retracting device, EndoGrab™ (Virtual Port
Caesarea, Israel), is now regularly used. Cholecystectomy is accomplished using
alternatively fl exible instruments introduced via the endoscope and 5-mm laparo-
scopic instruments via the umbilical port. The cystic duct and artery are clipped
using a laparoscopic clip applier. The colpotomy is closed by separate 3/0 Vicryl
stitches. Gynecological assessment is performed 1 and 3 months postoperatively
and includes both a physical exam performed by a gynecologist and a quality-of-life
questionnaire (GIQLI). Postoperative sexual function is evaluated using a dedicated
questionnaire (Sexual Function Questionnaire 31).
A similar technique was used by Pugliese et al. on a series of 18 transvaginal
cholecystectomies [
16 ] . The authors reported no intraoperative complications and
no conversions, an overall mean duration of procedures of 75 min (range 40–190),
and one biliary leak treated with drainage. At a mean follow-up of 12 months (range
1–22), none of the patients complained of dyspareunia or other colpotomy-related
complications.
For the transgastric cholecystectomy, in a similar fashion to the transvaginal
approach, we use a hybrid format by means of a 5-mm umbilical trocar. Placement
of this trocar is recommended when performing transgastric NOTES with contem-
porary instrumentation, to ensure an adequate exposure of the cystic duct and
artery, to allow the use of a 5-mm laparoscopic clip applier, and to monitor the
gastrotomy creation and closure. Endoscopic access to the peritoneum is obtained
by a modi fi ed PEG technique. A needle-knife is used to create a 5-mm gastrotomy
on the anterior gastric wall, which is then balloon-dilated to allow the passage of
the endoscope.
200
S. Perretta and J. Marescaux
With this starting one-trocar setup used initially to retract the gallbladder, the
dissection can be carried out exclusively using fl exible instruments inserted via the
two working channels of the endoscope. These instruments are obviously not
designed or adapted to perform such tasks and, as a result, the dissection becomes
very time-consuming. The operating time can be dramatically improved with the
use of standard endoscopic instruments such as the hook inserted through the umbil-
ical port. Prevention of injury during cholecystectomy relies on the accurate dissec-
tion of the cystic duct and artery, and avoidance of major biliary and vascular
structures. Speci fi c anatomical distortions due to NOTES technique, along with the
lack of exposure provided by present methods of retraction and retro fl exion, tend to
distort the Calot’s triangle by fl attening it rather than opening it out. Transparietal
assistance, using suspension of the falciform ligament, internal retraction systems,
or the introduction of an additional micro-laparoscopic grasper at the umbilicus or
in the right hypochondrium, is added liberally in order to obtain the safest possible
exposure of the operative fi eld.
As the cholecystectomy is completed, the gallbladder is removed through the
gastrotomy using a polypectomy snare. Preventive drainage of the gallbladder is
carried out to reduce the bulk of the specimen to avoid rupture of the gallbladder
during retrieval and consequently biliary spillage. Particular attention should be
paid to gallstones size. Stones larger than 2 cm should be retrieved via the abdomi-
nal trocar incision, to avoid esophageal impaction or laceration at retrieval. The
gastrotomy is then closed with extracorporeal interrupted 3/0 Vicryl 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. Gastroscopy is carried out to inspect the closure
and to con fi rm an airtight seal by the attainment of a satisfactory pneumogastrium.
From September 2007 to March 2009, a total of 30 patients with a mean age of
48.5 years (range: 28–65), a mean BMI of 23.3 (range: 21–31 kg/m
2
), underwent
NOTES cholecystectomy at our institution under IRB approval [ 3, 11 ] . Eleven
transgastric (6 men and 5 women) and 19 transvaginal cholecystectomies were per-
formed. All operations were performed using standard dual-channel endoscopes
with at least one 5-mm laparoscopic port for assistance. Transgastric procedures
resulted in longer total operative times [132 min (range: 90-180 minutes) vs. 104 min
(range: 20–270 min)], peritoneal access times, and access closure times. The post-
operative day 1 pain score (EVA 2/10 vs. 0.5/10) was slightly higher in the transgas-
tric group. None of the TV cholecytstectomy patients complained of pelvic pain.
Transgastric and transvaginal peritoneal accesses were achieved without complica-
tions or injury to adjacent organs. In the transgastric group, dissection of the gall-
bladder was completely performed with fl exible endoscopic instruments in two
patients, while a combination with a laparoscopic hook dissector was used in the
remaining patients. A 5-mm laparoscopic clip applier was systematically used to
secure the cystic pedicle. In two patients, there was a need to switch to a laparo-
scopic view to assess the biliary anatomy. No vascular or biliary injury to the adja-
cent organs occurred during the procedure. The routine use of additional retraction
via a transvaginal grasper and an internal retraction system (EndoGrab™) clearly
simpli fi ed the procedure and improved the critical view of the triangle of Calot, with
201
15 NOTES: Cholecystectomy (European Experience)
a consequent dramatic reduction in the mean cholecystectomy time to 25 min
(range: 20–30). There were no intraoperative complications. In one patient, a post-
operative hematoma due to oozing from the cystic artery occurred, requiring a lon-
ger 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, gastric leaks, or biliary leaks were noted at 30-day
follow-up. The mean postoperative hospital stay was 2 days (range: 2–3) for the
transgastric group and 2.8 days (range: 1–11) for the transvaginal cholecystectomy
patients.
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 assess-
ment showed a soft, well-healed cervix and vaginal vault in all patients.
Conclusions
NOTES techniques are becoming increasingly attractive for the surgeon and the
gastroenterologist. In Europe, NOTES cholecystectomy is growing with strong
patient acceptance. According to the European registries, complications occurred in
3 % of all patients and “conversions” to laparoscopy in 4.7 %, which is comparable
to current rates in minimally invasive surgery. Nevertheless, unexpected complica-
tions unique to the NOTES technique are being reported. Expected advantages of
NOTES relative to infection, hernia, postoperative pain, hospital stay, and time off
work are still only theoretical and have yet to be proven in randomized controlled
trials. Of the two key challenges to transluminal techniques, contamination has not
proven to be a signi fi cant problem, while luminal closure remains a concern for
transgastric approaches. Long-term sexual function is a concern for the transvaginal
approach. In most centers, collaboration with the gynecologist is reported at least
initially, to assess the absence of gynecological contraindications, address speci fi c
patients’ questions, and perform the colpotomy. So far reports indicate that postop-
erative sexual function is unchanged.
Transvaginal cholecystectomy with rigid instruments has been standardized and
may become routine in the near future, although limited to speci fi c procedures in
50 % of the population.
Currently, fl exible endoscopic NOTES is only being performed at highly skilled
centers under strict IRB supervision. The majority of centers consider NOTES suit-
able for uncomplicated symptomatic cholelithiasis and are hesitant to apply this
emerging technique to complex cases. Prevention of injury at cholecystectomy
remains an unbreakable rule relying on accurate exposure and visualization of the
Calot’s critical view of safety. Hybrid techniques are mandatory at this stage for
monitoring and assistance with both fl exible and rigid NOTES techniques.
202
S. Perretta and J. Marescaux
The use of a fl exible technique allows NOTES to be performed more in keeping
with the original intent of fl exible transluminal surgery, but is less adopted due to
technical challenges and longer operative time. Technical improvements by means
of a surgical endoscopic platform would greatly enable the advancement of pure
NOTES into the operating room.
The success of the Euronotes Society meetings and demand for training in new
techniques demonstrates surgeons’ enthusiasm for NOTES. Cholecystectomy today
might not be the killer application of NOTES but undoubtedly represents a steady
step forward to usher in new clinical applications and push surgical innovation. As
NOTES continues its translation into clinical use, training and technology develop-
ment is critical to achieve widespread applicability.
References
1. Kalloo AN, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and
therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004;60(1):114–7.
2. Bessler M, et al. Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid
approach to natural ori fi ce surgery. Gastrointest Endosc. 2007;66:1243–5.
3. Marescaux J, et al. Surgery without scars: report of transluminal cholecystectomy in a human
being. Arch Surg. 2007;142(9):823–6; discussion 826–7.
4. Lehmann KS, et al. The German registry for natural ori fi ce translumenal endoscopic surgery:
report of the fi rst 551 patients. Ann Surg. 2010;252(2):263–70.
5. Linke GR, et al. Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation in routine
clinical practice. Endoscopy. 2010;42(7):571–5.
6. Bueno B. Primer caso de apendicectomía por vía vaginal. Tokoginecol Pract. 1949;8:152–4 [in
Italian].
7. Pelosi III MA, Pelosi MA. Vaginal appendectomy at laparoscopic-assisted vaginal hysterec-
tomy: a surgical option. J Laparoendosc Surg. 1996;6(6):399–403.
8. McGowan L. Incidental appendectomy during vaginal surgery. Am J Obstet Gynecol.
1966;95(4):588.
9. Kelly HA. Treatment of ectopic pregnancy by vaginal puncture. Bull Johns Hopkins Hosp.
1986;7:208.
10. Gordts S, et al. Risk and outcome of bowel injury during transvaginal pelvic endoscopy. Fertil
Steril. 2001;76(6):1238–41.
11. Dallemagne B, et al. Transgastric hybrid cholecystectomy. Br J Surg. 2009;96(10):1162–6.
12. Gauderer MW, Ponsky JL, Izant Jr RJ. Gastrostomy without laparotomy: a percutaneous endo-
scopic technique. J Pediatr Surg. 1980;15(6):872–5.
13. Hazey JW. Transgastric instrumentation and bacterial contamination of the peritoneal cavity.
Surg Endosc. 2007;22(3):605–11.
14. Zornig C, et al. Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases
with mid-term follow-up. Endoscopy. 2009;41(5):391–4.
15. Zornig C, et al. NOTES cholecystectomy: matched-pair analysis comparing the transvaginal
hybrid and conventional laparoscopic techniques in a series of 216 patients. Surg Endosc.
2011;25(6):1822–6.
16. Pugliese R, et al. Hybrid NOTES transvaginal cholecystectomy: operative and long-term
results after 18 cases. Langenbecks Arch Surg. 2010;395(3):241–5.
203
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_16, © Springer-Verlag London 2013
Keywords Natural ori fi ce • Cholecystectomy • Human • Scarless • Endoscopic
Endoluminal surgery
Someday in the future, people will look back at a regular surgical incision
as something archaic and barbaric.
—Paul A. Wetter, M.D.
Introduction
Medicine has taken an enormous step from the performance of life-saving open
procedures to minimally invasive surgery that assures not only survival, but also a
relatively good quality of life. The general acceptance of laparoscopic surgery has
S. F. Majid , M.D. (*)
Center for the Future of Surgery/Minimally Invasive Surgery ,
University of California at San Diego ,
200 W. Arbor Dr, #8401 , San Diego , CA 92103 , USA
e-mail: sanieam@gmail.com
B. J. Sandler , M.D., FACS
Center for the Future of Surgery , UC San Diego Health System,
Medical Education and Telemedicine Building , 9500 Gilman Drive, MC 0740 ,
La Jolla , CA 92093 , USA
e-mail: bsandler@ucsd.edu
S. Horgan , M.D., FACS
Center for the Future of Surgery , UC San Diego Health System,
Medical Education and Telemedicine Building , 9500 Gilman Drive, MC 0740 ,
La Jolla , CA 92093 , USA
Department of Minimally Invasive Surgery , University of California at San Diego ,
San Diego , CA 92103 , USA
e-mail: shorgan@ucsd.edu
Chapter 16
NOTES: Cholecystectomy (U.S. Experience)
Saniea F. Majid , Bryan J. Sandler , and Santiago Horgan
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