Single-incision laparoscopic cholecystectomy using flexible endoscopy: saline infiltration gallbladder fossa dissection technique

Background

The introduction of natural orifice translumenal endoscopic surgery has led to the development of new techniques to accomplish minimally invasive procedures using flexible endoscopic instruments. This study evaluated a technique used in endoscopic mucosal resection and applied it to dissection of the gallbladder from the liver bed.

Methods

Eight patients underwent an elective transumbilical single-incision cholecystectomy using a flexible endoscope at the authors’ institution from August 2007 to February 2008. An endoscopic injection needle was used to inject 20 ml of saline strategically into the gallbladder fossa. After infiltration, dissection of the gallbladder and hilum was performed with endoscopic instruments, whereas the cystic duct and artery were clipped using laparoscopic instruments.

Results

None of the eight patients had inadvertent perforation of the gallbladder during dissection. The technique of infiltrating the potential space between the gallbladder and the liver bed leads to a significantly improved visualization of the plane between them.

Conclusion

The injection of saline to develop surgical planes is an effective tool in performing a cholecystectomy using flexible endoscopic instrumentation. The enhancement of this potential space improved visualization in all patients. This technique has great potential value for dissections and requires further evaluation of its effectiveness in other applications.     

A comparison of NOTES transvaginal and laparoscopic cholecystectomy procedures based upon task analysis

Background

A virtual reality-based simulator for natural orifice translumenal endoscopic surgery (NOTES) procedures may be used for training and discovery of new tools and procedures. Our previous study (Sankaranarayanan et al. in Surg Endosc 27:1607–1616, 2013) shows that developing such a simulator for the transvaginal cholecystectomy procedure using a rigid endoscope will have the most impact on the field. However, prior to developing such a simulator, a thorough task analysis is necessary to determine the most important phases, tasks, and subtasks of this procedure.

Methods

19 rigid endoscope transvaginal hybrid NOTES cholecystectomy procedures and 11 traditional laparoscopic procedures have been recorded and de-identified prior to analysis. Hierarchical task analysis was conducted for the rigid endoscope transvaginal NOTES cholecystectomy. A time series analysis was conducted to evaluate the performance of the transvaginal NOTES and laparoscopic cholecystectomy procedures. Finally, a comparison of electrosurgery-based errors was performed by two independent qualified personnel.

Results

The most time-consuming tasks for both laparoscopic and NOTES cholecystectomy are removing areolar and connective tissue surrounding the gallbladder, exposing Calot’s triangle, and dissecting the gallbladder off the liver bed with electrosurgery. There is a positive correlation of performance time between the removal of areolar and connective tissue and electrosurgery dissection tasks in NOTES (r = 0.415) and laparoscopic cholecystectomy (r = 0.684) with p < 0.10. During the electrosurgery task, the NOTES procedures had fewer errors related to lack of progress in gallbladder removal. Contrarily, laparoscopic procedures had fewer errors due to the instrument being out of the camera view.

Conclusion

A thorough task analysis and video-based quantification of NOTES cholecystectomy has identified the most time-consuming tasks. A comparison of the surgical errors during electrosurgery gallbladder dissection establishes that the NOTES procedure, while still new, is not inferior to the established laparoscopic procedure.     

Magnetic retraction for NOTES transvaginal cholecystectomy

Background

Natural orifice translumenal endoscopic surgery (NOTES) has the potential to decrease the burden of an operation on a patient. Limitations of the endoscopic platform require innovative solutions to provide retraction and create an operation comparable with the gold standard, laparoscopic cholecystectomy.

Methods

Four patients underwent transvaginal cholecystectomy. All procedures were performed under laparoscopic vision to ensure safety. The endoscope and a long articulating RealHand instrument were placed via a 15-mm vaginal trocar. A magnetic retraction system was used to retract the gallbladder safely. Laparoscopic clips were used to ligate the cystic duct and artery. All four gallbladders were successfully removed. No complications occurred. The mean operating time was 102 min.

Results

All four procedures were completed without complications. The four patients all were discharged shortly after surgery and reported normal sexual activity without pain.

Conclusions

Transvaginal cholecystectomy can be completed safely using current technology. Further studies are needed to determine the safety of the procedure and to determine whether it confers any benefits other than cosmesis.     

Totally NOTES (T-NOTES) transvaginal cholecystectomy using two endoscopes: preliminary report

Background

Clinical applications of transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) are still limited in the literature, mostly case reports performed by hybrid procedures with laparoscopic assistance. Avoiding complications from incisions is the main goal for natural orifice surgery. This study reports on a technique developed at our institution that uses two endoscopes inserted into the vagina to perform a Totally NOTES (T-NOTES) transvaginal cholecystectomy, and describes preliminary results.

Methods

IRB approval was obtained at the institution for transvaginal NOTES clinical trials, and informed consent was obtained. The technique of T-NOTES transvaginal cholecystectomy was clinically applied in four female patients with symptomatic cholelithiasis, and data were prospectively documented. Transvaginal NOTES access was obtained by direct vaginal incision, and two endoscopes were simultaneously introduced in the abdominal cavity. Dissection was accomplished with available endoscopic instruments. Ligation of cystic duct and artery was performed using endoscopic clips. Vaginal closure was achieved using the direct-vision sutured technique.

Results

The technique was successfully performed in the four patients. Insufflation and spatial orientation was of good quality. Mean operative time was 210 min. There were no complications during the 30-day follow-up. Postoperative course was uneventful, and patients were released from the hospital on the first postoperative day.

Conclusion

Tranvaginal T-NOTES using two endoscopes provides a feasible method for natural orifice cholecystectomy using available technology. Large-series studies are needed to evaluate the results with respect to safety of the approach.     

Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review

Background

In the setting of difficult dissection of Calot’s triangle during laparoscopic cholecystectomy, conversion is commonly advocated. An alternative approach aimed at preventing bile duct injury is laparoscopic partial cholecystectomy (LPC). The safety and efficacy of this procedure are unclear.

Methods

A systematic review of the literature was performed independently by three researchers. The outcomes were conversion rate, hospital length of stay (LOS), bile duct injury, bile leak, symptomatic gallstones in the remnant gallbladder, need for reoperation, postoperative endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous intervention, and mortality.

Results

The review included 15 publications, which reported on 625 patients. Four different operative techniques could be distinguished. Conversion to open (partial) cholecystectomy was performed in 10.4 % of the cases. The median LOS was 4.5 days (range, 0–48 days). The most common complication was postoperative bile leak, which occurred in 66 patients (10.6 %). One case of bile duct injury occurred. During the follow-up period, 2.2 % of the patients experienced recurrent symptoms of gallstones. Eight patients (2.7 %) underwent reoperation. Postoperative ERCP was performed for 26 (7.5 %) of 349 patients. A percutaneous intervention was performed for 5 (1.4 %) of 353 patients. Three deaths were described in the reviewed series (1 of pulmonary sepsis and 2 of myocardial infarctions). A rough comparison showed that fewer bile leaks, less need for ERCP, and less recurrent symptoms of gallstones seemed to occur when the cystic duct and gallbladder remnant were closed.

Conclusions

Literature concerning LPC is scarce. Four different LPC techniques can be distinguished. When a difficult gallbladder is encountered during LC, LPC seems to be a safe and feasible alternative to conversion. Closing of the cystic duct, gallbladder remnant, or both seems to be preferable.     

Exposure for laparoscopic cholecystectomy dissection adversely alters biliary ductal anatomy

Background

Exposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystectomy (LC), as initially described, is done with cephalad traction on the gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury.

Methods

Twenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a percutaneous introducer placed anterior to the gallbladder. Exposure of Calot’s triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured by a blinded radiologist.

Results

The mean angle of the cystic to hepatic duct was 30? ± 19? in the IOCs taken with cephalad traction on the gallbladder fundus vs 59? ± 22?,P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts were seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction.

Conclusions

From these data we conclude (1) extrahepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot’s triangle should utilize a second clamp on the infundibulum with lateral, caudal traction.     

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

Background

NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.

Methods

Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.

Results

At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.

Conclusion

As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods—combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

     

Combined vascular and biliary fluorescence imaging in laparoscopic cholecystectomy

Background

Bile duct injury in patients undergoing laparoscopic cholecystectomy is a rare but serious complication. Concomitant vascular injury worsens the outcome of bile duct injury repair. Near-infrared fluorescence imaging using indocyanine green (ICG) is a promising, innovative, and noninvasive method for the intraoperative identification of biliary and vascular anatomy during cholecystectomy. This study assessed the practical application of combined vascular and biliary fluorescence imaging in laparoscopic gallbladder surgery for early biliary tract delineation and arterial anatomy confirmation.

Methods

Patients undergoing elective laparoscopic cholecystectomy were enrolled in this prospective, single-institutional study. To delineate the major bile ducts and arteries, a dedicated laparoscope, offering both conventional and fluorescence imaging, was used. ICG (2.5 mg) was administered intravenously immediately after induction of anesthesia and in half of the patients repeated at establishment of critical view of safety for concomitant arterial imaging. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized. Intraoperative recognition of the biliary structures was registered at set time points, as well as visualization of the cystic artery after repeat ICG administration.

Results

Thirty patients were included. ICG was visible in the liver and bile ducts within 20 minutes after injection and remained up to approximately 2 h, using the ICG-filter of the laparoscope. In most cases, the common bile duct (83 %) and cystic duct (97 %) could be identified significantly earlier than with conventional camera mode. In 13 of 15 patients (87 %), confirmation of the cystic artery was obtained successfully after repeat ICG injection. No per- or postoperative complications occurred as a consequence of ICG use.

Conclusion

Biliary and vascular fluorescence imaging in laparoscopic cholecystectomy is easily applicable in clinical practice, can be helpful for earlier visualization of the biliary tree, and is useful for the confirmation of the arterial anatomy.     

Training in laparoscopic cholecystectomy

There is no clear consensus on the best way to train general surgeons to perform laparoscopic cholecystectomy (LC). We attempted to quantify the “learning curve” for 86 surgeons attending eight consecutive 3-day, three-pig courses in LC. Each step of the operation was scored by the instructor for successful performance: Uncomplicated pneumoperitoneum (p), cystic duct and artery dissection (cd), artery and duct clipping (cc), operative cholangiography (oc), gallbladder dissection without holes (gd), liver bed hemostasis (h), gallbladder removal in one piece (i), and no abdominal organ injury (in). As well, operative time, method of dissection, and contact Nd: YAG or electrocautery were recorded. The percentage of students successfully completing each task for the first and third pigs on which they acted as surgeon was as follows: The operative time for the first and third pigs was 1.3±0.56 and 0.70±0.34 (mean±SD) h, respectively (P<0.01). When students were trained with the contact Nd: YAG laser there was more blood loss than with electrosurgery (P<0.001). Statistically significant improvement could only be demonstrated in the most difficult task, gallbladder dissection without perforation, but that task had not been mastered by the end of 3 days. The flat portion of the laparoscopic cholecystectomy “training curve” had not been reached by the end of the program.     

Systemic Inflammatory Response After Natural Orifice Translumenal Surgery: Transvaginal Cholecystectomy in a Porcine Model

Objective:

We analyzed circulating TNF-α and IL-6 to determine systemic inflammatory responses associated with transvaginal cholecystectomy in a porcine model.

Methods:

Six female pigs were used for a survival study after transvaginal cholecystectomy (NOTES group) using endoscopic submucosal dissection (ESD) instruments and a single-channel endoscope. Blood was drawn preoperatively and 24 hours and 48 hours postoperatively. Four pigs were used as controls. In addition, laparoscopic cholecystectomy was performed in 2 pigs for laparoscopic control.

Results:

In all 6 pigs in the NOTES group, no major intraoperative complications occurred. No significant differences were found between control, laparoscopic, and NOTES groups in terms of preoperative IL-6 level (P=0.897) and at 24 hours (P=0.790), and 48 hours postoperatively (P=0.945). Similarly, there was no significant difference in mean preoperative (P=0.349) and mean day 2 postoperative TNF-α levels (P=0.11). But a significant increase in day 1 postoperative TNF-α levels in the laparoscopic group compared with that in the control and NOTES groups was observed (P=0.049). One limitation of our study is that the sample size was relatively small.

Conclusion:

NOTES is safe in animal models in terms of anatomical and cellular level changes with minimal systemic inflammatory host responses elicited. Further study needs to be carried out in humans before NOTES can be recommended for routine use.     

Application of fluorescent cholangiography to single-incision laparoscopic cholecystectomy

Background

Although the use of single-incision laparoscopic cholecystectomy (SILC) is spreading rapidly, this technique has disadvantages. It does not allow for sufficient surgical views to be obtained or for intraoperative radiographic cholangiography to be performed. Fluorescent cholangiography using a preoperative intravenous injection of indocyanine green (ICG) may be useful for identifying the biliary tract during both SILC and conventional laparoscopic cholecystectomy.

Methods

For seven patients undergoing SILC, 1?ml of ICG (2.5?mg) was administered by intravenous injection before the surgery. The prototype fluorescent imaging system consisted of a xenon light source and a 30° laparoscope (diameter, 10?mm) equipped with a charge-coupled device camera capable of filtering out light with wavelengths shorter than 810?nm. The laparoscope was introduced through an umbilical trocar. Fluorescent cholangiography then was performed by changing the color images to fluorescent images using a foot switch during dissection of the triangle of Calot.

Results

Fluorescent cholangiography identified the confluence between the cystic duct and the common hepatic duct in all seven patients before and throughout the dissection of the triangle of Calot. The interval from the injection of ICG to the first obtained fluorescent cholangiography before dissection of the triangle of Calot ranged from 35 to 75?min.

Conclusions

Fluorescent cholangiography enabled real-time identification of the extrahepatic bile ducts during SILC without necessitating catheterization of the bile duct. Such properties of fluorescent cholangiography are expected to be helpful for ensuring the safety of SILC and expanding the indications for the procedure.     

NOTES retroperitoneal transvaginal distal pancreatectomy

Background

The retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.

Methods

With the pig supine, under general anesthesia, a 10-mm posterior colpotomy was performed with a needle-knife operated through a flexible 12-mm, double-channel endoscope (Karl Storz^®). A retroperitoneal tunnel was created with blunt dissection up to the left kidney with progressive visualization of the left iliac vessels, ureter, and abdominal aorta. To reach the posterior aspect of the pancreas, a space was opened medial to the upper renal pole dividing the Gerota’s fascia. The tail of pancreas was mobilized with blunt and sharp dissection, using monopolar cautery. Once the distal pancreas was dissected free, it was secured using a polypropylene endoscopic loop and then resected with an endoscopic snare (Olympus^®).

Results

The procedure was successfully accomplished by a totally NOTES approach in five pigs, with a mean operative time of 118 (range, 105–185) minutes with no intraoperative complications and no injury to any retroperitoneal structure.

Conclusions

The pancreas is accessible by a transvaginal retroperitoneal NOTES approach. Human cadavers studies are necessary to confirm the validity of this model and to explore the need for specific technological developments, such as flexible stapling devices, to improve the safety of pancreatic resection.     

Routine Intraoperative Cholangiography During Single-Incision Laparoscopic Cholecystectomy: a Review of 196 Consecutive Patients

Background

Single-incision laparoscopic cholecystectomy (SILC) has been increasingly performed as a potentially less invasive alternative to standard laparoscopic cholecystectomy. However, recent evidences suggest a higher incidence of complications, notably bile duct injuries, in SILC. We reviewed our experiences with routine intraoperative cholangiography (IOC) during SILC to investigate its feasibility and usefulness.

Methods

Among 228 patients who underwent SILC at our institution from September 2009 to July 2012, a total of 196 patients in which an IOC was attempted were retrospectively reviewed.

Results

IOC was successful in 178 of 196 patients, yielding a success rate of 90.8 %. There were no IOC-related complications. Common bile duct (CBD) stones were detected by IOC in 16 patients (8.2 %), all of which were treated by subsequent single-incision laparoscopic CBD exploration or postoperative endoscopic retrograde cholangiopancreatography with stone extraction. In addition, IOC revealed filling defects in the cystic duct (four patients) and poor passage of contrast medium into the duodenum (one patient). In one patient with severe acute cholecystitis, cholangiography via an endoscopic nasobiliary drainage tube revealed misinterpretation of CBD as cystic duct.

Conclusions

We, thus, conclude that routine IOC during SILC is feasible and useful to detect biliary stones and to gain an accurate picture of biliary anatomy.     

Laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy for gallbladder cancer

Background

Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer.

Methods

Like the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy.

Results

Six patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1–6).

Conclusion

The minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage.     

A cystic duct with no visible signal on magnetic resonance cholangiography is associated with laparoscopic difficulties: an analysis of 695 cases

Background/aims

We investigated the association between the magnetic resonance cholangiography (MRC) results and surgical difficulties and bile duct injuries during laparoscopic cholecystectomy (LC).

Methods

MRC was performed on 695 consecutive patients before LC. We divided the patients into two groups (visible cystic duct group and “no signal” cystic duct on MRC group) and compared them with regard to the length of the operation, conversion rate to open cholecystectomy (OC) and rate of bile duct injury.

Results

The “no signal” cystic duct on MRC group had a longer operation and higher rate of conversion to OC compared with the visible cystic duct group. However, there was no statistically significant difference in the occurrence rate of bile duct injury between the two groups.

Conclusions

The “no signal” cystic duct on MRC group was associated with laparoscopic difficulties, but not with an increased rate of biliary injury. When a visible cystic duct is not observed on MRC an early conversion to open surgery may avoid a bile duct injury during LC.     

Fluorescence cholangiography during laparoscopic cholecystectomy: a feasibility study on early biliary tract delineation

Background

Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic procedures. Bile duct injury is a rare but serious complication during this procedure, mostly caused by misidentification of the extrahepatic bile duct anatomy. Intraoperative cholangiography may be helpful to reduce the risk of bile duct injury; however, this is not a common procedure worldwide. Near-infrared fluorescence cholangiography (NIRFC) using indocyanine green (ICG) is a promising alternative for the identification of the biliary tree. This prospective observational study was designed to assess the feasibility and image quality of intermittent NIRFC during LC, using a newly developed laparoscopic fluorescence system.

Methods

Consecutive patients undergoing elective LC were included and received a single intravenous injection of ICG directly after induction of anesthesia. During dissection of the base of the gallbladder and the cystic duct, the extrahepatic bile ducts were visualized by using a dedicated laparoscope, which offers both conventional state-of-the-art imaging and fluorescence imaging. Intraoperative recognition of the biliary structures was registered at set time points, as well as the establishment of the critical view of safety.

Results

Fifteen patients were included between December 2011 and May 2012. ICG was visible in the liver and bile ducts within 20 min after intravenous administration and remained for approximately 2 h, using the fluorescence mode of the laparoscope. The common bile duct and cystic duct could be clearly identified at an early stage of the operation and, more important, significantly earlier than with the conventional camera mode. No per- or postoperative complications occurred as a consequence of ICG use.

Conclusions

Intermittent fluorescence imaging using a newly developed laparoscope and preoperative administration of ICG seems a useful aid in accelerating visualization of the extrahepatic bile ducts during laparoscopic cholecystectomy.     

Evaluation of the clinical and inflammatory responses in exclusively NOTES transvaginal cholecystectomy versus laparoscopic routes: an experimental study in swine

Background

The aim of this study was to evaluate the clinical and inflammatory responses to surgical trauma caused by the natural orifice transluminal endoscopic surgery (NOTES) transvaginal endoscopic procedure compared with those of the laparoscopic route.

Methods

Twenty-one female swine were divided into three groups of seven animals and subjected to cholecystectomy using laparoscopic, laparotomic, and exclusively NOTES transvaginal routes. A group of five animals served as a control. The animals were monitored during surgery to evaluate anesthetic/surgical time and the presence of complications, which were evaluated after surgery with respect to roaming time, feeding, and the presence of clinical occourrence Measurements of TNF-α, IL-1β, IL-6, CRP, IFN-γ were obtained before and after surgery, on the second and seventh postoperative days, and when the animals were killed and necropsied.

Results

All procedures were successfully completed as proposed in each group. Perioperative complications consisted of only gallbladder perforation and hepatic bleeding. The anesthetic/surgical time was longer in the NOTES vaginal group (p?<?0.001). The postanesthetic recovery time, roaming, nutrition, and clinical evolution were similar in all groups. IL-1β and IL-6 were undetectable in all groups. Levels of TNF-α, CRP, and IFN-γ were similar among the groups. However, the evolution of the inflammatory process, measured as the difference between the peak dose and the basal dose of IFN-γ, was lower in the NOTES group than in the laparotomy group. In the necropsy findings, only adhesions were found, with no difference among the groups.

Conclusions

The entirely NOTES transvaginal cholecystectomy was feasible and safe. The surgical time was greater for the NOTES vaginal route. The inflammatory response was similar among the groups based on the levels of CRP and IFN-γ. However, the evolution of the inflammatory process seems to have been shorter in the vaginal NOTES group than in the laparotomy group as demonstrated by the difference between the peak and basal doses of IFN-γ.     

Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy

Introduction

A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC).

Methods

Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18?years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.).

Results

Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68?min; p?<?0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8?mg morphine equivalents; p?=?0.02). Visual Analog Scale pain scores (scale 0–10) were less in the TVC group at 30?min (1 vs. 5; p?=?0.02) and 60?min (2 vs. 5; p?=?0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p?=?0.01). SF-36 scores were similar at 1 and 3?months postoperatively.

Conclusions

This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.     

Effectiveness of Intraoperative Cholangiography Using Indocyanine Green (Versus Contrast Fluid) for the Correct Assessment of Extrahepatic Bile Ducts During Day-Case Laparoscopic Cholecystectomy

Introduction

During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the “gold standard” for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy.

Materials and Methods

Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the “analyzability rate” (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis.

Results

The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p?=?0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure.

Conclusion

IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts.