NOTES transvaginal cholecystectomy: preliminary clinical application |
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Authors: | R Zorron L C Maggioni L Pombo A L Oliveira G L Carvalho M Filgueiras |
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Institution: | (1) Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Av. Américas 13554 BL.1 AP.207 Barra da Tijuca, Rio de Janeiro, Brazil;(2) Department of Surgery, Hospital Veterinário UENF, Campos de Goytacazes, Rio de Janeiro, Brazil;(3) Department of Surgery, Universidade de Pernambuco, UPE, Recife, Brazil |
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Abstract: | Background Natural orifice translumenal endoscopic surgery (NOTES) is an emerging concept in the recent literature that could lead to
potential benefits in clinical applications. Restricted to animal experiments, however, human procedures have not yet been
published. Because of the technical and ethical challenges involved in perforation and closure of a healthy organ—as is also
seen in operating via the transgastric route—and because of the lack of understanding of the physiopathology and infection
risk with these approaches, they have not been applied in the clinical setting. Thus the present study, based on previous
animal experiments, describes preliminary clinical application in four cases of transvaginal NOTES cholecystectomy, and discusses
safety, feasibility, and potential benefits of the method.
Methods Preliminary acute and survival animal experiments developed by the NOTES Research Group at our institution solved such technical
problems for transvaginal NOTES as spatial orientation, insufflation, and instrumentation, making possible the introduction
of NOTES as a clinical application. The trials were approved by ethics committee of our institution, and informed consent
was obtained from all patients. Since 13 March 2007, four female patients with elective surgical indication for cholecystectomy
have undergone transvaginal NOTES cholecystectomy. All intraoperative and postoperative parameters were documented. Vaginal
access was achieved under direct vision with conventional instruments, and a 2-channel colonoscope was inserted into the abdominal
cavity. After endoscopic insufflation to achieve pneumoperitoneum with CO2, instruments were inserted through and alongside a colonoscope, allowing successful NOTES cholecystectomy in all patients,
with vaginal extraction of the gallbladder. The vaginal wound was closed by direct vision using conventional instruments.
Results The procedure was successful in all patients, with operative time of 45–115 min. Patients experienced low need for postoperative
analgesia. Free oral intake was permitted 2 h after the procedure. There were no postoperative complications, and patients
were discharged, according to the study protocol, 48 h after the procedure.
Conclusions Preliminary results showed the feasibility and safety of the transvaginal NOTES method in this small initial study population.
The technique, developed in our institution, and not transgastric NOTES, may be the preferred approach to serve as the basis
for clinical studies. |
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Keywords: | Flexible endoscopy NOTES endoscopic surgery minimally invasive surgery vaginal surgery cholecystectomy |
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