A single surgeon's experience with a modified NOTES cholecystectomy: How to keep it safe and comfortable

Objective: The transvaginal approach prolongs the average operation time of a laparoscopic cholecystectomy. Even a high experienced endoscopic surgeon probably has to undergo a learning process. We use a minor modification by the placement of one additional 5-mm instrument (mostly in the left upper abdomen) in order to increase the practical comfort and safety. In this single surgeon retrospective analysis of all performed laparoscopic cholecystectomies (n ((equals)) 579) from January 2009 till December 2011 we compare the transvaginal contingent (TVC, n ((equals)) 138) with the female fraction of the conventional laparoscopic contingent (CLC, n ((equals)) 301).

Methods: Generally the transvaginal approach is offered to all our female patients. The only exception would be a gynaecological contraindication (e.g. advanced endometriosis). In the reviewed period 138 patients opted for a transvaginal procedure. All patients are listed in our standard clinical database, so all needed specifications are available.

We start like generally common with a 5-mm invisible incision deep in the umbilicus, than we apply the additional 5-mm instrument and perform the colpotomy and the transvaginal placement of a 10-mm optic and a 5-mm dissector under visual control.

Results: 5 of 138 TVC-cases were converted into a conventional laparoscopic approach (because of severe postoperative adhesions in the small pelvis or an affixed uterus myomatosus). There was one postoperative vaginal bleeding that requires a reintervention and one vaginal mycosis that was treated with local antimycotica.

Mean age was 50 years (CLC ((equals)) 54 y.). Mean BMI 25,3 (CLC ((equals)) 27,6).

The average operation time was 37,5 minutes (CLC ((equals)) 31,9).

The required operation time for the TVC adds up to 45,8 min in 2009 and 34,4 min in 2011.

Conclusions: The risk of further complications by using an additional 5-mm incision is negligible, but you can achieve an optimal surgical comfort and an unproblematic triangulation during a NOTES cholecystectomy. The cosmetic outcome is still excellent. You can observe a moderate learning curve and the required operation time is only marginally prolonged in comparison to the CLC.