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First NOTES cholecystectomy

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This video shows the first totally NOTES cholecystectomy via a transvaginal approach in a 30-year-old woman with symptomatic cholelithiasis. The operation was performed by a multidisciplinary team, which included a gynecologist who performed and closed the colpotomy. The peritoneal cavity was entered through an incision in the posterior vaginal cul-de-sac. The transvaginal access to the peritoneal cavity and the introduction of the double channel gastroscope (KARL STORZ-Endoskope®, Germany) were performed under laparoscopic control by a 2 mm needle-scope.
The placement of this 2 mm needle-port was mandatory to insufflate CO2 and to monitor the pneumoperitoneum and it turned out helpful for further retraction of the gallbladder. Complete identification of the structures of Calot’s triangle was achieved. The dissection began in close proximity of the gallbladder at the junction between the infundibulum and the cystic duct. The peritoneum covering the cystic duct was incised anteriorly and posteriorly and gently brushed away with blunt dissection. Once sufficiently skeletonized, the cystic duct and artery were clipped twice on patient side and once on gallbladder side and divided with endoscopic scissors. Using an endoscopic grasper and a Storz unipolar round-tip electrode, the gallbladder was dissected away from the intrahepatic fossa and placed in a specimen retrieval bag prior to removal through the vagina. The operative site was checked to ensure hemostasis and rule out any inadvertent injury to the adjacent organs. The colpotomy was closed with interrupted 2/0 Vicryl stitches.
All the procedure was carried out using a standard double channel video flexible gastroscope and standard endoscopic instruments. All the principles of laparoscopic cholecystectomy were strictly respected. At no stage of the procedure there was a need of laparoscopic assistance. No complications occurred during the procedure. The advantages of laparoscopy, namely minimal postoperative pain and abdominal scarring appeared to be enhanced by this approach. The patient had no postoperative pain, “no scars” and was discharged on the second postoperative day.

English - 04'08'' 00'07''  Introduction This video shows the first totally NOTES cholecystectomy. Our group at IRCAD-EITS has been actively involved in the development of NOTES since 2004, a dedicated project “Anubis” was created to develop visibility and survival study, as well as endoscopic technology. 00'36''  Case presentation The first human NOTES experience was delivered via transvaginal cholecystectomy in a 30 year old woman with symptomatic gallstones. The operation was performed by a multi-disciplinary team, which included a gynaecologist experienced in transvaginal surgery who performed and closed a colpotomy. 00'58''  Procedure overview The peritoneal cavity was entered through an incision in the posterior vaginal cul-de-sac. The transvaginal access to the peritoneal cavity and the introduction of the double channel gastroscope were performed under laparoscopic control by a 2 mm needle-scope. 01'20''  Procedure The placement of this 2 mm needle-port was mandatory to insufflate CO2 and to monitor the pneumoperitoneum and it turned out helpful for further retraction of the gallbladder. All the principles of laparoscopic cholecystectomy were strictly respected, the elements of Calot’s triangle were clearly identified and dissected with excellent visualisation of the cystic duct and artery, which were clipped twice on patient’s side and once on gallbladder side and divided. The peritoneum covering the cystic duct was incised anteriorly and posteriorly and gently brushed away with blunt dissection. Once sufficiently skeletonized, the cystic duct and artery were clipped twice on patient side and once on gallbladder side and divided with endoscopic scissors. The results obtained in the animal lab and the combination of surgical and endoscopic skills were essential for accomplishing these procedures. All the procedure was carried out using a standard Storz double-channel video flexible gastroscope. The quality of the operative view obtained with the endoscope was excellent. At no stage of the procedure there was a need for laparoscopic assistance. No bleeding or bi-leak occurred during the procedure.Using an endoscopic grasper and a Storz unipolar round-tip electrode, the gallbladder was dissected away from the enterohepatic fossa and placed in a specimen retraction bag prior to removal through the vagina. The colpotomy on the posterior vaginal wall was sutured with uninterrupted 2/0 vicryl stitches. 03'18''  Conclusions Today, the constraints on visual feedback and dexterity will limit the scope of NOTES procedures. The strategy to succeed is to create a multi-disciplinary approach which combines instrument manufacturers, robotics and computer scientists. All the advantages of laparoscopy, namely minimal post-operative pain and abdominal scarring appeared to be greatly enhanced by this approach. The patient in fact had no post-operative pain and indeed no scars. No longer if, no longer when, NOTES is here. With its invisible mending and tremendous potential in improving patient’s care and well-being, NOTES may represent the next greatest surgical revolution.

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