Transvaginal Cholecystectomy Called Pain Free

STRASBOURG, France, Sept. 17 -- Transvaginal cholecystectomy heralds the next stage in surgical evolution, offering the potential for pain-free surgery and "invisible mending," surgeons here proclaimed after doing their first procedure.

Using standard endoscopic instruments, a surgical team gained access to and removed the patient's gallbladder through a colpotomy, Jacques Marescaux, M.D., of Louis Pasteur University, and colleagues reported in the September issue of Archives of Surgery.

The patient had an uneventful postoperative course, reported no pain, and was discharged on the second postoperative day, the surgeons said.

The transvaginal cholecystectomy represents the first clinical endeavor using natural orifice transluminal endoscopic surgery (NOTES).

"Will NOTES generate a major paradigm shift in surgical care?" the authors asked. "We know that laparoscopic surgery was just the beginning of the minimally invasive evolution of surgery."

"We have come to an even more critical juncture in the history of surgery," they continued. "With its invisible mending and tremendous potential for improving patient care and well-being, NOTES might represent the next greatest surgical evolution."

By offering the potential for surgery without an abdominal incision, NOTES could "break the physical barrier between bodily trauma and surgery," Dr. Marescaux and colleagues stated.

Since 2004 the team has worked on a dedicated project to develop and refine NOTES, beginning with animal models and cadavers.

Noting that laparoscopic cholecystectomy "changed the focus of surgery and the mindset of nearly all surgeons," the authors said cholecystectomy seemed a logical starting point for clinical application of NOTES.

The patient was a 30-year-old woman with symptomatic cholelithiasis. The surgical team included a gynecologist who performed and closed the colpotomy.

Instrumentation used during the procedure included a standard double-channel flexible videogastroscope and standard endoscopic tools. The procedure entailed creation of a 2-mm needle port for insufflation and monitoring the pneumoperitoneum.

"The quality of the operative view obtained with the endoscope was excellent, and complete identification of the structures of Calot's triangle was achieved," the authors wrote.

The team adhered to the principles of laparoscopic cholecystectomy. Upon complete dissection of the gallbladder, the operative site was examined for hemostasis and inadvertent injury, and the colpotomy was closed.

The procedure required three hours to perform, and no bleeding or bile leakage occurred during the procedure.

The authors concluded that NOTES enhances all of the advantages of laparoscopy, specifically minimal postoperative pain and abdominal scarring. The patient had no postoperative pain or scars and could have left the hospital the evening of the surgery, but the team elected to keep her hospitalized overnight for observation.

At the 10-day follow-up visit, the patient had resumed all normal activities. She reported no discharge or bleeding and no discomfort at the perineal access site.

Dr. Marescaux and colleagues wrote that the evolution and acceptance of NOTES will require a "fundamental revision in surgical training . . . Ultimately, it will not matter whether the operators are surgeons or gastroenterologists but that they are adequately trained to perform NOTES safely and responsibly."

Despite their enthusiasm for NOTES, the authors remained circumspect about the future of the technique, acknowledging that "transvaginal cholecystomy is time-consuming and difficult."

In an invited commentary, John G. Hunter, M.D., of Oregon Health & Science University in Portland, said the additional benefits offered by NOTES over laparoscopic cholecystectomy are unlikely to "be nearly so compelling to the public."

"The road to the incision-free, pain-free, anesthesia-free, scar-free, risk-free cholecystectomy is full of twists and turns," Dr. Hunter continued. " . . . we are not there yet."

Offering a word of caution to the surgical community, Dr. Hunter said, "Do not rush to be first, but forge ahead when you have built a solid base for safe exploration of this new landscape."