[Transvaginal notes Cholecystectomy in humans: first series of cases in Costa Rica]. / Colecistectomía notes transvaginal en humanos: primera serie de casos en Costa Rica.

OBJECTIVES. To report the first case series of transvaginal NOTES cholecystectomy in humans in Costa Rica and its clinical potential in the treatment of abdominal diseases in this country. PATIENTS AND METHODS. We present a series of three cases of adult female patients of 44, 58 and 69 years of age (average 57 years), symptomatic, with a gall bladder polyp diagnosed by an abdominal ultrasound, who underwent a transvaginal cholecystectomy modified with laparoscopic technique. A 5 mm trocar was inserted through the umbilicus to create and to monitor the pneumoperitoneum, as well as to possibilitate endoscopic vision during the intravaginal introduction of an endoscope and a forceps device for cephalic retraction of the gall bladder. Through the intraumbilical trocar a conventional laparoscopic hook device was also inserted for dissection of the pedicle and hepatic bed, and also a laparoscopic clip applier for clipping of the cystic artery and duct. The gall bladder was extracted through the vagina. RESULTS. The three cases were successfully performed without intra- or postoperative complications. The average operative time was 107 minutes (range 100-115 minutes). The patients were discharged within 24 hours. At the 1-month follow-up, none of the patients complained neither of incisional pain nor dyspareunia. CONCLUSION. The transvaginal NOTES cholecystectomy combined with laparoscopic technique is feasible, safe, reproducible, and constitutes one step further in the development of pure NOTES procedures. More effort in technological investigation and dedication is to be required to apply this technique to other more complex procedures.

Colecistectomía notes transvaginal en humanos: primera serie de casos en Costa Rica / Transvaginal notes cholecystectomy in humans: first series of cases in Costa Rica

OBJETIVO. Reportar la primera serie de casos de colecistectomía NOTES transvaginal en humanos en Costa Rica y su potencial clínico en el abordaje de patologías abdominales en este país. PACIENTES Y MÉTODOS. Presentamos una serie de tres casos de pacientes femeninas adultas de 44, 58 y 69 años (promedio 57 años), asintomáticas, con diagnóstico de pólipo vesicular por un ultrasonido abdominal, sometidas a una colecistectomía por vía transvaginal modificada con técnica laparoscópica. Se insertó un trócar de 5 mm a través del ombligo para creación y monitoreo del pneumoperitoneo, así mismo posibilitando visión endoscópica durante la introducción intravaginal de un endoscopio y una pinza para retracción cefálica de la vesícula. A través del trócar intraumbilical se insertó un dispositivo laparoscópico de gancho convencional para disección del pedículo y cama hepática, y posteriormente una clipadora laparoscópica para clipeo de la arteria y conducto cístico. La extracción de la vesícula se realizó por vía transvaginal. RESULTADOS. Los tres casos fueron realizados con éxito, sin presentar ninguna complicación intra o postoperatoria. El tiempo operatorio promedio fue de 107 minutos (rango 100-115 minutos). Las pacientes fueron egresadas al cabo de 24 horas. En el control postoperatorio al mes, ninguna paciente refirió dolor incisional ni dispareunia. CONCLUSIÓN. La colecistectomía NOTES transvaginal combinada con técnica laparoscópica es viable, segura, reproducible y constituye un paso más en el desarrollo de la cirugía NOTES pura. Mayores esfuerzos en investigación tecnológica y dedicación se requieren para generalizar esta técnica a otros procedimientos más complejos.

OBJECTIVES. To report the first case series of transvaginal NOTES cholecystectomy in humans in Costa Rica and its clinical potential in the treatment of abdominal diseases in this country. PATIENTS AND METHODS. We present a series of three cases of adult female patients of 44, 58 and 69 years of age (average 57 years), asymptomatic, with a gall bladder polyp diagnosed by an abdominal ultrasound, who underwent a transvaginal cholecystectomy modified with laparoscopic technique. A 5 mm trocar was inserted through the umbilicus to create and to monitor the pneumoperitoneum, as well as to possibilitate endoscopic vision during the intravaginal introduction of an endoscope and a forceps device for cephalic retraction of the gall bladder. Through the intraumbilical trocar a conventional laparoscopic hook device was also inserted for dissection of the pedicle and hepatic bed, and also a laparoscopic clip applier for clipping of the cystic artery and duct. The gall bladder was extracted through the vagina. RESULTS. The three cases were successfully performed without intra- or postoperative complications. The average operative time was 107 minutes (range 100-115 minutes). The patients were discharged within 24 hours. At the 1-month follow-up, none of the patients complained neither of incisional pain nor dyspareunia. CONCLUSION. The transvaginal NOTES cholecystectomy combined with laparoscopic technique is feasible, safe, reproducible, and constitutes one step further in the development of pure NOTES procedures. More effort in technological investigation and dedication is to be required to apply this technique to other more complex procedures.

Peroral dual scope for natural orifice transluminal endoscopic surgery (NOTES) gastrotomy closure.

BACKGROUND: Although transgastric intraperitoneal surgery is feasible both in experimental models and humans, secure gastrotomy closure remains challenging. As there is still no method that is simple, reliable, inexpensive, and effective, we aimed to evaluate the feasibility, efficacy, and safety of a novel endoscopic approach to this issue that intends to ensure secure healing by obtaining full thickness gastric wall apposition without requiring specialized instrumentation. METHODS: Six pigs underwent general anesthesia followed by peritoneoscopy through a 12-mm gastrotomy by a double-channel endoscope. Gastrotomy closure was performed by our innovative technique. In short, this involves the insertion of a second single-channel gastroscope alongside the NOTES gastroscope. Both scopes are then worked in tandem within the stomach by separate operators using conventional endoscopic graspers and an endoclip device. The first animal was used to ascertain feasibility and standardize the technical steps, whereas the other five were survived. Postoperative follow-up then included endoscopy 1 week later and repeat endoscopy, laparoscopy, and necropsy on day 14. RESULTS: All closures were immediately successful. Postoperatively, each animal demonstrated appropriate weight gain and behavioral pattern without overt postoperative complication. Necropsy showed normal healing at the gastrotomy site although there were signs of minor peritoneal irritation and infection in 2 pigs. CONCLUSIONS: This transoral dual-scope clipping method of gastrotomy closure after NOTES, as well as the general concept of employing 2 separate instruments at the same time perorally, is proven technically feasible, safe, and effective in this model.

Challenges and lessons learned from NOTES cholecystectomy initial experience: a stepwise approach from the laboratory to clinical application.

BACKGROUND/PURPOSE: The initial idea behind natural orifice transluminal endoscopic surgery (NOTES) was that of an incisionless surgery. NOTES cholecystectomy is a good model of human ingenuity and technological advance. NOTES cholecystectomy in a human being was performed at our institution after extensive laboratory work in live pig models. In this process we gained helpful information related to NOTES cholecystectomy. METHODS: More than 250 cholecystectomies in pigs have been performed. From May 2007 to November 2008 a total of 10 and 6 transvaginal and transgastric human cholecystectomies, respectively, have been performed. RESULTS: The procedure was successful in all patients, with a mean operative time of 120 min. There were no intraoperative or postoperative complications. Patients recovered promptly after surgery and had minor postoperative pain. They were discharged on the second postoperative day. CONCLUSIONS: The advantages of laparoscopy appeared to be enhanced by this approach: patients had minor postoperative pain and minimal scarring. This stepwise experience in the cholecystectomy procedure is an important first step in the development of methods and devices to enable the evaluation of potential incisionless NOTES surgery. Additional research and comparison studies are needed for further improvement in order to provide NOTES procedures to a wider range of patients.