• Byron F Santos, Ezra N Teitelbaum, Fahd O Arafat, Magdy P Milad, Nathaniel J Soper, and Eric S Hungness.
• Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, IL 60611, USA.
• Surg Endosc. 2012 Nov 1;26(11):3058-66.

IntroductionA natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC).MethodsPatients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.).ResultsSeven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively.ConclusionsThis series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.

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