Chapter 14 Natural Orifice Transluminal Endoscopic Cholecystectomy

Eric S. Hungness, Nathaniel J. Soper

The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.

Cholecystectomy for gallbladder disease is one of the most common general surgical procedures with about 750,000 procedures performed per year. Up until the 1980s, open cholecystectomy was the norm, but laparoscopic cholecystectomy revolutionized surgery and is now the recognized gold standard. This is based on the reduction in overall morbidity with less postoperative pain, decreased hospital stay, and quicker return to work compared with open surgery. Despite the minimally invasive nature of laparoscopic cholecystectomy, some morbidity does exist. The usual four incisions do cause pain and scarring and can get infected, and incisional hernias may occur. As a result, potentially less invasive options for cholecystectomy have been developed over the past 5 years, including single-incision laparoscopy (SIL) and natural orifice transluminal endoscopic surgery (NOTES).

Single-incision laparoscopic cholecystectomy is usually performed with one umbilical skin incision, but it can include either a single or multiple fascial incisions depending on the technique and equipment used. The umbilical skin and fascial incisions may actually be longer than usually made during laparoscopic cholecystectomy and may not decrease pain or result in quicker return to normal functioning for patients. The long-term rate of incisional hernia is also a concern.

NOTES cholecystectomy may offer a less morbid minimally invasive surgical option by greatly reducing or eliminating skin and fascial incisions. The NOTES concept is to use a body’s natural orifice (i.e., mouth, vagina, anus) as the entry point into the peritoneal cavity, by making a hole in a hollow viscus (i.e., stomach, vagina, rectum), passing flexible or rigid instruments into the peritoneal cavity, performing a procedure, and closing the viscus. Transvaginal (TV) cholecystectomy has been performed much more frequently than transgastric (TG) cholecystectomy. All TG and most TV NOTES cholecystectomies have been performed in a hybrid fashion, with at least a 5-mm laparoscope inserted at the umbilicus to ensure safe peritoneal access, assist in dissection, and offer a traditional laparoscopic view should orientation become difficult.

The main advantage of the TG approach is that is it applicable to both sexes, but several disadvantages exist. First, retroflexion of a flexible endoscope to the right upper quadrant is required and can result in spatial disorientation. Steerable overtubes can help overcome this drawback, but this equipment is expensive and requires small-caliber specialized flexible endoscopic equipment. Most reported cases also recommend liberal laparoscopic dissection and additional retraction ports. The risk for gastrotomy leak and specimen extraction must also be considered. The cricopharyngeus is the narrowest point of the esophagus and can be a limiting factor if attempting to extract gallbladders with multiple gallstones or single stones larger than 1 cm in diameter. Esophageal perforation during TG cholecystectomy has been reported.

The TV approach offers several advantages for female patients needing cholecystectomy. First, most gallbladder disease occurs in women. Second, TV access to the pelvis is a standardized procedure in gynecologic surgery that is performed under direct visualization, allowing for easy closure. The gallbladder is also a “straight shot” from the vagina to the right upper quadrant, allowing for better spatial orientation. TV cholecystectomy is usually performed in a hybrid fashion; however, pure NOTES cholecystectomy has been described. The TV approach also allows for the use of rigid instrumentation and thus more accurate force transmission and precision. In fact, most TV cholecystectomies (>1000) have been performed in Germany using rigid instruments. There are several concerns about the TV approach, including dyspareunia, fertility, and hollow-organ injury. The gynecologic literature suggests that the risk for dyspareunia after TV surgery is less than 1%. TV surgery has also been used by infertility experts and poses little risk to fertility. Hollow-organ injury (bladder and rectum) has been reported as a complication of TV cholecystectomy. Regardless of the approach, at this time NOTES cholecystectomy must be considered an investigational procedure, and institutional review board approval should be obtained.

Preoperative evaluation, testing, and preparation

Patients being considered for TG or TV cholecystectomy should have a benign disease of the gallbladder necessitating cholecystectomy and should be worked up in standard fashion. Patients with acute cholecystitis or known choledocholithiasis should be excluded because of the expected inflammation or adhesions in the triangle of Calot.

Right upper quadrant ultrasound with gallstone sizing is mandatory, especially when considering TG cholecystectomy owing to the possibility of large specimens becoming stuck at the cricopharyngeus. If the largest gallstone cannot be measured and a wall-shadow sign is encountered, the gallbladder is most likely filled with multiple small stones that may act as one stone too large for removal. These patients, as well as those with gallstones larger than 1.5 cm in diameter, should not be offered the TG approach. For the TV approach, gallstones larger than 2 to 3 cm in diameter may cause a tearing of the vaginotomy and should be considered a relative contraindication.

Routine preoperative laboratory tests consistent with institutional outpatient surgery guidelines, routine use of a single preoperative dose of intravenous antibiotics, and prophylaxis for deep venous thrombosis are recommended. Patients undergoing TV cholecystectomy should also have a preoperative vaginal bimanual examination by a gynecologist, have a negative Papanicolaou test within the prior 12 months, and undergo bladder catheterization and a povidone-iodine vaginal prep. Other exclusion criteria for both TG and TV cholecystectomy are listed in Table 14-1. Female patients with a contraindication to the TV approach may be considered for the TG approach.

Table 14-1 Exclusion Criteria

Transvaginal Prior abdominal or pelvic surgery Severe endometriosis History of vaginal trauma Gallstone diameter >3 cm Existing dyspareunia Positive Papanicolaou test Cervical cancer Transgastric Prior esophageal or stomach surgery Large hiatal hernia Gallstone diameter >1.5 cm Indeterminate gallstone size with wall-shadow complex Esophageal stricture or web

Patient positioning in the operating suite

NOTES cholecystectomy requires multiple surgical teams and access to both endoscopic and laparoscopic equipment with the ability to project both images simultaneously to closely placed monitors. Careful planning, communication, and coordination are required among the surgical team, operating room nursing staff, and anesthesia team to ensure proper positioning and visualization.

Patients undergoing TG cholecystectomy are placed in a supine position with a flexible anode tube for tracheal intubation. A bite block should be used to help with esophageal intubation with the endoscope or a flexible overtube, or both. The operating surgeon is positioned at the head of the bed cephalad to the left shoulder, with the endoscopy assistant to the left. The laparoscopic assistant is positioned on the patient’s left side with the scrub technician to his or her left. Depending on the type of retraction used, an additional assistant on the patient’s right is helpful. With this setup, all members of the team have good visualization of both the endoscopic and laparoscopic monitors that are positioned on the patient’s right side toward the head (Fig. 14-1).

FIGURE 14-1 Patient positioning and operating room layout for transgastric cholecystectomy.

Patients undergoing the TV approach are positioned in a low lithotomy position with the hips not flexed, similar to the position for a laparoscopic sigmoid colectomy. This will minimize any laparoscopic instrument interference with the patient’s left thigh. Careful attention is given to ensuring minimal pressure on the patient’s calves to avoid peroneal nerve injury. The operating surgeon is seated between the patient’s legs, with the endoscopy assistant to the left. The laparoscopic assistant is positioned on the patient’s left side, with the scrub technician to his or her left. The monitors are positioned similarly to the TG approach (Fig. 14-2).

FIGURE 14-2 Patient positioning and operating room layout for transvaginal cholecystectomy.

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