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1)O ve rv ie w o f S urg ic a l P ro ce ss

2)O pera tiv e o utc o m es


1)R is ks

2)P erc e ptio n in P atie nts


1)H yb rid

2)L eve l C

3)H ow to m ake n o te s b ette r

1)Im pro ve m ents to in str u

2)V R S im ula to rs

3)In te gra tio n w it h r o botic s u rg ery

The Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) was founded
in 2005, consisting of members from The Society of American Gastrointestinal Endoscopic
Surgeons (SAGES) and American Society of Gastrointestinal Endoscopy (ASGE) . ?1
proposed the term NOTES (natural orifice transluminal endoscopic surgery) for “surgery
performed using instruments which gain access through a natural orifice” .2

NOTES is performed by introducing instruments in the body cavity (usually the peritoneal
cavity) by gaining access through a natural orifice such as the mouth,urethra, vagina or anus, as
opposed to percutaneous access.2This is in contrast to traditional laparotomy, where one large
incision is made in the abdominal wall, or laparoscopic surgery, where a small incision is made
in the abdominal wall to allow a laparoscope to enter. 3
Hybrid NOTES combine NOTES with direct transcutaneous access to the abdominal cavity,
usually in combination with laparoscopic instrumentation.2
NOTES is known to improve the cosmetic outcome, and also reduce surgical injury. This, in
turn decreases the inflammatory and neuroendocrine response resulting in less post-operative
pain and quicker recovery.4

Vaginal NOTES

In 2007, Zorron et. al. performed the first transvaginal NOTES for cholecystectomy on a 43 year
old patient who was discharged within 48 hours of surgery. The operative procedure is close to
that of the Hasson technique.


Regarding NOTES access to the peritoneum, the posterior fornix of the vagina is described to
have the lowest risk of infections post-operatively, but the long-term risks to fertility and
dyspareunia remains unclear.5 However, follow up studies have occured in the case wherein 68
patients(mean age 50 years) were interviewed 3-10 months post-surgery and none reported any
discomfort during sexual

According to a study by Yoshiki(2017), The vagina can be easily decontaminated and provides
direct access to the peritoneum as it has no interposed organ or anatomical structure.
Trans-vaginal procedures mandate an incision in the vaginal wall, which has been approved as
safe and easy to close. With regard to closure of the perforation site within the natural orifices,
an acceptable closure method is not yet present in any other access site except the vagina. He
concludes that the transvaginal port is the most reliable for NOTES in humans.7

Overview of surgical process:
To describe the surgical instruments used in pure transvaginal NOTES, we have isolated 2
reports, which were reportedly one of the first few surgeries for cholecystectomy. Gumbs et
al(2009) performed the surgery on one patient, with colpotomy and subsequent introduction of a
trocar under direct vision into the abdominal cavity. A 15-mm port was established through the
colpotomy, which was used to create the pneumoperitoneum. A double channel gastroscope was
then introduced. An extra 5-mm port was placed beside the 15-mm port to allow placement of a
curved retractor. The cystic duct and artery were clipped using endoscopically placed clips and
the gallbladder was removed through the vagina. The colpotomy was then closed with
absorbable sutures. The duration for the entire procedure was ?185 minutes.9
The authors reported that the main problem was to get a real safe view as the gastroscope is
inserted from behind and there some risk of biliary duct lesions.10
The patient was discharged within 23 hours post surgery, and had 2 follow-ups, one after 2
weeks of the surgery and one after 4 weeks. In both the follow-ups, the patient reported no pain,
no post-operative complications, followed a regular diet and did not need any pain medication.
However, it is important to note that the patient reported pain of around 7(out of 10) on the
Universal pain assessment tool immediately after the surgery.9

De Sousa et al11 published 4 pure NOTES transvaginal cholecystectomies in 2004.
Tra n sv a g in al N OTE S a cce ss w as o b ta in ed b y d ir e ct v a g in al i n cis io n , a n d t w o

en dosc o p es w ere s im ult a n eo u sly i n tr o d u ce d i n t h e a b d om in al c a vit y .
pneumoperitoneum was established connecting a flexible tube to a standard gastroscope that was
inserted through a 2.5 cm posterior colpotomy. A second colonoscope with two operative

channels was inserted using the same access. ?Dis se ctio n w as a cco m pli s h ed w it h a va ila b le

en dosc o p ic i n str u m en ts . L ig atio n o f c y stic d u ct a n d a rte ry w as p erfo rm ed u sin g

en dosc o p ic c li p s. V ag in al c lo su re w as a ch ie v ed u sin g t h e d ir e ct- v is io n s u tu re d

te ch n iq u e.
?The authors considered the view and the spatial resol ution to be of good quality. The

main problem was represented by the introduction of working tools through a small access (the
vagina) and the lack of triangulation.10

Search methodology ??: Google Scholar, PubMed, and Cochrane databases for articles (including
randomized control trials)

Google Scholar (“cholecystectomy” AND/OR “vaginal” AND “NOTES”), n=64
PubMed(“cholecystectomy” AND/OR “vaginal” AND “NOTES”): n=44
Cochrane (“cholecystectomy” AND/OR “vaginal” AND “NOTES”): n=7

(n=2 excluded since non-English)
(15 excluded since mentioned technique wasn’t adhered to, not NOTES but hybrid NOTES)
(10 excluded because not cholecystectomy)
(2 trials were non-randomized and were excluded)
(2 article excluded based on abstract)

Searches were limited to English
7 randomised trials were found out of which two were excluded since the procedure adopted was
Hybrid NOTES. All years of publication were included in the search.

Types of articles included: Articles were either systematic reviews, clinical trials, established
medical articles, surveys, perception studies, case control studies, and case series. The
participants were chosen by random allocation. Obese patients and patients with previous gall
bladder surgeries were excluded from the study. One porcine model study was included as well.

Types of data collected: The quantitative parameters that were included were length of operation
(LOS), postoperative pain (measured on a Visual Analogue Scale, or VAS), length of stay (non
Intensive Care), number of cases with intra and post-operative complications, number of patients
opting for analgesics post discharge, and conversion to open surgery or standard laparoscopy.

The qualitative parameters that were included were scarring, sexual function, fertility, and
dietary change(s).


Quality analysis: The quality of the articles was assessed and implemented in a PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. A total of
12 articles were left after screening which we have further utilized to discuss the effect of
transvaginal NOTES on cholecystectomy. The papers ranged from 2005-2018.

The criteria for inclusion were: patients with no surgical comorbidities, non-obese patients (Body
Mass Index (BMI);=30 kg/m2), patients with no multiple procedures (only cholecystectomy),
middle-aged (to reduce risks of infertility), patients with a vagina, and articles and studies in
English. For better clarity we have included studies with control trials (Vaginal NOTES vs
Conventional Laparoscopy).

Operative Outcomes

First and foremost, NOTES is considered to be more cosmetic than Laparoscopy, simply because
it involves no external
incision. ? ? The primary
advantage of this route is that it reduces the risk associated with standard laparoscopy (bile
leakage, infections, and post operative pain due to residual effects of CO2). According to an
article about a multicenter clinical trial comparing transvaginal and oral NOTES, the principal
investigator stated that ” ?Post-operatively, many patients experience pain while walking or coughing
due to contraction of the abdominal muscles. This discomfort is absent following the natural orifice
approach” with regards to gallbladder removal
The transvaginal route has been proven to be the most effective route in a cholecystectomy.
According to Michelle et. al. a natural orifice entry reduces risks of infection, intraoperative
hernias with a complication of just 1.5%-2.5% in 612 cases.Although the operating time of
patients undergoing TVC is greater than that in conventional laparoscopy.(87.3 minutes v/s 71.1

minutes avg), the average length of stay in the hospital reduces and dependence on analgesics
reduces. This is also reduces the risk of nosocomial infections.
According to Andolfi et al, in 714 NOTES surgeries, the average length of stay in the hospital
was 1.9 days Marerscaux et. al. performed a TVC on one female patient after which the patient
had no scarring and was discharged on the day of the surgery
( ?
ccess=true ?). A one month follow up detected no complications.
According to Hensel
( ? ?) there was a significant
reduction in consumption of opiates (p

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