Forgione Antonello, Maggioni Dario, Sansonna Fabio, Ferrari Carlo, Di Lernia Stefano, Citterio Davide, Magistro Carmelo, Frigerio Luigi, Pugliese Raffaele
Department of General and Emergency Surgery, ILCAM-Institute for Minimal Access Surgery, Niguarda Ca' Granda Hospital, Milan, Italy.
J Laparoendosc Adv Surg Tech A. 2008 Jun;18(3):345-51. doi: 10.1089/lap.2007.0203.
The exciting concept of performing surgery in the peritoneal cavity without abdominal incisions by means of flexible endoscopes introduced through natural orifices-natural orifice transluminal endoscopic surgery (NOTES) has been widely investigated in recent years in experimental settings. However, experience with this procedure in human beings is still lacking. In this paper, we report the preliminary results of a small consecutive series of transvaginal endoscopic cholecystectomies.
A standard double-channel gastroscope introduced into the abdominal cavity through a posterior colpotomy was used to perform the cholecystectomy. The introduction of a 5-mm trocar in the left-upper abdominal quadrant was mandatory to create and monitor the pneumoperitoneum and allow the application of the standard laparoscopic clips. This port was also used to introduce a grasper that assisted in the exposure of the gallbladder. The gallbladder was removed through the vagina and was protected in a plastic bag.
Since July 2007, 3 patients were successfully operated on by this approach, including 1 morbidly obese woman with a body mass index (BMI) of 45. The mean operative time was 136 minutes (range, 110-190). No postoperative complications occurred, and the patients did not complain of pain at both access sites. At the 1-month follow-up, none of the patients complained of dyspareunia.
The transvaginal cholecystectomy is feasible, safe, and reproducible in women within a wide range of BMI. NOTES might dramatically change the way surgery will be conceived and performed in the future, as it holds the potential to abolish the historic association of surgery with pain and scars.
近年来，通过自然孔道将柔性内镜引入腹腔进行无腹部切口手术这一令人兴奋的概念——自然孔道内镜手术（NOTES），已在实验环境中得到广泛研究。然而，目前仍缺乏该手术在人体上的经验。在本文中，我们报告了一系列连续的经阴道内镜胆囊切除术的初步结果。
通过后穹窿切开术将标准双通道胃镜引入腹腔以进行胆囊切除术。必须在左上腹象限置入一个5毫米的套管针，以建立和监测气腹，并允许应用标准腹腔镜夹。该端口还用于引入一个抓钳，辅助暴露胆囊。胆囊通过阴道取出，并置于塑料袋中保护。
自2007年7月以来，3例患者通过该方法成功进行了手术，其中包括1例体重指数（BMI）为45 的病态肥胖女性。平均手术时间为136分钟（范围110 - 190分钟）。术后无并发症发生，患者在两个手术入路部位均未诉疼痛。在1个月随访时，所有患者均未诉性交困难。
经阴道胆囊切除术在BMI范围广泛的女性中是可行、安全且可重复的。NOTES可能会极大地改变未来手术的构思和实施方式，因为它有可能消除手术与疼痛和疤痕之间由来已久的关联。
