Gumbs Andrew A, Fowler Dennis, Milone Luca, Evanko John C, Ude Akuezunkpa O, Stevens Peter, Bessler Marc
Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA.
Ann Surg. 2009 Jun;249(6):908-12. doi: 10.1097/SLA.0b013e3181a802e2.
Initial excitement for Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been partly tempered by the reality that a NOTES procedure without laparoscopic or needleoscopic-assistance has not been performed by most groups. After safely performing laparoscopically-assisted transvaginal cholecystectomy in an IACUC-approved porcine model, we embarked on an IRB-approved protocol to ultimately perform a pure NOTES cholecystectomy.
We describe our experience with performing a true NOTES tansvaginal cholecystectomy after safely accomplishing 3 laparoscopically-assisted hybrid NOTES procedures in humans. To overcome the retracting limitations of currently available endoscopes, we used a 5-mm curved or articulating retractor that was placed into the abdomen via a separate colpotomy in the second and third patient. In a fourth patient, pneumoperitoneum to 15 torr was obtained via a transvaginal trocar placed through a colpotomy made under direct vision and endoscopically placed clips were used for both the cystic duct and artery, thus, obviating the need for any transabdominally placed instruments or needles.
This patient was the first patient to undergo a completely NOTES cholecystectomy at our institution and to our knowledge in the United States. She was discharged on the day of surgery and has not suffered any complication after 1 month of follow-up.
Pure NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe in humans. Additional experience with this technique will be required before comparative studies to standard laparoscopy and hybrid techniques are appropriate.
自然腔道内镜手术（NOTES）最初引发的兴奋情绪，在一定程度上因多数团队尚未开展无腹腔镜或针式内镜辅助的NOTES手术这一现实而有所缓和。在国际实验动物护理评估与认证协会（IACUC）批准的猪模型中安全实施腹腔镜辅助经阴道胆囊切除术后，我们着手开展一项经机构审查委员会（IRB）批准的方案，最终实施纯粹的NOTES胆囊切除术。
我们描述了在人类患者中安全完成3例腹腔镜辅助混合NOTES手术后，实施真正的NOTES经阴道胆囊切除术的经验。为克服现有内镜的牵拉限制，在第二例和第三例患者中，我们使用了一个5毫米的弯曲或可弯曲牵开器，通过单独的阴道切开术置入腹腔。在第四例患者中，通过经阴道套管针在直视下经阴道切开术建立15毫米汞柱的气腹，并在内镜下用夹子夹闭胆囊管和动脉，从而无需任何经腹置入的器械或针。
该患者是我们机构以及据我们所知在美国首例接受完全NOTES胆囊切除术的患者。她在手术当天出院，随访1个月后未出现任何并发症。
在无腹腔镜或针式内镜器械辅助的情况下，纯粹的NOTES经阴道胆囊切除术在人体中是可行且安全的。在进行与标准腹腔镜手术和混合技术的比较研究之前，还需要积累更多该技术的经验。
