Page 56 - WJOLS - Laparoscopic Journal

Sarat Chandra Jayasingh
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used by Romanelle for SILS. Merchant et al have used
GelPort multichannel system, which allows four working
instruments including the telescope. 9

TECHNIQUE OF NOTES CHOLECYSTECTOMY

Transvaginal laparoscopically-assisted cholecystectomy
using a single 5 mm and two 3 mm trocars through the
anterior abdominal wall has been described by Besslor.
A 5 mm trocar was used for clip applicator and 3 mm
trocars were used for gallbladder retraction and
pneumoperitonium. A double channel flexible endoscope,
which accommodates a grasper and hook knife was
introduced transvaginally. The procedure took three and
half hours. Marescaux et al used a similar technique with a
2 mm transumbilical needle for pneumoperitonium and
1
laparoscopic-guided colpotomy. Rest of the procedure was
performed transvaginally over three hours.
Fig. 5: Transvaginal NOTES
A different technique by Zorning in which the umbilical
scope was replaced by a dissector and a 10 mm 30 degrees
scope was introduced transvaginally. With this technique,
20 cases were conducted with an average operating time of
62 minutes.
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Forgione et al described another technique in which a
single incision is made in left upper quadrant for
pneumoperitonium, colpotomy, retraction of gallbladder and
clip application. The mean operating time was 136 minutes.

DISCUSSIONS

After analysis of different literature about SILS and NOTES,
it is presumed that there is probably better acceptance of
SILS, although high cost and technical expertise are two
important drawbacks. But for NOTES, patient acceptance
and concerns about safety and complications are major
drawbacks. Older and uneducated patients and those
undergone upper GI endoscopy or colonoscopy in past are
more likely to refuse for the procedure. It is still unproven
whether NOTES has a real advantage over traditional
laparoscopy and SILS or not. SILS offers better cosmetics
by reducing the multiple incisions used in conventional
laparoscopy to a single umbilical incision. Multiple
Fig. 6: Gallbladder removal through the mouth laparoscopic procedures can be simultaneously performed

Fig. 7: NOTES instrument

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JAYPEE