Laparoscopic Assisted Transvaginal Cholecystectomy (LATC) in a Series of 100 Patients

by Verena Mueller, MD; Matthias Federlein, MD;Klaus Gellert, MD; and Jens Burghardt, MD

Drs. Mueller, Federlein, and Gellert are from the Department of General and Visceral Surgery, Sana Klinikum Lichtenberg, Berlin, Germany. Dr. Burghardt is from the Department of General and Visceral Surgery, Evangelisch Freikirchliches Krankenhaus Rüdersdorf, Rüdersdorf, Germany.

Abstract

Background: Laparoscopic surgery has improved the surgical outcome of reducing wound infections, postoperative pain, risk of hernia, etc. Due to this and the cosmetic result, the patient’s satisfaction is high. Natural orifice surgery has been widely discussed during the last year. It is even less traumatic to the abdominal wall than conventional laparoscopy and might further improve minimally invasive surgery in patients. But it might also increase surgical risk. We performed our first natural orifice surgery procedure, laparoscopic assisted transvaginal cholecystectomy, in October, 2007. Since then, we have performed more than 100 of these procedures and achieved mostly good results.

Objective: Clinical practice of laparoscopic assisted transvaginal cholecystectomy.

Methods: We use a 5-mm port in the umbilicus as a working channel, a 12-mm optical, and a long, bended clamp through the posterior vaginal vault to remove the gallbladder transvaginally.

Results: During a one-year period, 112 women agreed to a transvaginal procedure. In 100 women, the operation was performed transvaginally. Initial laparoscopy revealed 12 patients not suitable for the transvaginal approach due to adhesions, acute cholecystitis, etc. The average age of the patients was 52.4 (23–78) years and their body mass index (BMI) averaged 28.6 (18.8–50). The operating time was 58 minutes (22–120 minutes). Out of all the surgeries, three complications occurred.

Conclusion: In our series, we showed that laparoscopic assisted transvaginal cholecystectomy can be routinely performed.

Patients
The indication for the laparoscopic assisted transvaginal cholecystectomy (LATC) is symptomatic cholecystolithiasis in female patients. Up until December 2008, we operated on 100 women using this technique. The average age was 52.4 years (23–78). The average BMI was 28.6 (18.8–50). Many women were previously operated on, with surgical histories that comprised the whole spectrum of visceral surgery, including appendectomies, incisional hernias, splenectomies, and hysterectomies.

Methods
We performed LATC according to the technique of Zornig.[1]h First, the patient is placed in a modified lithotomy position with spread and lowered legs. The assistant is sitting in a gynecological position and the operator is standing on the left side of the patient.

We insufflate carbon dioxide through an infra-umbilical incision using a Veress needle to build up a pneumoperitoneum. Then we insert a 5mm trocar and through this a 5mm camera. Afterward, the patient is placed in a head-down position to remove the bowels from the pelvis and to explore the small pelvis. (Figure 1 shows trocar and long bended clamp through posterior vaginal vault.) (Figure 2 shows a transvaginal view.)

We then perform the transvaginal approach through the posterior vaginal vault under direct view. We insert a blunt trocar and a long bended clamp, both without any cut incision. Then we change the cameras. Transvaginally, we insert a long 45-degree camera. The infra-umbilical trocar is now used as a working channel. We clamp the gall bladder and we dissect the calot’s triangle in a typical way. The dissection is to be performed using a one-hand technique. After safe identification of the cystic duct and the cystic artery, both structures are severed between metal clips. We use a 5mm, multifire clip applicator. After the dissection of the gall bladder we transfer the bladder into a plastic bag. The bladder can be removed softly through the transvaginal incision. Big stones especially can be removed easily. Sometimes a blunt dilatation is necessary. The incision in the posterior vault is sutured. We used the following instrumentation: Olympus laparoscope; two Ethicon atraumatic trocars (5mm Optiview and 12mm Excel), two clamps, and a clip applier; Olympus Endoscope long bended clamp, 5mm Ethicon clip applicator, and a 5mm Aesculap dissector.

Results
One hundred and twelve women agreed to a transvaginal procedure. In 100 patients, the operation was successfully ended transvaginally. The operations were finished by standard laparoscopical cholecystectomy in 10 patients. In nine of these patients, a transvaginal access was not created due to intraoperative findings (1 lesion of the bowel during the installation of the pneumoperitoneum, 7 adhesions or acute cholecystitis, and 1 previously unknown endometriosis). In one patient with already performed transvaginal access, we refrained from transvaginal salvage due to an accidental intraoperative opening of the gallbladder, which was filled with multiple concrements.

We had to convert to a conventional open cholecystectomy twice—once due to adhesions following a previous liver rupture and once because of a previously unknown penetration of a gallstone into the stomach. In the second of these two patients, the decision of the open approach was made after culdotomy and failure of standard laparoscopy.
The average operating time was 58 minutes (22–120min).

We have not experienced any severe complications following the transvaginal approach. We had one vaginal bleeding, which was treated by a tamponade for one day. We saw one perforation of the urinary bladder. After three days of urinary permanent catheter, the patient was discharged on Day 5 without any clinical symptoms. One superficial lesion of the rectum was sutured laparoscopically.

The pain levels of the transvaginal operation on Days 1 and 2 were similar to the standard cholecystectomy. We will further investigate this in a future study.

On the seventh day after surgery, we asked the women whether they would recommend the procedure to others. A high percentage of them gave an affirmative response. We also asked them whether they are satisfied with the result of the operation and most of them (97%) were satisfied. All patients were seen by a gynecologist 28 days after surgery without any negative findings. No dyspareunia occurred.

Discussion
Since our first transvaginal cholecystectomy in October 2007, the procedure has become a routine operation. It is proposed to all women who have the appropriate indication. The operation is contraindicated in women with expected severe adhesions, virginity, gynecological disease, and partus less than four months previously. An acute cholecystitis is a relative contraindication, if there is just a short time between educational interview and operation. A consent given less than 24 hours prior to a new procedure may cause problems due to the German law.

The problems that may result from the use of flexible multichannel endoscopes, such as improper triangulation, unstable pneumoperitoneum, improper hemostasis, and lack of overview, are avoided by the rigid instruments.
The complication rate of the transvaginal approach is low. This is a long-established access in gynecology. [2–4]

Zornig[5] described an abscess in the Douglas room in one patient, which required a relaparoscopy with drainage. Since this experience, he recommends an antibiotic prophylaxis. We independently accomplished the prophylaxis in our patients from the beginning.

The reduction of the risk for infection in the area of the abdominal wall is one goal of the NOS procedures. The infections at the abdominal wound arise mostly at the gallbladder’s recovery incision, particularly if it contains large gallstones. No infection occurred in our cohort of patients. Disturbances of sexual function due to the transvaginal access were not reported.

Despite missing study results, the dyspareunia as a possible complication of the transvaginal approach is mentioned.[6]

In our clinical experiences, the closure of the incision at the posterior vault is not compellingly necessary. This is in line with experiences from gynecology where after hysterectomy, not in all cases is a closure of the vagina accomplished.[7,8]

Conclusion
The described technique is not a pure NOS procedure. Except for transvaginal access, the operation technique does not differ from the standard laparoscopic cholecystectomy. The literature and our own experiences confirm that the LATC is a safe procedure. The transvaginal access will most likely be used for further procedures. Prospective, randomized studies must follow to confirm these experiences.

References
1.    Zornig C, Mofid H, Emmermann A, et al. Scarless cholecystectomy with combined transvaginal and transumbilical approach in a series of 20 patients. Surg Endosc. 2008;22:1427–1429.
2.    Senn N. The early history of vaginal hysterectomy. JAMA. 1895;25:476–482.
3.    Ott. Ventroscopia. Zhurnal Akush I Zhensk Boliez. 1901.15:1045–1049.
4.    Klaften E. Die Kolpolaparoskopie; eine Methode zur direkten Betrachtung der Organe der Becken-Bauchhöhle vom hinteren Scheidengewölbe. Wien Klin Wochenschr. 1947. 59(50):829–831.
5.    Zornig C, Mofid H, Emmermann A, et al. Combined transvaginal and transumbilical approach for cholecystectomy with no visible scarring. Chirurg. 2008; Nov 22 (Epub ahead of print).
6.    Thele F, Zygmunt M, Glitsch A, et al. How do gynecologists feel about transvaginal NOTES surgery? Endoscopy. 2008;40(7):576–580.
7.    Al-Inany H. Peritoneal closure vs. non-closure: estimation of pelvic fluid by transvaginal ultrasonography after abdominal hysterectomy. Gynecol Obstet Invest. 2004;58(4):83–185.
8.    Franchi M, Ghezzi F, Zanaboni F, et al. Nonclosure of peritoneum at radical abdominal hysterectomy and pelvic node dissection: a randomized study. Obstet Gynecol. 1997;90:622–627.

Tags: Laparoscopic Assisted Transvaginal Cholecystectomy (LAT)

Category: Original Research, Past Articles