This video shows a completely transvaginal NOTES cholecystectomy in a porcine model using novel endoscopic instrumentation.

Novel endoscopic instrumentation has been developed for NOTES procedures. A vaginotomy was created and a prototype transvaginal access port with an endoscope inserted inside of a rigid optical obturator was advanced for peritoneal access. A long rigid grasper was inserted outside of the access port for gallbladder retraction and tissue manipulation. The gallbladder was fixated to the abdominal wall using an endoscopic suturing device for retraction. A saline lift was used for assistance with endoscopic dissection using an articulating hook cautery. An endoscopic Maryland and the long rigid transvaginal grasper was also used for blunt dissection. An endoscopic clip applier with tightly approximating clips was used for ligation of the cystic duct and artery. Endoscopic scissors were then used to divide the cystic duct and artery. The gallbladder was completely divided from its attachments, leaving a clean gallbladder fossa. The retraction suture attaching the gallbladder to the abdominal wall was cut using the endoscopic scissors. The endoscopic snare was used to retrieve the specimen through the transvaginal access port. The vaginotomy was closed under direct vision using standard open instrumentation with absorbable sutures.

The animal was survived for 2 weeks and no complications were detected at autopsy.

A pure transvaginal approach without laparoscopic assistance is feasible in a porcine model.