Surgical Endoscopy

, Volume 27, Issue 2, pp 580–586 | Cite as

Less pain after transvaginal/transumbilical cholecystectomy than after the classical laparoscopic technique: short-term results of a matched-cohort study

  • Dirk Rolf Bulian
  • Linda Trump
  • Jürgen Knuth
  • Robert Siegel
  • Axel Sauerwald
  • Michael A. Ströhlein
  • Markus Maria Heiss



Natural orifice surgery (NOS) is gaining acceptance as an alternative to the traditional laparoscopic technique, especially for cholecystectomy through the transvaginal route. However, NOS remains controversial concerning expected advantages in terms of short- and long-term outcomes and potential side effects. This study was designed to compare short-term outcomes between transvaginal/transumbilical and classical laparoscopic cholecystectomy (LC).


A prospective matched-cohort study compared the authors’ first 50 transvaginal/transumbilical cholecystectomies (TVC) with a group of 50 classical LCs from the corresponding period matched in terms of age, body mass index, and American Society of Anesthesiology classification. In both groups, elective surgery was performed for symptomatic cholecystolithiasis. In the NOS group, a hybrid procedure was performed with one transumbilical rigid instrument and two transvaginal rigid instruments. A numeric rating scale was used for daily pain assessment, initiated postoperatively in the recovery room. Both groups were compared with regard to length of surgery, intra- and postoperative complications, length of hospital stay, postoperative pain, and consumption of analgesics.


The length of surgery and the rate of complications were similar in the two groups. But significant advantages were found for the transvaginal access in terms of pain using Numeric Rating Scale (NRS) on the day of surgery (NRS, 1.5/10 vs 3.1/10; p = 0.003) as well as in the morning (NRS, 1.9/10 vs 2.8/10; p = 0.047) and in the evening (NRS, 1.1/10 vs 1.8/10; p = 0.025) of postoperative day 1, and with regard to the length of the postoperative hospital stay (2.7 vs 3.4 days; p = 0.035).


The findings show that TVC is a safe procedure for female patients. It has a risk comparable with that of classic LC, causes significantly less pain in the early postoperative period, and leads to a significantly shorter hospital stay. Prospective randomized trials are necessary to confirm these results.


Cholecystolithiasis Classical laparoscopic technique Natural orifice surgery Postoperative pain Transvaginal/transumbilical cholecystectomy 



The authors thank Prof. Dr. R. Lefering and PD Dr. S. Sauerland of the Institute for Research in Operative Medicine (IFOM), Cologne, University of Witten/Herdecke, for assistance with the statistical analysis of this study.


Dirk Rolf Bulian, Linda Trump, Jürgen Knuth, Robert Siegel, Axel Sauerwald, Michael A Ströhlein, and Markus Maria Heiss have no conflicts of interest or financial ties to disclose.


  1. 1.
    Zornig C, Emmermann A, von Waldenfels HA, Mofid H (2007) Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach. Endoscopy 39:913–915PubMedCrossRefGoogle Scholar
  2. 2.
    Lehmann KS, Ritz JP, Wibmer A et al (2010) The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients. Ann Surg 252:263–270PubMedCrossRefGoogle Scholar
  3. 3.
    Keus F, Gooszen HG, van Laarhoven CJ (2010) Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis: an overview of Cochrane hepato-biliary group reviews. Cochrane Database Syst Rev CD008318Google Scholar
  4. 4.
    Schwenk W, Haase O, Neudecker J, Muller JM (2005) Short-term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev CD003145Google Scholar
  5. 5.
    Peters MJ, Mukhtar A, Yunus RM et al (2009) Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery. Am J Gastroenterol 104:1548–1561 quiz 7, 62PubMedCrossRefGoogle Scholar
  6. 6.
    Hoffman MS, DeCesare S, Kalter C (1994) Abdominal hysterectomy versus transvaginal morcellation for the removal of enlarged uteri. Am J Obstet Gynecol 171:309–313 discussion 13–15PubMedGoogle Scholar
  7. 7.
    Teng FY, Muzsnai D, Perez R, Mazdisnian F, Ross A, Sayre JW (1996) A comparative study of laparoscopy and colpotomy for the removal of ovarian dermoid cysts. Obstet Gynecol 87:1009–1013PubMedCrossRefGoogle Scholar
  8. 8.
    Childers JM, Huang D, Surwit EA (1993) Laparoscopic trocar-assisted colpotomy. Obstet Gynecol 81:153–155PubMedGoogle Scholar
  9. 9.
    Delvaux G, Devroey P, De Waele B, Willems G (1993) Transvaginal removal of gallbladders with large stones after laparoscopic cholecystectomy. Surg Laparosc Endosc 3:307–309PubMedGoogle Scholar
  10. 10.
    Ghezzi F, Raio L, Mueller MD, Gyr T, Buttarelli M, Franchi M (2002) Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc 16:1691–1696PubMedCrossRefGoogle Scholar
  11. 11.
    Emmermann A, Zornig C, Peiper M, Weh HJ, Broelsch CE (1995) Laparoscopic splenectomy: technique and results in a series of 27 cases. Surg Endosc 9:924–927PubMedGoogle Scholar
  12. 12.
    Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter D, Coumaros D (2007) Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg 142:823–826 discussion 6–7PubMedCrossRefGoogle Scholar
  13. 13.
    Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007) Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 66:1243–1245PubMedCrossRefGoogle Scholar
  14. 14.
    Dolz C, Noguera JF, Martin A, Vilella A, Cuadrado A (2007) Transvaginal cholecystectomy (NOTES) combined with minilaparoscopy. Rev Esp Enferm Dig 99:698–702PubMedCrossRefGoogle Scholar
  15. 15.
    Hensel M, Schernikau U, Schmidt A, Arlt G (2011) Surgical outcome and midterm follow-up after transvaginal NOTES hybrid cholecystectomy: analysis of a prospective clinical series. J Laparoendosc Adv Surg Tech 21:101–106CrossRefGoogle Scholar
  16. 16.
    Ramos AC, Murakami A, Galvao Neto M et al (2008) NOTES transvaginal video-assisted cholecystectomy: first series. Endoscopy 40:572–575PubMedCrossRefGoogle Scholar
  17. 17.
    Zornig C, Mofid H, Siemssen L et al (2009) Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases with midterm follow-up. Endoscopy 41:391–394PubMedCrossRefGoogle Scholar
  18. 18.
    Federlein M, Borchert D, Muller V et al (2010) Transvaginal video-assisted cholecystectomy in clinical practice. Surg Endosc 24:2444–2452PubMedCrossRefGoogle Scholar
  19. 19.
    Linke GR, Tarantino I, Hoetzel R et al (2010) Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation in routine clinical practice. Endoscopy 42:571–575PubMedCrossRefGoogle Scholar
  20. 20.
    Noguera JF, Cuadrado A, Dolz C et al (2009) Non-randomised, comparative, prospective study of transvaginal endoscopic cholecystectomy versus transparietal laparoscopic cholecystectomy. Cir Esp 85:287–291PubMedCrossRefGoogle Scholar
  21. 21.
    Hensel M, Schernikau U, Schmidt A, Arlt G (2012) Comparison between transvaginal and laparoscopic cholecystectomy: a retrospective case-control study. Zentralbl Chir 137:48–54PubMedCrossRefGoogle Scholar
  22. 22.
    Kilian M, Raue W, Menenakos C, Wassersleben B, Hartmann J (2011) Transvaginal-hybrid vs single-port access vs “conventional” laparoscopic cholecystectomy: a prospective observational study. Langenbecks Arch Surg 396:709–715PubMedCrossRefGoogle Scholar
  23. 23.
    Zornig C, Siemssen L, Emmermann A et al (2011) NOTES cholecystectomy: matched-pair analysis comparing the transvaginal hybrid and conventional laparoscopic techniques in a series of 216 patients. Surg Endosc 25:1822–1826PubMedCrossRefGoogle Scholar
  24. 24.
    Suzuki K, Yasuda K, Kawaguchi K et al (2010) Cardiopulmonary and immunologic effects of transvaginal natural-orifice transluminal endoscopic surgery cholecystectomy compared with laparoscopic cholecystectomy in a porcine survival model. Gastrointest Endosc 72:1241–1248PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Dirk Rolf Bulian
    • 1
  • Linda Trump
    • 1
  • Jürgen Knuth
    • 1
  • Robert Siegel
    • 1
  • Axel Sauerwald
    • 2
  • Michael A. Ströhlein
    • 1
  • Markus Maria Heiss
    • 1
  1. 1.Department of Abdominal, Vascular, and Transplant SurgeryCologne-Merheim Medical Center, University of Witten/HerdeckeCologneGermany
  2. 2.Frauenklinik Holweide, Kliniken der Stadt KölnCologneGermany

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