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Safety of Culdotomy As a Surgical Approach: Implications for Natural Orifice Transluminal Endoscopic Surgery

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Safety of Culdotomy As a Surgical Approach: Implications for Natural Orifice Transluminal Endoscopic Surgery SCIENTIFIC PAPER Safety of Culdotomy as a Surgical Approach: Implications for Natural Orifice Transluminal Endoscopic Surgery Mary Catherine Tolcher, MD, Eleftheria Kalogera, MD, Matthew R. Hopkins, MD, Amy L. Weaver, MS, Juliane Bingener, MD, Sean C. Dowdy, MD ABSTRACT cess portal for natural orifice transluminal endoscopic surgery. Objective: To evaluate the efficacy and safety of cul- dotomy as a surgical approach to access the peritoneal Key Words: Culdotomy, Transvaginal approach/route/ cavity and discuss its implications for natural orifice surgery, Natural orifice transluminal endoscopic surgery transluminal endoscopic surgery (NOTES). (NOTES), transluminal surgery. Methods: A retrospective chart review of women under- going culdotomy for tubal sterilization (Nϭ219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of INTRODUCTION complications. The continual drive to minimize surgical morbidity Results: No intraoperative complications were noted. brought to fruition laparoscopic surgery followed by ad- Postoperative complications occurred in 7 patients (3.2%): ditional minimally invasive approaches including single- 6 infections (grade 2) and 1 case of hemorrhage (grade 3). incision laparoscopic surgery (SILS) and robotics. These Conversion to laparoscopy was necessary in 10 patients advances marked a revolutionary leap in the practice of (2.2%) due to anatomical constraints or pelvic adhesions; surgery and have emerged as the standard of care for however, culdotomy with entry into the abdominal cavity procedures including cholecystectomy, appendectomy, was nevertheless successful in all 10 cases. The difference oophorectomy, and hysterectomy in select patients over in the proportion with a history of pelvic surgery between the last 2 decades. An overwhelming body of evidence in the conversion and nonconversion groups was not statis- the literature indicates that minimally invasive surgery not tically significant (P ϭ .068). Patients with BMI Ն30 had a only offers superior cosmetic results but, most impor- higher conversion rate compared to patients with BMI tantly, also reduces surgical trauma and blood loss, neu- Ͻ30 (11.4% versus 1.5%, P ϭ .011). Tubal sterilization via roendocrine stress and inflammatory response, postoper- culdotomy was successfully performed in all 11 women ative pain, and recovery time.1,2 Culdotomy meets the with no prior vaginal deliveries. criteria for a minimally invasive surgical approach with the potential to provide all the aforementioned benefits. Conclusion: Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated Culdotomy consists of a transverse incision in the poste- with a low complication rate. These data support the rior vaginal fornix into the cul-de-sac which establishes feasibility and safety of utilizing the cul-de-sac as an ac- direct access to the pelvis; culdotomy is also the first step for vaginal hysterectomy. As reported by Hofmeister, Pel- leton3 is credited as the first to have reported drainage of Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA (Drs. a tubo-ovarian abscess by colpotomy in 1835. In 1896, Tolcher, Kalogera, Hopkins, Dowdy). Kelly4 reported 10 cases of ectopic pregnancies managed Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA surgically through the vaginal route and thus was the first (Ms. Weaver). to suggest the use of culdotomy as a route for specimen Department of Surgery, Mayo Clinic, Rochester, MN, USA (Dr. Bingener). retrieval. Culdoscopy, in which an endoscope is inserted Presented at the 39 AAGL Global Congress of Minimally Invasive Gynecology, into the abdominal cavity through a puncture in the pos- November 8-12, 2010, Las Vegas, NV. terior vaginal fornix for visual examination of the female Address correspondence to: Sean C. Dowdy, MD, 200 first Street SW, Rochester, 5 MN 55905, USA. Telephone: (507) 284-2511, Fax: (507) 266-9300, E-mail address: viscera, was first reported by Dimitri Oscarovich Ott, a [email protected] gynecologist from St. Petersburg in 1901 followed by 6 DOI: 10.4293/108680812X13462882735854 Decker and Cherry in 1944. Since then, culdotomy has © 2012 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by traditionally been used as a means of investigating the the Society of Laparoendoscopic Surgeons, Inc. pelvis for the diagnosis and treatment of various gyneco- JSLS (2012)16:413–420 413 Safety of Culdotomy as a Surgical Approach: Implications for Natural Orifice Transluminal Endoscopic Surgery, Tolcher MC et al. logic diseases among which tubal sterilization and ovarian dotomy in a contemporary cohort of patients with special cystectomy have predominated.7–15 emphasis on transvaginal tubal sterilization as a model. Culdotomy was popular in the 1970s, but as laparoscopy became more widely accepted, culdotomy fell out of favor MATERIALS AND METHODS despite its merits. However, in recent years, interest in A retrospective chart review was conducted following exploring even less invasive approaches has resulted in approval from the Mayo Foundation institutional review the reappraisal of transvaginal surgery by both gyneco- board. Both the institutional surgical index and the gyne- logic surgeons and general surgeons. The former have cologic surgery database were queried for all gynecologic used this approach to perform salpingectomy, oophorec- surgical procedures involving a culdotomy, and all pa- 15–27 tomy, myomectomy, and hysterectomy, whereas the tients who underwent culdotomy for a variety of indica- latter have utilized culdotomy to extract large specimens tions between 1995 and 2005 at Mayo Clinic Rochester (gallbladder, appendix, colon, kidney, spleen) during lap- were identified. Exclusion criteria were culdotomy per- 28–32 aroscopy to minimize the transabdominal incision. A formed for an indication other than tubal sterilization (TS) more recent development is culdolaparoscopy, a culdos- and lack of postoperative follow-up data. In accordance copy assisted laparoscopic technique that utilizes a 12-mm with the Minnesota Statute for Use of Medical Information trocar in the vagina as a multifunctional port in conjunc- in Research, only those individuals who had previously 33 tion with traditional laparoscopy, first described by Tsin provided informed consent for the use of their medical 26,34 in 2001. records were included. The safety and efficacy of culdotomy became of even Medical records including operative notes, inpatient and greater interest recently with the introduction of the outpatient clinic notes, as well as correspondence from emerging concept of natural orifice transluminal endo- outside health facilities on postoperative follow-up were scopic surgery (NOTES).35–46 NOTES is a surgical technique retrospectively reviewed. Postoperative adverse events whereby an “incisionless” abdominal surgery is performed occurring up to 45 days following surgery were consid- using a flexible endoscope introduced through a natural ered as postoperative complications. The contracted Ac- orifice (mouth, urethra, anus, vagina) then through an inter- cordion Severity Grading System50 was adopted as a nal incision in the stomach, vagina, bladder, or colon to method to report the severity of these complications. gain access to the abdominal cavity without abdominal wall incisions. This technique has the potential to obviate All procedures were performed by gynecologic surgeons, complications associated with abdominal incisions, such and the technique used to carry out the culdotomy has been as wound infections and hernia formation, further mini- previously described in detail in the literature.19,23,24,27,30 mize postoperative pain and the potential for adhesion Briefly, patients are prepped and draped while in the formation, shorten hospital stay and recovery time, and dorsal lithotomy position. The posterior lip of the cervix is improve overall morbidity and cosmesis over that ob- grasped with a tenaculum and retracted caudally and served with laparoscopy.35–46 The first published report of anteriorly to expose the posterior fornix. Countertraction a NOTES procedure was in 2004 when Kalloo et al.47 is applied to the posterior vagina, and an incision is made presented a porcine survival model of transgastric perito- with Metzenbaum scissors at an angle parallel to the floor. neoscopy. The first human NOTES procedure is credited This allows direct access to the cul-de-sac between the to Reddy and Rao48 who in the same year performed a uterus and rectum. It is important that the incision not be transgastric appendectomy in a male patient. Since then, a made too close to the cervix to avoid cutting into the growing volume of research in animals and recently in cervix/uterus rather than the peritoneal cavity. Deaver humans has supported the feasibility, efficacy, and safety retractors are then used to visualize pelvic structures like of transluminal surgery. The transvaginal approach is a the ovaries and fallopian tubes. In this series, tubal steril- potential access portal for NOTES. The first report of izations performed were achieved by salpingectomy, as human transvaginal cholecystectomy, carried out during a follows. The fallopian tubes were identified, grasped with vaginal hysterectomy, was published in 2003 by Tsin et an Alice clamp, and followed to the fimbriated end. The al.33 whereas Marescaux et al.49 reported in 2007 the first entire
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