Principles of laparoscopic and

robotic surgery
 Phillipe Mouret’s first video-laparoscopic
cholecystectomy was performed in Lyon, France in 1987

Laparoscopic
cholecystectomy has
revolutionised the surgical
management of
cholelithiasis and has
become the mainstay of
management of
uncomplicated gallstone
disease
The core principles of minimal access surgery

Acronym “I-VITROS”
● Insufflate/create space – to allow surgery to take place
in the minimal access setting
● Visualise – the tissues, anatomical landmarks and the
environment for the surgery to take place
● Identify – the specific structures for surgery
● Triangulate – surgical tools (such as port placement) to
optimise the efficiency of their action, and ergonomics by
minimising overlap and clashing of instruments
● Retract – and manipulate local tissues to improve
access and gain entry into the correct tissue planes
● Operate – incise, suture, anastomose, fuse
● Seal/haemostasis.
Laparoscopy. A rigid endoscope (laparoscope) is introduced
through a port into the peritoneal cavity. This is insufflated with
carbon dioxide to produce a pneumoperitoneum. Further ports are
inserted to enable instrument access and their use for dissection

Thoracoscopy. A rigid endoscope is introduced through an

incision in the chest to gain access to the thoracic contents. Usually
there is no requirement for gas insufflation, as the operating space
is held open by the rigidity of the thoracic cavity. In specific cases,
such as mediastinal tumour resection and diaphragmatic surgery,
gas insufflation at low pressure (5–8 mmHg) may be applied.
Arthroscopy and intra-articular joint surgery.
Orthopaedic surgeons have applied arthroscopic access to the knee
for some time and are applying this modality to other joints,
including the shoulder, wrist, elbow and hip.

Endoluminal endoscopy. Flexible or rigid endoscopes are

introduced into hollow organs or systems, such as the urinary
tract, upper or lower gastrointestinal tract, and respiratory and
vascular systems.
Perivisceral endoscopy. Body planes can be accessed even in the
absence of a natural cavity. Examples are mediastinoscopy,
retroperitoneoscopy and retroperitoneal approaches to the kidney,
aorta and lumbar sympathetic chain. Extraperitoneal approaches to
the retroperitoneal organs, as well as hernia repair, are now
becoming increasingly commonplace, further decreasing morbidity
associated with visceral peritoneal manipulation. Other, more
recent, examples include subfascial ligation of incompetent
perforating veins in varicose vein surgery.
Combined approach. The diseased organ is visualised and
treated by an assortment of endoluminal and extraluminal
endoscopes and other imaging devices. Examples include the
combined laparoendoscopic approach for the management of
biliary lithiasis, colonic polyp excision and several urological
procedures, such as pyeloplasty and donor nephrectomy. In some
cases the application of this combined approach offers the ability
to execute operations via a single incision, thereby better adhering
to the minimally invasive approach. The evidence for improved
outcomes using these combined approaches remains limited for the
majority of procedures.
 SURGICAL TRAUMA IN OPEN,
MINIMALLY INVASIVE AND
ROBOTIC SURGERY
Advantages of minimal access
surgery
● Decrease in wound size
● Reduction in wound infection, dehiscence,
bleeding, herniation and nerve entrapment
● Decrease in wound pain
● Improved mobility
● Decreased wound trauma
● Decreased heat loss
● Improved visualisation
LIMITATIONS OF MINIMAL
ACCESS SURGERY
Limitations of minimal access
surgery
● Reliance on remote vision and
operating
● Loss of tactile feedback
● Dependence on hand–eye coordination
● Difficulty with haemostasis
● Reliance on new techniques
● Extraction of large specimens
 ROBOTIC SURGERY
A robot is a mechanical device that performs automated physical tasks
according to direct human supervision, a predefined program or a set of
general guidelines, using artificial intelligence techniques. In terms of
surgery, robots have been used to assist surgeons during procedures. This
has been primarily in the form of automated camera systems and
telemanipulator systems, thus resulting in the creation of a human–
machine interface.
The advantages of robotic surgery are two-fold: first for the patient and
second for the surgeon. The advantages for the surgeon include better
visualisation (higher magnification) with stereoscopic views; elimination
of hand tremor allowing greater precision; improved manoeuvring as a
result of the ‘robotic wrist’, which in some systems allows up to seven
degrees of freedom; and the fact that large external movements of the
surgical hands can be scaled down and transformed to limited internal
movements of the ‘robotic hands’, extending the surgical ability to
perform complex technical tasks in a limited space. Also, the surgeon is
able to work in an ergonomic environment with less stress and to achieve
higher levels of concentration. The computer may also be able to
compensate for the beating movement of the heart, making it
unnecessary to stop the heart during cardiothoracic surgery. There may
also be less need for assistance once surgery is under way.
One major operative barrier to adoption remains the
prohibitive costs for many healthcare environments. This is
partly because of the high cost of design and development of
new robot technologies and surgical instruments compatible
withthem, which all require design, translation and
intellectual property costs. In addition to the remote master–
slave platform design, direct robot systems exist and include:

● tremor suppression robots;

● active guidance systems;
● articulated mechatronic devices;
● force control systems;
● haptic feedback devices.

Each of these systems offers different advantages to the

operating surgeon, ranging from reducing the need for
assistants and providing better ergonomic operating positions
to providing experienced guidance from surgeons not
physically present in the operating theatre.
Robotic surgery – the first 30 years
The 99 studies revealed data from approximately 14 500
patients in trials undergoing robotic surgical procedures
versus open and minimally invasive operations. The overall
pooled results, regardless of specialty, revealed a decrease in
blood loss and blood transfusion rate with robotic surgery
when compared with both open surgery and minimally
invasive surgery. Specifically, when compared with open
surgery, robotic procedures demonstrated that there was a
reduction in length of hospital stay and overall
complication rate. However, robotic procedures did suffer
from significantly longer operative times and their cost-
effectiveness varied depending on operative site, technique,
patient and healthcare setting. While this reveals an overall
perspective from the first 30 years of robotics surgery, there
remains an incumbent need to offer clearer clinical evidence
regarding the most apposite operative method and
technology for each individual patient.
Disadvantages of robotic surgery
● increased cost;
● increased set up of the system and operating
time;
● socioeconomic implications;
● significant risk of conversion to conventional
techniques;
● prolonged learning curve;
● multiple repositioning of the arms can cause
trauma;
● haemostasis;
● collision of the robotic arms in extreme
positions.
Preparation of the patient
History. Patients must be fit for general anaesthesia and open
operation if necessary. Potential coagulation disorders (e.g.
associated with cirrhosis) are particularly dangerous in
laparoscopic surgery. As adhesions may cause problems, previous
abdominal operations or peritonitis should be documented.
Examination. Laparoscopic/ thoracoscopic surgery allows
quicker recovery, it may involve longer operating times and the
establishment of the pneumoperitoneum may provoke cardiac
arrhythmias. Severe chronic obstructive airways disease and
ischaemic heart disease may be contraindications to the
laparoscopic approach. Particular attention should be paid to the
presence or absence of jaundice, abdominal scars, palpable masses
or tenderness. Moderate obesity does not increase operative
difficulty significantly, but massive obesity may make
pneumoperitoneum difficult and standard instrumentation may
be too short.
Prophylaxis against thromboembolism. Venous stasis induced
by the reverse Trendelenburg position during laparoscopic surgery may
be a particular risk factor for deep vein thrombosis, as is a lengthy
operation and the obesity of many patients. Subcutaneous low
molecular weight heparin and antithromboembolic stockings should be
used routinely, in addition to pneumatic leggings during the operation.
Patients already taking warfarin for other reasons should have this
stopped temporarily or converted to intravenous heparin, depending on
the underlying condition, as it is not safe to perform laparoscopic
surgery in the presence of a significant coagulation deficit.
Urinary catheters and nasogastric tubes. In the early days of
laparoscopic surgery, routine bladder catheterisation and nasogastric
intubation were advised. Most surgeons now omit these, but it remains
essential to check that the patient is fasted and has recently emptied
their bladder, particularly before the blind insertion of a Verres needle.
However, currently, most general surgeons prefer the direct cut-down
technique into the abdomen for the introduction of the first port for
the establishment of the pneumoperitoneum (Hasson technique and
modified Hasson approaches). More recently, direct optical entry has
been used, especially in the setting of bariatric surgery.
 GENERAL INTRAOPERATIVE PRINCIPLES
Creating a pneumoperitoneum
There are two methods for creation of a pneumoperitoneum: open and
closed. The closed method involves blind puncture using a Verres needle.
Although this method is fast and relatively safe, there is a small but
significant potential for intestinal or vascular injury on introduction of the
needle or first trocar.
The routine use of the open technique for creating a pneumoperitoneum
avoids the morbidity related to a blind puncture. To achieve this, a 1 cm
vertical or transverse incision is made at the level of the umbilicus. The
umbilicus carries importance as it is a reliable anatomical landmark
deriving from the embryological coalescence of the rectus sheath and
peritoneum and is devoid of other myofascial planes that could complicate
subsequent entry into the peritoneum. Two small retractors are used to
dissect bluntly the subcutaneous fat and expose the midline fascia. Two
sutures are inserted each side of the midline incision (into the rectus
sheath confluence), followed by the creation of a 1 cm opening in the fascia.
Free penetration into the abdominal cavity is confirmed by the gentle
introduction of a finger.
Rarely, a third, or combination, approach may be employed. Here an open
technique is followed with a smaller than usual midline incision. Once
access to the peritoneum is visualised, a Verres needle is inserted under
direct vision, and then insufflation is carried out.
 Preoperative problems
Previous abdominal surgery
Previous abdominal surgery is no longer a contraindication to
laparoscopic surgery, but preoperative evaluation is necessary to
assess the type and location of surgical scars. As mentioned
earlier, the open technique for insertion of the first trocar is safer.
Before trocar insertion, the introduction of a fingertip helps to
ascertain penetration into the peritoneal cavity and also allows
adhesions to be gently removed from the entry site. After the tip of
the cannula has been introduced, a laparoscope is used as a blunt
dissector to tease adhesions gently away and form a tunnel
towards the quadrant where the operation is to take place. This
step is accomplished by a careful pushing and twisting motion
under direct vision. With experience, the surgeon learns to
differentiate visually between thick adhesions that may contain
bowel and should be avoided and thin adhesions that would lead
to a window into a free area of the peritoneal cavity.
 Obesity
Some procedures are less difficult than their open counterparts for the
morbidly obese patient, e.g. in bariatric surgery. Technical difficulties occur,
however, in obtaining pneumoperitoneum, reaching the operative region
adequately and achieving adequate exposure in the presence of an obese
colon. Increased thickness of the subcutaneous fat makes insufflation of the
abdominal cavity more difficult. With the closed technique, a larger Verres
needle is often required for morbidly obese patients. Pullingthe skin up for
fixation of the soft tissues is better accomplished with towel clamps. Only
moderate force should be used, to avoid separating the skin farther from the
fascia. The needle should be passed at nearly a right angle to the skin and
preferably above the umbilicus, where the peritoneum is more firmly fixed to
the midline. The open technique of inserting a Hasson trocar is easier and
safer for obese patients, but technically demanding in morbidly obese
patients, where optical entry is now more commonplace. The main difficulty
is reaching the fascia. A larger skin incision (1–3 cm), starting at the
umbilicus and extending superiorly, may facilitate this. To reach the
operative area adequately, the location of some of the ports has to be
modified and, in some instances, larger and longer instruments are
necessary. When the length of the laparoscope appears to be insufficient to
reach the operative area adequately, the initial midline port should be
placed nearer to the operative field.
 Operative problems
Intraoperative perforation of a viscus
Perforation of any viscus, such as bowel, solid organs and blood
vessels (including the aorta), is a potential hazard of using the
laparoscopic approach and these complications may be minimised
with surgical experience, education, preparation and patient
selection. One example, in a common laparoscopic procedure such as
cholecystectomy, includes perforation of the gallbladder. This is more
common with the laparoscopic technique than with the open
Technique. It is well known that bile is not a sterile fluid and bacteria
can be present in the absence of cholecystitis. Unless the perforation
is small, closure with endoloops or endoclips should be attempted to
avoid contamination prior to extraction, which should be with the
use of an endobag. Bilious leakage should be suctioned and washed
out. If there is stone spillage, every attempt must be made to collect
and extract the stones, and if there is a possibility of stones being
retained in the peritoneum, then an ultrasound should be arranged 6
weeks postoperatively to assess a collection around a stone and the
patient should be informed of this outcome postoperatively.
Antibiotics to manage known sepsis or
septicaemia in a patient undergoing surgery

Operating on a patient with established septicaemia or sepsis

is not typically recommended unless the operation will contribute
to removing or minimising infectious origins. Where
necessary pre-, peri- and postoperative antibiotics should
be administered, in accordance with local microbiological advice.

Antibiotics to prevent infections and sepsis

A single dose of antibiotics should be administered within 1 hour of

skin incision; in contaminated, semi-contaminated or complex
procedures, additional doses should be administered, based on local
microbiological advice.
 Bleeding
Bleeding plays a more important role in laparoscopic surgery
because of factors inherent to the technique. These include a limited
field that can easily be obscured by relatively small amounts of blood,
magnification that makes small arterial bleeding appear to be a
significant haemorrhage and light absorption that obscures the
visual field.
As in any surgical procedure, the best way to handle intraoperative
bleeding is to prevent it from happening. This can usually be
accomplished by identifying patients at high risk of bleeding, having
a clear understanding of the laparoscopic anatomy and employing
careful surgical technique.

Risk factors that predispose to increased bleeding include:

● cirrhosis;
● inflammatory conditions (acute cholecystitis, diverticulitis);
● patients on clopidogrel and or dipyridamole;
● coagulation defects: these are contraindications to a laparoscopic
procedure.
 BLEEDING FROM A MAJOR VESSEL
Damage to a large vessel requires immediate assessment of the
magnitude and type of bleeding. When the bleeding vessel is identified,
a fine-tip grasper can be used to grasp it and apply either
electrocautery or a clip, depending on its size. When the vessel is not
identified early and a pool of blood forms, compression should be
applied immediately with a blunt instrument, a cotton swab or with the
adjacent organ. Good suction and irrigation are of utmost importance.
Once the area has been cleaned, pressure should be released gradually
to identify the site of bleeding. Insertion of an extra port may be
required to achieve adequate exposure and at the same time to enable
the concomitant use of a suction device and an insulated grasper.
Although most bleeding vessels can be controlled laparoscopically,
judgement should be used in deciding when not to prolong bleeding,
but to convert to an open procedure at an early stage. Absorbable
fibrillar oxidized cellulose polymer or other clot-promoting strips,
tissue glues or other haemostatic agent may also be used
laparoscopically to aid haemostasis. If at any stage bleeding is difficult
to stem laparoscopically, there should be no delay in converting to an
open procedure in the interests of patient safety.
 BLEEDING FROM ORGANS
ENCOUNTERED DURING SURGERY
Intraoperative bleeding from organs can usually be prevented by
performing the dissection in the correct plane. As previously
mentioned, the common laparoscopic example of a cholecystectomy
requires understanding the management of bleeding from the
gallbladder bed. When a bleeding site appears during detachment of
the gallbladder, the dissection should be carried a little farther to
expose the bleeding point adequately. Once this step has been
performed, direct application of electrocautery usually controls the
bleeding. If bleeding persists, indirect application of electrocautery is
useful because it avoids detachment of the formed crust. This
procedure is accomplished by applying pressure to the bleeding point
with a blunt, insulated grasper and then applying electrocoagulation
by touching this grasper with a second insulated grasper that is
connected to the electrocautery device. One must be careful to keep
all conducting surfaces of the graspers within the visual field while
applying the electrocautery current.
 BLEEDING FROM A TROCAR SITE
Bleeding from the trocar sites is usually controlled by applying upwards
and lateral pressure with the trocar itself. Considerable bleeding may
occur if the falciform ligament is impaled with the substernal trocar or
if one of the epigastric vessels is injured. If significant continuous
bleeding from the falciform ligament occurs, haemostasis is achieved by
percutaneously inserting a large, straight needle at one side of the
ligament. A monofilament suture attached to the needle is passed into
the abdominal cavity and the needle is exited at the other side of the
ligament using a grasper.

Management of bleeding
from a surgical trocar site
The loop is suspended and compression is achieved. Maintaining
compression throughout the procedure usually suffices. After the
procedure has been completed, the loop is removed under direct
laparoscopic visualisation to ensure complete haemostasis.
When significant continuous bleeding from the abdominal wall
occurs, haemostasis can be accomplished either by pressure or by
suturing the bleeding site. Pressure can be applied using a Foley
balloon catheter. The catheter is introduced into the abdominal
cavity through the bleeding trocar site wound, the balloon is
inflated and traction is placed on the catheter, which is bolstered
in place to keep it under tension. The catheter is left in situ for 24
hours and then removed.Although this method is successful in
achieving haemostasis, the authors favour direct suturing of the
bleeding vessel. This manoeuvre is accomplished by extending
the skin incision by 3 mm at both ends of the bleeding trocar site
wound. Two figure-of-eight sutures are placed in the path of the
vessel at both ends of the wound. Devices such as the EndoClose
may also be used to apply transabdominal sutures under direct
laparoscopic view to close port sites that bleed.
EVACUATION OF BLOOD CLOTS
The best way of dealing with blood clots is to avoid them. As
mentioned, careful dissection and identification of the cystic
artery and its branches, as well as identifying and carrying
out dissection of the gallbladder in the correct plane, help to
prevent bleeding from the cystic vessels and the hepatic bed.
Nevertheless, clot formation takes place when unsuspected
bleeding occurs or when inflammation is severe and a clear
plane is not present between the gallbladder and the hepatic
bed. The routine use of 5000–7000 units of heparin per litre of
irrigation fluid helps to avoid the formation of clots. When
extra bleeding is foreseen, a small pool of irrigation fluid can
be kept in the operative field to prevent clot formation. After
clots have formed, a large bore suction device should be used
for their retrieval. Care should be taken to avoid suctioning in
proximity to placed clips.
 Principles of electrosurgery during
laparoscopic surgery
Electrosurgical injuries during laparoscopy are potentially serious. The
vast majority occur following the use of monopolar diathermy. The
overall incidence is between one and two cases per 1000 operations.
Electrical injuries are usually unrecognised at the time that they occur,
with patients commonly presenting 3–7 days after injury with
complaints of fever and abdominal pain. As these injuries usually
present late, the reasons for their occurrence are largely speculative.
The main theories are: (1) inadvertent touching or grasping of tissue
during current application; (2) direct coupling between a portion of
bowel and a metal instrument that is touching the activated probe
(Figure 8.6); (3) insulation breaks in the electrodes; (4) direct sparking
to bowel from the diathermy probe; and (5) current passage to the
bowel from recently coagulated, electrically isolated tissue. Bipolar
diathermy is safer and should be used in preference to monopolar
diathermy, especially in anatomically crowded areas. If monopolar
diathermy is to be used, important safety measures include attainment
of a perfect visual image, avoiding excessive current application and
meticulous attention to insulation. Alternative methods of performing
dissection, such as the use of ultrasonic devices, may improve safety.
 POSTOPERATIVE CARE
The postoperative care of patients after laparoscopic surgery is
generally straightforward, with a low incidence of pain or other
problems. The most common routine postoperative symptoms are a
dull upper abdominal pain, nausea and pain around the shoulders
(referred from the diaphragm). There has been some suggestion that
the instillation of local anaesthetic to the operating site and into the
suprahepatic space, or even leaving 1 litre of normal saline in the
peritoneum, serves to decrease postoperative pain. It is a good general
rule that if the patient develops a fever or tachycardia, or complains of
severe pain at the operation site, something is wrong and close
observation is necessary. In this case, routine investigation should
include a full blood count, C reactive protein (CRP) measurement, liver
function tests, an amylase test and, probably, an ultrasound scan of
the upper abdomen to detect fluid collections. If bile duct leakage is
suspected, endoscopic retrograde cholangiopancreatography (ERCP)
may be needed. If in doubt, relaparoscopy or laparotomy should be
performed earlier rather than later. Death following technical
errors in laparoscopic cholecystectomy has often been associated with
a long delay in deciding to re-explore the abdomen.
Nausea
About half of patients experience some degree of nausea
after laparoscopic surgery and, rarely, this may be
severe. It usually responds to an antiemetic, such as
ondansetron, and settles within 12–24 hours. It is made
worse by opiate analgesics and these should be avoided.

Shoulder tip pain

The patient should be warned about this preoperatively
and told that the pain is referred from the diaphragm
and not due to a local problem in the shoulders. It can be
at its worst 24 hours after the operation. It usually
settles within 2–3 days and is relieved by simple
analgesics, such as paracetamol.
Abdominal pain
Pain in one or other of the port site wounds is not
uncommon and is worse if there is haematoma
formation. It usually settles very rapidly. Increasing pain
after 2–3 days may be a sign of infection and, with
concomitant signs, antibiotic therapy is occasionally
required. Occasionally, herniation through a port may
account for localised pain and this can sometimes be due
to a Richter’s hernia, such that the patient exhibits no
sign of intestinal obstruction. Successful laparoscopic
surgery should not cause a patient increasing or undue
pain. If there are any clinical concerns postoperatively
due to worsening pain, tachycardia and or pyrexia,
senior review with a view to imaging, or increasingly
commonly relaparoscopy, should be considered.
Analgesia
A 100-mg diclofenac suppository may be given at the time
of the operation. It is important that the patient provides
separate consent for this if the suppository is to be
administered peroperatively. Suppositories may be
administered a further two or three times postoperatively
for relief of more severe pain. Otherwise, 500–1000 mg of
paracetamol 4-hourly usually suffices. Opiate analgesics
cause nausea and should be avoided unless the pain is very
severe. In this case, suspect a postoperative complication.
The majority of patients require between one and four
doses of 1 g of paracetamol postoperatively. Severe pain
after routine laparoscopic cases should warn the clinician
that there may be an iatrogenic or surgical cause of this
pain that may need further investigation with blood tests,
imaging and even relaparoscopy
Oral fluids
There is no significant ileus after laparoscopic surgery,
except in resectional procedures, such as colectomy or
small bowel resection. Patients can start taking oral
fluids as soon as they are conscious; they usually do so 4–
6 hours after the end of the operation.
Oral feeding
Provided that the patient has an appetite, a light meal
can be taken 4–6 hours after the operation. Some patients
remain slightly nauseated at this stage, but almost all eat
a normal breakfast on the morning after the operation.
Patients will require advice about what they can eat at
home. They should be told that they can eat a normal diet
but should avoid excess. It seems sensible to avoid high-
fat meals for the first week, although there is no clear
evidence that this is necessary.
Urinary catheter
This depends on the operation. If a urinary catheter has been placed
in the bladder during an operation with likely short stay, it should be
removed before the patient regains consciousness if the procedure
has proceeded well. The patient should be warned of the possibility
and symptoms of postoperative cystitis and told to ask advice in the
unlikely event of this occurring.
Drains
The use of postoperative drains in laparoscopy patients depends on
the operation performed. Drains are used to assess postoperative
blood loss if this is a clinical concern or to assess the nature of
intraperitoneal fluids, depending on procedure and postoperative
monitoring needs. Some surgeons drain the abdomen at the end of
laparoscopic cholecystectomy, although this is controversial. If a
drain is placed to vent the remaining gas and peritoneal fluid, it
should be removed within 1 hour of the operation. If it has been
placed because of excessive hepatic bleeding or bile leakage it should
be removed when that problem has resolved, usually after 12–24
hours. Continued blood loss from a drain is an indication for e-
exploration of the abdomen.
 Mobility and convalescence
Patients can get out of bed to go to the toilet as soon as they have
recovered from the anaesthetic and they should be encouraged to do
so. Such movements are remarkably pain free when compared with
the mobility achieved after an open operation. Similarly, patients
can cough actively and clear bronchial secretions, and this helps to
diminish the incidence of chest infections. Many patients are able to
walk out of hospital on the evening of their operation and almost all
are fully mobile by the following morning. Thereafter, the
postoperative recovery is variable. Some patients prefer to take
things quietly for the first 2–3 days, interspersing increasing exercise
with rest. After the third day, patients will have undertaken
increasing amounts of activity. The average return to work is about
10 days.
Skin sutures
If non-absorbable sutures or skin staples have been used, they can be
removed from the port sites after 7 days
 Single incision laparoscopic
surgery
Single incision laparoscopic surgery (SILS) is a
technique adopted by some surgeons to insert all
the instrumentation via a single incision, through a
multiple channel port via the umbilicus, to carry out
the procedure. The benefit is that only one incision,
through a natural scar (the umbilicus), is made,
therefore these procedures are virtually ‘scarless’.
Second, the use of fewer port sites around the
abdomen gives the potential for less pain, less risk of
port site bleeding and reduced incidence of port site
hernia.
 Natural orifice translumenal
endoscopic surgery (NOTES)

This technique, whereby surgeons enter the peritoneal

cavity via endoscopic puncture of a hollow viscus, has
been much publicised in recent years. The NOTES
approach has been utilised in nearly every body system
and operative speciality addressing the pelvis, abdomen
and thorax. Transvaginal NOTES cholecystectomies
have been performed in humans successfully, although
hybrid procedures (joint laparoscopy and NOTES) are
still employed regularly for safety reasons.