Safety of culdotomy as a surgical approach: Implications for natural orifice transluminal endoscopic surgery

Objective: To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES). Methods: A retrospective chart review of women undergoing culdotomy for tubal sterilization (N=219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications. Results: No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P =.068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI < 30 (11.4% versus 1.5%, P =.011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries. Conclusion: Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.