Emergency transvaginal hybrid natural orifice transluminal endoscopic surgery

• Introduction
• Case series
• Discussion
• References

In a clinical series, 10 consecutive female patients with intra-abdominal infections were successfully treated with natural orifice transluminal endoscopic surgery (NOTES) performed transvaginally. The surgery, which consisted of a hybrid NOTES procedure using a transvaginal approach, was performed on an emergency basis by the surgical team on call. The indications for surgery were acute cholecystitis (n = 6), acute appendicitis (n = 2), and pelvic peritonitis (n = 2) with intra-abdominal infection. The procedure was successfully performed in all patients using a dual-channel endoscope and mini-laparoscopy assistance. This is the first clinical series in which NOTES has been performed on an emergency basis to treat intra-abdominal infections. Transvaginal surgery for intra-abdominal infection is a feasible procedure for groups experienced in the elective NOTES approach.

Introduction

Natural orifice transluminal endoscopic surgery (NOTES) includes a variety of new endoscopic approaches for reaching the abdominal cavity. It has several potential advantages over conventional laparoscopic surgery, the most important of which is that, when performed transvaginally, it reduces abdominal wall trauma, requires fewer and smaller parietal trocars, facilitates specimen extraction, and makes it possible to extract large specimens.

NOTES was first described and reported in experimental animal models by Kalloo in 2004 [1]. Rao and Reddy then reported the first transgastric appendectomy in humans [2], thereby rousing enormous interest in the potential clinical application of NOTES. In early 2007, Zorron reported the first transvaginal cholecystectomy [3], Bessler repeated the procedure with laparoscopic assistance [4], and soon after, Marescaux performed NOTES using a single abdominal trocar to create pneumoperitoneum [5].

Of all the approaches involving natural orifices, the vaginal approach is the one that has been most extensively developed in surgery because it permits easier access and closure and makes it possible to detect and successfully treat complications at an early stage [6] [7] [8]. Because of its short length, the vaginal canal poses none of the serious disadvantages of transgastric access related to inlet closure.

Despite their obvious advantages, these new surgical approaches have not yet been developed for implementation in surgical emergencies for three main reasons: they call for specially trained physicians and nurses, special equipment and instrumentation are needed, and operating time is lengthened. Although these shortcomings limit their application, the diagnosis and treatment of some intra-abdominal infections through flexible endoscopic examination are the two major areas in which these approaches may have a great impact.

Case series

We report on a clinical series of 10 women who underwent transvaginal surgery for intra-abdominal infections. The surgery was performed on an emergency basis by the surgical team on call. The surgical team consisted of two general surgeons with extensive experience in laparoscopic and transluminal endoscopic surgery following participation in transvaginal cholecystectomies that were performed during the local clinical hybrid NOTES trial [9] [10]. Patients were consecutively enrolled in the study if they met the following conditions: American Society of Anesthesiologists physical status I – II, age between 18 and 65 years, and previous delivery of at least one child. Furthermore, they had to have given consent for the transvaginal approach, and a team of experts in NOTES (two surgeons and one nurse with experience in such) had to be available.

A transvaginal surgical approach is traditionally indicated when good cosmetic results are desired. In this clinical case series, 100 % of the patients consented to the transvaginal approach. Every patient was given information about the surgery in general and about the transvaginal approach in particular. The Hospital’s Clinical Ethics Committee had already approved the use of the transvaginal approach for clinical applications. During the study period (January to November 2009), 105 patients with intra-abdominal infections underwent surgery, and NOTES was carried out in 10 of them (9.5 %).

The endoscope was sterilized with ethylene oxide. All patients received antibiotics (amoxicillin, clavulanic acid or gentamicin with metronidazole) for 1 day in cases of cholecystitis or appendicitis in patients with no free fluid in the pelvic cavity and for 3 (appendicitis) to 5 days (tubo-ovarian infections) if free pelvic fluid was found at surgery.

The 10 women were aged from 21 to 42 years (mean age 38.25 years). The indications for surgery were: acute cholecystitis (n = 6), acute appendicitis (n = 2), and pelvic peritonitis secondary to tubo-ovarian infection (n = 2). The pre-operative diagnosis was made clinically and was confirmed by ultrasound (direct signs of cholecystitis or appendicitis, and indirect signs of appendicitis such as free abdominal fluid near the appendix). Abdominal pain was the chief presenting symptom in all patients, and most of them also had leukocytosis (> 11 000 cells/mm³) and fever ([Table 1]).

A hybrid transvaginal endoscopic approach was applied in all cases. A pneumoperitoneum was created by inserting a 5-mm trocar beneath the umbilicus. The vaginal trocar was 15 cm long and 15 mm wide ([Fig. 1]).

A double-channel endoscope (video gastroscope 13 806 PKS, Karl Storz, Tuttlingen, Germany) was introduced through the trocar as far as the abdominal cavity under laparoscopic vision from the umbilicus, as reported previously [9] [10]. An accessory 3-mm entry port was inserted into the right upper quadrant for gallbladder traction except in cases of adnexal infection and appendicitis, where the 5-mm umbilical trocar was the only parietal one used. The vaginal trocar was also used to place a surgical clip in patients with appendicitis and a 10-mm suction tube for peritoneal lavage in a patient with free purulent fluid throughout the peritoneal cavity. In every case the specimen was extracted vaginally without the need to extend the vaginal incision ([Fig. 2]).

Pelvic and abdominal lavage and prophylactic appendectomy were carried out in patients with pelvic peritonitis and tubo-ovarian infection. The posterior vaginal fornix was closed with two interrupted antibacterial resorbable sutures (Vicryl Plus^®; Ethicon, Somerville, New Jersey, USA). Follow-up consisted of weekly clinical examination for the first month after surgery, and every 3 months thereafter. The median follow-up period was 10.6 months, and the shortest follow-up was 6 months. We advised patients to avoid vaginal sexual intercourse for at least 2 weeks after surgery.

The following procedures were performed: six cholecystectomies for acute cholecystitis, four appendectomies, and two abdominal peritoneal lavages for acute peritonitis. In all reported cases the intervention was successfully performed by using the transvaginal hybrid NOTES approach. The mean operative time was 62.8 minutes. Surgery was longer in patients with acute cholecystitis (86.5 minutes) and shorter in patients with appendicitis or adnexal infection (66.3 and 55.6 minutes, respectively). Hospital stay ranged from 1 to 5 days (mean 2.1 days). The stays were longer in patients who had to complete antibiotic therapy ([Table 2]).

There were no general or surgical wound complications. The umbilical trocar and the vaginal approach generated no problems, and in four cases the surgery left no scar. To date no patient has complained of dyspareunia.

Discussion

NOTES can be very advantageous in cases with existing intra-abdominal infections. The transvaginal approach allows the removal of surgical specimens with an inflammatory component without contaminating surgical wounds in the abdominal wall. Colpotomy is a standard, consolidated approach in gynecological surgery [11] [12]. The transvaginal removal of abdominal organs, such as nephrectomy or hemicolectomy specimens, has also been occasionally reported [13].

Cholecystectomy and appendectomy are the surgical procedures most often used for the development of NOTES. The intra-abdominal infectious conditions for which they are performed, namely cholecystitis and acute appendicitis, are also treatable with transvaginal endoscopic surgery. In both cases, dissecting anatomical structures is more labor-intensive, and organ traction and electrocautery energy transfer to tissue are difficult. However, a hybrid NOTES procedure, with minimal transabdominal laparoscopic access, has been satisfactorily performed to treat both disorders. In cases of acute cholecystitis, the gallbladder was dissected through the endoscope using flexible tools, and with this approach the cholecystectomy took 20 minutes longer than a hybrid NOTES cholecystectomy performed electively: 86.5 vs. 69.5 minutes in our prospective clinical series [9]. The technique had been developed previously in the laboratory in an experimental animal model in which the gallbladder was dissected and removed in the presence of parietal tissue edema and inflammation [14]. Those results, representing more than 20 experimental NOTES interventions, offered us the possibility of treating intraperitoneal infections using the transvaginal hybrid NOTES approach.

In cases of acute appendicitis, a single 5-mm umbilical trocar support was used during surgery to achieve appendiceal traction and to place surgical clips and an endoloop. The flexible endoscope facilitated mesenteric dissection and appendiceal mobilization, section, and removal. The second channel of the flexible endoscope was better suited for pushing and pulling the appendix than the gallbladder without employing articulated tools because of the greater mobility of the appendix. Appendectomy becomes much more difficult when inflammation is present. In cases of pelvic peritonitis associated with tubo-ovarian infections, appendectomy and peritoneal lavage together took less time than appendectomy alone in cases with acute appendicitis.

In cases of adnexal pelvic peritonitis, transvaginal access is useful in performing peritoneal lavage and appendectomy but cumbersome for visualization and instrumentation of the tubes and ovaries. The retroflexed vision and the short length of the endoscope introduced into the abdominal cavity make it difficult to operate on the female genital organs, as is true when the gallbladder is resected through a transgastric approach. In these cases the 5-mm umbilical trocar was inserted subject to performing prophylactic appendectomy. A pure transvaginal NOTES approach can be used to assess adnexal disease and to perform peritoneal lavage.

Hybrid NOTES for the treatment of intra-abdominal infection is a reproducible technique in the hands of well-trained teams with experience in this type of surgery. Cholecystitis and appendicitis can be used as surgical case models to train surgeons in the use of NOTES for clinical applications. The transvaginal approach is useful in diagnosing pelvic peritonitis and is suitable for performing mini-laparoscopy-assisted surgical procedures.

Competing interests: None

References

• 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
  CrossrefPubMedSearch in Google Scholar
• 2 Rao G V, Reddy D N. Transgastric appendectomy in humans. Presented at the World Congress of Gastroenterology; September 2006; Montreal, Canada. 
• 3 Zorron R, Filgueiras M, Maggioni L C. et al . NOTES. Transvaginal cholecystectomy: report of the first case.  Surg Innov. 2007;  14 279-283
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• 4 Bessler M, Stevens P D, Milone L. et al . Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery.  Gastrointest Endosc. 2007;  66 1243-1245
  CrossrefPubMedSearch in Google Scholar
• 5 Marescaux J, Dallemagne B, Perretta S. et al . Surgery without scars: report of transluminal cholecystectomy in a human being.  Arch Surg. 2007;  142 823-826
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• 6 Ghezzi F, Raio L, Mueller M D. et al . Vaginal extraction of pelvic masses following operative laparoscopy.  Surg Endosc. 2002;  16 1691-1696
  CrossrefPubMedSearch in Google Scholar
• 7 Horng S G, Huang K G, Lo T S, Soong Y K. Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH.  J Am Assoc Gynecol Laparosc. 2004;  11 42-46
  CrossrefPubMedSearch in Google Scholar
• 8 Teng F Y, Muzsnai D, Perez R. et al . A comparative study of laparoscopy and colpotomy for the removal of ovarian dermoid cysts.  Obstet Gynecol. 1996;  87 1009-1013
  CrossrefPubMedSearch in Google Scholar
• 9 Noguera J F, Cuadrado A, Dolz C. et al . Non-randomised, comparative, prospective study of transvaginal endoscopic cholecystectomy versis transparietal laparoscopic cholecystectomy.  Cir Esp. 2009;  85 287-291
  CrossrefPubMedSearch in Google Scholar
• 10 Noguera J, Dolz C, Cuadrado A. et al . Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series.  Surg Endosc. 2009;  23 876-881
  CrossrefPubMedSearch in Google Scholar
• 11 Rovio P H, Heinonen P K. Transvaginal myomectomy with screw traction by colpotomy.  Arch Gynecol Obstet. 2006;  273 211-215
  CrossrefPubMedSearch in Google Scholar
• 12 Gill I S, Cherullo E E, Meraney A M. et al . Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy.  J Urol. 2002;  167 238-241
  CrossrefPubMedSearch in Google Scholar
• 13 Wilson J I, Dogiparthi K K, Hebblethwaite N, Clarke M D. Laparoscopic right hemicolectomy with posterior colpotomy for transvaginal specimen retrieval.  Colorectal Dis. 2007;  9 662
  CrossrefPubMedSearch in Google Scholar
• 14 Sanchez-Margallo F M, Asencio J M, Tejonero M C. et al . Training design and improvement of technical skills in the transvaginal cholecystectomy (NOTES).  Cir Esp. 2009;  85 307-313
  CrossrefPubMedSearch in Google Scholar

J. F. NogueraMD 

Hospital Son Llàtzer

Carretera de Manacor, km 4
Palma – 07198
Illes Balears
Spain

Fax: +34-871-202020

Email: jnoguera@hsll.es

References

• 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
  CrossrefPubMedSearch in Google Scholar
• 2 Rao G V, Reddy D N. Transgastric appendectomy in humans. Presented at the World Congress of Gastroenterology; September 2006; Montreal, Canada. 
• 3 Zorron R, Filgueiras M, Maggioni L C. et al . NOTES. Transvaginal cholecystectomy: report of the first case.  Surg Innov. 2007;  14 279-283
  CrossrefPubMedSearch in Google Scholar
• 4 Bessler M, Stevens P D, Milone L. et al . Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery.  Gastrointest Endosc. 2007;  66 1243-1245
  CrossrefPubMedSearch in Google Scholar
• 5 Marescaux J, Dallemagne B, Perretta S. et al . Surgery without scars: report of transluminal cholecystectomy in a human being.  Arch Surg. 2007;  142 823-826
  CrossrefPubMedSearch in Google Scholar
• 6 Ghezzi F, Raio L, Mueller M D. et al . Vaginal extraction of pelvic masses following operative laparoscopy.  Surg Endosc. 2002;  16 1691-1696
  CrossrefPubMedSearch in Google Scholar
• 7 Horng S G, Huang K G, Lo T S, Soong Y K. Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH.  J Am Assoc Gynecol Laparosc. 2004;  11 42-46
  CrossrefPubMedSearch in Google Scholar
• 8 Teng F Y, Muzsnai D, Perez R. et al . A comparative study of laparoscopy and colpotomy for the removal of ovarian dermoid cysts.  Obstet Gynecol. 1996;  87 1009-1013
  CrossrefPubMedSearch in Google Scholar
• 9 Noguera J F, Cuadrado A, Dolz C. et al . Non-randomised, comparative, prospective study of transvaginal endoscopic cholecystectomy versis transparietal laparoscopic cholecystectomy.  Cir Esp. 2009;  85 287-291
  CrossrefPubMedSearch in Google Scholar
• 10 Noguera J, Dolz C, Cuadrado A. et al . Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series.  Surg Endosc. 2009;  23 876-881
  CrossrefPubMedSearch in Google Scholar
• 11 Rovio P H, Heinonen P K. Transvaginal myomectomy with screw traction by colpotomy.  Arch Gynecol Obstet. 2006;  273 211-215
  CrossrefPubMedSearch in Google Scholar
• 12 Gill I S, Cherullo E E, Meraney A M. et al . Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy.  J Urol. 2002;  167 238-241
  CrossrefPubMedSearch in Google Scholar
• 13 Wilson J I, Dogiparthi K K, Hebblethwaite N, Clarke M D. Laparoscopic right hemicolectomy with posterior colpotomy for transvaginal specimen retrieval.  Colorectal Dis. 2007;  9 662
  CrossrefPubMedSearch in Google Scholar
• 14 Sanchez-Margallo F M, Asencio J M, Tejonero M C. et al . Training design and improvement of technical skills in the transvaginal cholecystectomy (NOTES).  Cir Esp. 2009;  85 307-313
  CrossrefPubMedSearch in Google Scholar

J. F. NogueraMD 

Hospital Son Llàtzer

Carretera de Manacor, km 4
Palma – 07198
Illes Balears
Spain

Fax: +34-871-202020

Email: jnoguera@hsll.es