Meta-analysis of hybrid natural-orifice transluminal endoscopic surgery versus laparoscopic surgery

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) right hemicolectomy with intracorporeal anastomosis for cecal cancer

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) for colorectal cancer utilizes transvaginal access for bowel mobilization, vascular pedicle ligation, oncological resection, and bowel anastomosis, along with subsequent transvaginal natural orifice specimen extraction (NOSE), reducing or eliminating the need for transabdominal access. In this report, we describe the technique of vNOTES right hemicolectomy for cecal cancer, with intracorporeal anastomosis and transvaginal NOSE, including a step-by-step operative video. The patient was a 59-year-old Chinese female (body mass index 32.0 kg/m2) with a cT3N0M0 3 cm cecal adenocarcinoma. Posterior colpotomy was created with insertion of a dual-ring wound protector. vNOTES D2 right hemicolectomy with a fully stapled intracorporeal anastomosis was performed via a homemade transvaginal glove port, using extra-long rigid instruments. A 10 mm, 30° rigid laparoscope was used for operative visualization through a transumbilical port, without additional percutaneous trocars. Operative difficulties pertained to suboptimal instrument reach, lack of triangulation, and frequent clashing within the restricted access space. Surgical duration was 300 min, with 50 ml of blood loss. There was minimal postoperative pain. Return of bowel function occurred on postoperative day 2, with discharge from hospital on postoperative day 3. The patient resumed normal daily activities and regular diet by 1-week post-surgery. Self-reported cosmetic satisfaction score was excellent. No operative complications were observed at 2 months' follow-up. vNOTES right hemicolectomy with intracorporeal anastomosis is safe and feasible in highly selected colon cancer patients. Operators should be proficient in conventional laparoscopic colectomy and transvaginal NOSE. More experience with the vNOTES technique is required to ascertain best practices.

Comparing vNOTES Hysterectomy with Laparoscopic Hysterectomy for Large Uteri

STUDY OBJECTIVE

Our study aimed to compare conventional laparoscopic hysterectomies (LHs) with vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies performed for patients with large uteri (weight >280 g) at our institution, which underwent a change in practice from conventional LH to vNOTES for large uteri.

DESIGN

Retrospective cohort.

SETTING

French tertiary university hospital.

PATIENTS

Two cohorts: the last 54 patients who underwent vNOTES hysterectomy and the last 52 patients who underwent conventional LH for large uteri.

INTERVENTION

Baseline characteristics and surgical outcomes were assessed, including uterine weight, mode of delivery for previous pregnancies, history of abdominal surgery, indication for hysterectomy, associated procedures, operative time (OT), complications, volume of intraoperative bleeding, and length of postoperative hospital stay.

MEASUREMENTS AND MAIN RESULTS

Both groups were comparable, with a mean uterine weight of 586.4 ± 289.2 g in the laparoscopy group compared with 686.7 ± 374.6 g in the vNOTES group. There was a significant decrease in the OT in the vNOTES group with a median of 99 minutes (66.5-138.5 minutes) compared with 171 minutes (131-208 minutes) in the laparoscopy group, p <.001. The length of hospital stay was also decreased in the vNOTES group with a median of 0.5 nights compared with 2 nights in the laparoscopy group, p <.001. More patients were managed in an ambulatory setting in the vNOTES group (50% vs 3.7%, p <.001). Our study did not find any significant difference in terms of bleeding or the number of conversions to another surgical approach. The frequency of intraoperative and postoperative complications was very low.

CONCLUSION

Compared with the laparoscopic approach, vNOTES hysterectomy for large uteri (>280 g) is associated with decreased OT, a shorter hospital stay, and increased performance in the ambulatory setting.

Feasibility and safety of hybrid transvaginal natural orifice transluminal endoscopic surgery for colon cancer: Protocol for a multicenter, single-arm, phase II trial (vNOTESCA)

Introduction

It has been a decade since the first patient with colon cancer underwent colectomy by hybrid transvaginal natural orifice transluminal endoscopic surgery (hvNOTES). However, the efficacy and safety of this procedure is not well established.

Methods

This study is an open-label, multicenter, single-arm, phase 2 trial undertaken at six centers in China. Female patients aged over 18 years and below 80 years old with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, with pathologically proven, resectable, cT1-3N0-2M0 disease who have previously untreated colon cancer are eligible for inclusion. The primary endpoint is a composite of major intraoperative and postoperative complications (greater than grade III, the Common Terminology Criteria for Adverse Events [CTCAE], version 5.0). Secondary endpoints include conversion to laparoscopic or open surgery, postoperative concentration of C-Reactive Protein and procalcitonine, complete pathological assessment of complete mesocolic excision specimens, postoperative pain, amount of narcotic pain medication administered, time to first flatus after surgery, number of harvested lymph nodes, R0 resection rate, length of hospital stay, sexual function assessment, quality of recovery, satisfaction with surgical scars, quality of life, postoperative recurrence patterns, relapse-free survival, and overall survival.

Ethics and dissemination

The study was approved by the Research Ethics Committee, Renmin Hospital of Wuhan University, China, number: WDRY2022-K053. All patients will receive written information of the trial and provide informed consent before enrollment. The results of this trial will be disseminated in academic conferences and peer-reviewed medical journals.Trial registration number NCT04048421.

Women's Perception of Transgastric and Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) - Impact of Medical Education, Stage of Life and Cross-Cultural Aspects

Introduction

Despite that NOTES produces at least matchable clinical long-term results when compared to laparoscopy, still a restraint within the medical community and among patients is evident. Consequently, it might be meaningful to evaluate factors of patient's NOTES perception to promote its acceptance. NOTES is still quite novel and questionnaires regarding its perception by the public is still lacking even so in the Middle East. Aim of our survey is to investigate the viewpoint of female healthcare staff on NOTES.

Materials and Methods

A total of 350 questionnaires along with written information about Minimally Invasive Surgery and NOTES were distributed among the female staff in a Tertiary-care Hospital in Abu Dhabi, 257 were returned completely anonymously and voluntarily and entered into a database with a response rate of 73%. We surveyed factors like religion, medical background, age as well as history of previous laparoscopy, endoscopy, birth and other aspects that may impact a woman's perception of both transgastric and transvaginal NOTES for cholecystectomy and ovariectomy, respectively.

Results

Univariate analyses revealed the majority of Muslim women to be more receptive to NOTES as a choice of surgical technique for cholecystectomy and for ovariectomy, respectively, when compared to Christians and Hindus. However, when compared to Muslims, Christian and Hindu groups had a larger share of medical professions. Women with a medical background would opt significantly less for NOTES. Among younger women, NOTES cholecystectomy was refused due to anxiety concerning future pregnancies and sexual dysfunction. Multinomial logistic regression analysis determined medical background and with independent predictive value for the overall choice of interventional technique (p<0.001). Marital status played a significant role only in the comparison of laparoscopy vs transgastric NOTES when performing cholecystectomy and ovariectomy (p<0.01).

Conclusion

In this first study emanating from the Middle East, medical education and partly life stage rather than cross-cultural differences seem to influence NOTES perception in women.

A New and Alternative Route: Transvaginal Natural Orifice Transluminal Endoscopic Scarless Surgery (vaginal natural orifice transluminal endoscopic surgery) For Class 2 and Class 3 Obese Patients Suffering From Benign and Malignant Gynecologic Pathologies

Background. This study was conducted to investigate the effectiveness of vaginal natural orifice transluminal endoscopic surgery (vNOTES) gynecologic scarless surgery in benign and malignant class 2 and class 3 obese patients. Materials and methods. The class 2 and class 3 obese women undergoing vNOTES scarless surgery for benign and malign indications at a tertiary referral medical center between January 2019 and April 2021 were retrospectively analyzed and surgical outcomes were measured. Results. In this study, 81 class 2 and class 3 obese patients underwent gynecological procedures using vNOTES scarless surgery. Of the 81 operations, 55 of the class 2 obese patients with benign pathologies, and 26 of the class 3 obese patients had malign pathologies. No conversion to conventional laparoscopy or even laparotomy was needed in any of the procedures. All of the surgeries were performed by the same surgeon (Prof. Dr Ahmet Kale). vNOTES scarless surgery was performed on 26 class 3 obese patients with malign pathologies. Of the 26 class 3 obese patients, 22 of the class 3 obese patients with early-stage endometrial carcinoma had very high mean body mass index 41.5 kg/m2 (range 20.6-56) and 4 of the class 3 obese patients had ascites with unknown cause and diagnosed with peritoneal carcinomatosis. The mean postoperative pain VAS scores of class 2 obese patients undergoing vNOTES scarless surgery with benign pathology at 6, 12, and 24 h were 3.19, 1.11, and .66, respectively, and the mean postoperative pain VAS scores of class 3 obese patients underwent vNOTES scarless surgery with malign pathology at 6, 12, and 24 h were 3.30, 1.76, and 1.03, respectively. Conclusion. vNOTES scarless surgery is an alternative surgical method for diagnosis and treatment not only in benign obese cases, but also in severely obese patients with early stage endometrial cancer and patients had with ascites with unknown cause. In the near future, vNOTES scarless surgery will become more preferable by experienced surgeons in benign and malignant obese cases as it has increased satisfaction with esthetic results such as less pain, and improved postoperative quality of life in the short and long term.

Transvaginal Specimen Extraction After Laparoscopic Gastrectomy for Tumors

AIM

The aim was to evaluate the feasibility of transvaginal specimen extraction after laparoscopic gastrectomy for tumors.

METHOD

Inclusion criteria were females not planning to deliver a child and an accessible vaginal entry. Exclusion criteria were benign gastric pathologies and emergency cases.

RESULTS

There were 24 females with a mean age of 54.5±12.0. Subtotal, total, central, and vertical gastrectomies were implemented in 17, 4, 2, and 1 patients, respectively. There was no conversion to open or conventional laparoscopic surgery. Specimens were removed from the vagina in all cases successfully. Histopathologies were adenocarcinoma in 20, gastrointestinal stromal in 3, neuroendocrine tumors in 2 and high-grade dysplasia in the rest. Mean blood loss and duration of surgery were 122.5±163.4 (range: 10 to 800) ml. and 287.7±95.9 (range: 120 to 440) minutes, respectively. No patient required intraoperative blood transfusions. The median length of hospital stay was 7 days (range: 3 to 22). The mean tumor size was 7.8±6.5 (range: 0.5 to 24) cm. Fourteen of 24 cases were advanced gastric cancers. Mean dissected lymph node numbers in the patients with radical gastrectomy was 35.3±12.9 (range: 18 to 62). There were no early or late complications related to the specimen extraction and no wound-related problems were observed.

CONCLUSIONS

In the selected cases, transvaginal specimen extraction was feasible after laparoscopic gastric resections in patients with stomach tumors. As far as we know, this was the largest study on the transvaginal extraction of gastric tumors.

Laparoscopic cholecystectomy by the modified bikini line approach as a simple and safe technique

OBJECTIVE

The gold standard technique for laparoscopic cholecystectomy (LC) is using four ports in the upper abdomen. However, this operative approach may not provide aesthetic satisfaction for some patients because of visible incision marks. This study sought to demonstrate that these incision marks can be hidden by safely changing the port locations.

METHODS

For patients with symptomatic cholelithiasis undergoing LC between March 2019 and March 2020, the modified bikini line approach was used. With the patient in the supine position with open legs, the first trocar (10 mm) was inserted into the abdomen through an 11-mm incision in the umbilicus. The other three trocars were placed in the abdomen at the bikini line with the help of a camera. The standard equipment for LC was then used to perform the surgery.

RESULTS

The modified bikini line approach to LC was used for 38 patients. Average operative time was 28.65 min, and the average hospital stay was 1.07 days. No perioperative or postoperative complications occurred. Follow-up was at 1 week, 1 month, and 6 months. Cosmetic results were satisfactory for all patients.

CONCLUSIONS

As an alternative to the standard LC approach, the modified bikini line technique is safe and useful in patients for whom postoperative aesthetic appearance is important. The modified approach is simple to learn and use and is effective to hide the incision marks well.

Adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery versus laparoscopy: results of a first randomised controlled trial (NOTABLE trial)

OBJECTIVE

To compare adnexectomy by vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) versus laparoscopy.

DESIGN

Parallel group, 1:1 single-centre single-blinded randomised trial, designed as non-inferiority study with a margin of 15%.

SETTING

Belgian teaching hospital.

POPULATION

Non-pregnant non-virgin women with an intact uterus and without obliteration of the pouch of Douglas scheduled to undergo removal of an adnexal mass assessed to be benign on ultrasound by IOTA criteria.

METHODS

Randomisation to laparoscopy (control group) or vNOTES (experimental group). Stratification according to adnexal size. Blinding of participants and outcome assessors by sham incisions.

MAIN OUTCOME MEASURES

The primary outcome measure was adnexectomy by the allocated technique. Secondary outcomes included duration of surgery, pain scores and analgesics used, quality of life and adverse events.

RESULTS

We randomly assigned 67 participants (34 to the vNOTES group and 33 to the laparoscopy group). The primary end point was always reached in both groups: there were no conversions. We performed a sensitivity analysis for the primary outcome, assuming one conversion in the vNOTES group and no conversions in the laparoscopy group: the one-sided 95% upper limit for the differences in proportions of conversion was estimated as 13%, which is below the predefined non-inferiority margin of 15%. The secondary outcomes demonstrated a shorter duration of surgery, lower pain scores, lower total dose of analgesics and a trend for more adverse events in the vNOTES group.

CONCLUSIONS

vNOTES is non-inferior to laparoscopy for a successful adnexectomy without conversion. vNOTES allowed shorter operating times and less postoperative pain but there was a trend for more adverse events.

Transvaginal natural orifice endoscopic surgery for extremely obese patients with early-stage endometrial cancer

AIM

The purpose of this study was to assess the feasibility and efficacy of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) staging surgery for extreme obese patients with early-stage type-1 endometrial cancer.

METHODS

Study included cases of extreme obese patients with early-stage endometrial cancer who underwent v-NOTES between January 2019 and June 2019 at a tertiary referral medical center. The following parameters were noted: patient age, body mass index (BMI), operating time, conversion to conventional laparoscopy or laparotomy, any intraoperative or postoperative complications, estimated blood loss, pre- and postoperative hemoglobin levels, postoperative pain scores of the patients using visual analogue scale (VAS) at 6th, 12th and 24th h, length of hospital stay and final pathology report.

RESULTS

Six cases of extreme obese patients with early-stage endometrial cancer underwent hysterectomy and bilateral salpingo-oophorectomy via the transvaginal NOTES. These six patients had a mean body mass index of 51.4 kg/m² (SD = 6,13). No conversion to conventional laparoscopy or even laparotomy was needed in any of these patients. No adjuvant therapy was needed since all of the patients had early-stage endometrial carcinoma.

CONCLUSION

Given the increased risk of surgical morbidity and mortality associated with increasing BMI, it is paramount importance to establish safe surgical approaches to gynecological pathologies. We think that v-NOTES offers greater benefit to obese patients when performed by an experienced surgeon and v-NOTES is a safe, effective and feasible minimally invasive surgery in extreme obese patients with early endometrial cancer.

Randomized clinical trial on the use of a colon-occlusion device to assist rectal washout

Background

Transrectal Natural Orifice Transluminal Endoscopic Surgery is currently limited by the inherent risk of surgical site infection due to peritoneal contamination after rectotomy. Coloshield has been developed as a temporary colon occlusion device to facilitate rectal washout. However, effectiveness and safety has not been evaluated in humans.

Methods

Twenty-two patients have been randomly assigned to undergo proctological intervention with a rectal washout with and without the use of Coloshield. Patients and assessors were blinded. Boston Bowel Preparation Scale (BBPS) has been determined 30 min as well as immediately after rectal washout. Feasibility, pain, intra- and postoperative morbidity as well as bowel function and continence 6 weeks after surgery were assessed.

Results

BBPS 30 min after rectal washout with and without Coloshield was in mean 2.42 ± 1.02 and 2.12 ± 0.89 (p = 0.042). Mean BBPS immediately after rectal washout was 2.39 ± 1.02 and 2.24 ± 0.66 (p = 0.269). Mean BBPS immediately after rectal washout and 30 min thereafter did not differ (p = 0.711). Coloshield application was feasible without any complications. The median (interquartile range) numeric rating scale for pain 4 h after surgery was 1 (0–1) and 3 (0–4) (p = 0.212). Six weeks after surgery 0/11 and 1/11 patients suffered from evacuation difficulties (p = 1.0) and the median Vaizey–Wexner score was 1 (0–3) and 1 (0–2) (p = 0.360).

Conclusions

Coloshield application in humans is feasible and safe. Slight benefits in rectal preparation by washout are found when Coloshield is used. Colon occlusion by Coloshield for transrectal NOTES should be evaluated within clinical studies.

Trial registration

Clinicaltrials.gov NCT02579330

Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies

Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90 days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

Transvaginal laparoscopic appendectomy using innovative submucosal tunnels: a conducive modification for improving hybrid NOTES access and its critical appraisal

Currently, transvaginal natural orifice transluminal endoscopic surgery (NOTES), the most minimally invasive option for laparoscopic surgery, suffers various technological restraints limiting its implementation. We discuss a simple modification for vaginal access to improve the existing hybrid NOTES technique. We retrospectively studied 18 women at our rural hospital in central India, who, under defined criteria, underwent transvaginal appendicectomy using innovative strategically designed submucosal tunnels. The procedure was successfully completed in all but the first three cases. None required additional abdominal trocar or analgesia beyond the first 6 h. The mean operative and hospitalisation times were 27.5 min and 18.5 h, respectively. We had no intraoperative complications and only one patient experienced postoperative self-limiting vaginal spotting. All patients were very pleased with the cosmetic results and sexual life as assessed by locally devised scales. On regular follow-up, all were progressing well. We recommend the method presented, as it is not only feasible and safe but has the potential to improve overall results. Clearly, a larger volume randomised trial would be optimal to confirm our conclusion.

Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer

BACKGROUND

To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery.

METHODS

This was a retrospective case-control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM).

RESULTS

Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively.

CONCLUSIONS

Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.

A reliable detachable balloon that prevents abdominal cavity contamination during transrectal natural orifice transluminal endoscopic surgery

OBJECTIVE

To evaluate the efficacy and safety of a detachable endoluminal balloon in the prevention of abdominal cavity contamination during transrectal natural orifice transluminal endoscopic surgery (NOTES).

METHODS

The efficacy and safety of a detachable endoluminal balloon to maintain disinfection in the distal colon of the pigs were evaluated. The bacterial loads and colonic cleanliness were monitored. Additionally, the device was applied to another nine pigs that underwent a cholecystotomy by transrectal NOTES. Necropsy and pathological examination were performed after 28-day follow-up.

RESULTS

All animals exposed to the device and one of the seven pigs not exposed to the device scored three points on the bowel cleanliness scale (P < 0.001). After 30 min bacterial loads of the test (with balloon occlusion) and control (without balloon occlusion) groups showed a significant difference (0.8 × 10³  CFU/mL vs 186.8 × 10³  CFU/mL, P < 0.01). Cholecystotomy by transrectal NOTES with the device was successfully performed. The mean intraperitoneal procedure time was 102.9 ± 37.7 min. There were no procedure-related adverse events. During the follow-up, all animals presented normal behavior and appetite. No peritoneal infection or adhesion was detected at autopsy. Cholecystotomy and rectal incision were histologically healed and no histological abnormalities were detected in the colon related to balloon placement.

CONCLUSIONS

The detachable balloon provides a reliable solution for preventing peritoneal contamination during transluminal operations. The technique may assist in future transrectal NOTES.

Comparison of Major Clinical Outcomes Between Transvaginal NOTES and Traditional Laparoscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

The advent of transvaginal natural orifice transluminal endoscopic surgery (transvaginal NOTES) aims to minimize surgical trauma and reduce recovery time.

MATERIALS AND METHODS

Clinical trials comparing transvaginal NOTES and traditional laparoscopy were identified by searching EMBASE, MEDLINE, and Web of Science (from 2004 to March 2018). Major outcomes evaluated were risk of postoperative complications and secondary outcomes were pain on postoperative day (POD) 1, POD2, and POD3, time needed for full recovery, risk of intraoperative complications, the duration of surgery, and hospital stay. The results of the meta-analysis are presented as standardized mean difference (SMD) and risk difference (RD) with 95% confidence intervals (CIs).

RESULTS

Thirteen trials with 1340 patients were identified. There were no statistical differences for risk of complications between transvaginal NOTES and traditional laparoscopy (intraoperative complications: RD -0.01, 95% CI -0.03 to 0.01; P = 0.37; postoperative complication: RD -0.02, 95% CI -0.05 to 0.01; P = 0.148). The pain score was lower in transvaginal NOTES on POD1 (SMD: -0.71, 95% CI: -1.30 to -0.11, P = 0.019), on POD2 (SMD -0.41, 95% CI -0.75 to -0.07; P = 0.018), and on POD3 (SMD -0.43, 95% CI -0.63 to -0.23; P < 0.001). Patients in transvaginal NOTES needed much shorter time to fully recover after surgery (SMD -1.36, 95% CI -1.84 to -0.87; P < 0.001). In addition, patients underwent transvaginal NOTES had less pain and shorter time of recovery.

CONCLUSIONS

It is recommended that patients have cholecystectomy, adnexectomy, and appendectomy using transvaginal NOTES as it is safe and minimally invasive.

Contamination After Disinfectant Rectal Washout in Left Colectomy as a Model for Transrectal NOTES: A Randomized Controlled Trial

BACKGROUND

In natural orifice transluminal endoscopic surgery (NOTES) with transrectal (TR) access the intraoperative opening of the rectal wall poses a risk of intraperitoneal contamination and subsequent infectious complications. A rectal washout with a disinfectant may reduce this risk. The aim of the study was to assess the intraoperative contamination on the circular stapler pin when a rectal washout with povidone-iodine (RW-PI) or Ringer solution was performed in patients undergoing left-sided colectomy. Furthermore, the additional effect of an irrigation instrument on the contamination was evaluated.

METHODS

In a patient and assessor blinded randomized controlled trial, patients undergoing left-sided colectomy were assigned to rectal washout with PI with an irrigation instrument (RW-PI; n = 23), rectal washout with Ringer solution with an irrigation instrument (RW-R; n = 21) or rectal washout with Ringer solution without an irrigation instrument (RW; n = 25). An end-to-end anastomosis with a circular stapler was performed. The contamination on the pin of the circular stapler was chosen as primary endpoint in order to simulate the intraabdominal contamination risk during TR NOTES. Secondary endpoints were contamination of the rectal mucosa, peritoneal contamination and postoperative morbidity.

RESULTS

The contamination rate of the pin of the circular stapler did not differ (RW-PI 39.1%, RW-R 33.3%, RW 52.0%; P = 0.421), but contamination of the rectal mucosa was reduced (47.8% versus 95.2% versus 100%; P < 0.001) and peritoneal contamination tended to be reduced (39.1% versus 71.4% versus 60.0%; P = 0.09) when a rectal washout with PI was performed. The rates of infectious complications (17.4% versus 9.5% versus 12.0%; P = 0.821) and of overall complications (30.4% versus 28.6% versus 44.0%; P = 0.476) did not differ.

CONCLUSIONS

Despite an intense rectal washout with PI, contamination of the stapler pin did not differ. Intraabdominal bacterial translocation was frequently encountered even after disinfectant rectal washout with PI. Further studies might focus on the clinical impact of intraabdominal contamination in TR NOTES.

Tireoidectomia endoscópica transoral por acesso vestibular (TOETVA): experiência inicial no Brasil

RESUMO Objetivo: apresentar a experiência inicial no Brasil com a tireoidectomia transoral endoscópica por abordagem vestibular (TOETVA). Métodos: estudo prospectivo de pacientes submetidos à TOETVA no Serviço de Cirurgia de Cabeça e Pescoço do Hospital Regional do Oeste, Chapecó, Santa Catarina. Foram candidatos para o estudo os pacientes entre 18 e 65 anos de idade, ASA I e II, com volume glandular de até 35cm3e nódulos de até de 4cm. Dados dos pacientes, dos nódulos, tempo cirúrgico, complicações, e tempo de internação foram registrados. Resultados: nove pacientes foram operados entre maio de 2017 e abril de 2018. Todos eram mulheres, com idades entre 33 e 64 anos. O tamanho do nódulo variou de 1cm a 4cm. Dois pacientes eram portadores de neoplasia maligna e a tireoidectomia total foi feita em oito casos. Sete pacientes tiveram uma internação de apenas um dia. Um paciente sofreu uma complicação menor na pele, mas não ocorreram lesões dos nervos laríngeos recorrentes ou hipoparatireoidismo definitivo. Conclusão: a TOETVA é uma técnica segura para pacientes bem selecionados, com condições favoráveis e com especial preocupação com resultados estéticos.

Transluminal Cancer Surgery

Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.

Hysterectomy and salpingo-oophorectomy by transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) assisted by an umbilical camera: Case report and new hybrid technique in gynecology

•

Hybrid-Natural orifice transluminal endoscopic surgery (NOTES) makes us to perform NOTES more safer with the direct visualization of the abdominal cavity.

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Hybrid NOTES can lesser the exclusion criterias for NOTES.

•

Hybrid NOTES can lesser the complications; by capability of seeing all the major structures such as ureters, uterine vessels, bowels and pelvic adhesions.

Introduction

Natural orifice transluminal endoscopic surgery (NOTES) is a new development in the field of minimally invasive surgery. The aim of this study was to demonstrate a new hybrid NOTES technique in gynecology which can be used for hysterectomy and salpingo-oophorectomy in patients with adnexal pathology and multiple operation histories.

Presentation of case

A 50-year-old woman with gravida 2 para 2 was referred to our clinic with left-sided abdominal pain. She had a history of two previous abdominal surgeries and a persistent ovarian cyst for 2 years. An ultrasound examination revealed a left complex hypoechoic ovarian cyst of 10 cm. Tumor markers were normal and the patient had no suspicion for malignancy. The hybrid NOTES technique assisted by an umbilical camera was planned due to the possibility of pelvic adhesions and her concerns about cosmesis.

Discussion

The major difference between NOTES and umbilical camera assisted NOTES is seeing all of the major structures, such as the ureters, uterine vessels, bowels, and pelvic adhesions, which can lead to complications during the surgery. In fact, hybrid NOTES can make surgeries more feasible.

Conclusion

This new hybrid NOTES offers effective and safer surgical management in patients who have had previous surgery and adnexal masses.

Transvaginal extraction of laparoscopic liver resection specimen

The application of laparoscopic surgery via the vagina has been introduced at the beginning of this millennium. Here, we report a case of transvaginal extraction of a laparoscopic hepatectomy specimen. An exophytic liver mass originated from segment VI in a 24-year-old female was excised with laparoscopic technique using four trocars (0.5–1.2 cm sizes). The specimen (11 × 8.5 cm) was removed transvaginally instead of an abdominal incision. To the best of our knowledge, only six similar cases have been previously reported, with a patient age range of 32–74 years. Our case, due to younger age, had high cosmetic expectations. Specific to this case, we aimed a better aesthetic outcomes and better convalescence period and, we achieved these objectives. We believe that patient selection and experience on natural orifice specimen extraction were the keys to the success of the operation. We shared this technique with a video presentation.

Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study

BACKGROUND AND STUDY AIMS

The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment.

METHODS

Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination.

RESULTS

Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002).

CONCLUSIONS

After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.