Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES—world’s first report

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Surg Endosc DOI 10.1007/s00464-008-9811-5


Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES—world’s first report Chinnusamy Palanivelu Æ Pidigu Seshiyer Rajan Æ Muthukumaran Rangarajan Æ Ramakrishnan Parthasarathi Æ Palanisamy Senthilnathan Æ Mohan Prasad

Received: 18 September 2007 / Accepted: 24 January 2008 Ó Springer Science+Business Media, LLC 2008

Abstract Background Natural orifice translumenal endoscopic surgery (NOTES) is the newest technique emerging in the field of surgery. There are several techniques described in the literature; however there is no standardization yet. We describe the transvaginal approach for endoscopic appendectomy in humans, probably the world’s first report. Materials and methods Pneumoperitoneum was achieved via a Veress needle in the umbilicus. Routine 12-mm endoscope and routine instruments were used. Peritoneal access was gained via a transvaginal approach through the posterior fornix. Results Out of a total of six patients, a totally endoscopic transvaginal appendectomy was successfully performed for one patient. The other five patients were either converted to conventional laparoscopy or aided by a laparoscope. The average age of the patients was 29.5 years. The mean operating time was 103.5 min. Hospital stay was 1–2 days. The follow-ups were scheduled at 7 days, 30 days, 90 days, and 6 months. The vaginal wound was examined by the gynecologist and found to have completely healed during the first and second follow–up. Discussion So far in humans, transgastric appendectomy and cholecystectomy, and transvaginal cholecystectomy have been reported. A transvaginal endoscopic appendectomy in humans has not been reported yet. The transvaginal approach provided a normal image of the target organ, unlike the inverted image of a transgastric approach caused by the inability to manipulate the scope

outside the mouth. The technical ease of the procedure and early outcome seem satisfactory, although comparative studies are needed to confirm this. Keywords NOTES  Transvaginal appendectomy  Endoscopy

Access to the abdominal cavity is required for all surgical procedures and this can be achieved via a formal laparotomy, or more recently, laparoscopy. Natural orifice translumenal endoscopic surgery (NOTES) is an emerging experimental technique of surgery that eliminates abdominal incisions, thereby reducing or eliminating incisionrelated complications such as wound infections, incisional hernias, postoperative pain, and adhesions [1]. To achieve this, commercially available flexible video endoscopes are currently being utilized to perform NOTES. A new breed of specialists called surgical endoscopists have started to take the center stage of NOTES, giving surgical endoscopy a whole new meaning. There are several approaches and techniques described in the literature, each with its own advantages [2–4]. No single technique has been standardized, as far as the approach is concerned. In this report, we assess the feasibility and early outcome of the transvaginal approach to appendectomy in human patients. There are no reports in the literature describing this transvaginal approach for appendectomy in human subjects. Materials and methods

C. Palanivelu  P. S. Rajan  M. Rangarajan (&)  R. Parthasarathi  P. Senthilnathan  M. Prasad GEM Hospital & Postgraduate Institute, 45-A Pankaja Mill Road, Coimbatore 641045, India e-mail: [email protected]

At our institute in the last 6 months, we enrolled six female patients with acute appendicitis for a transvaginal appendectomy. The details of this new technique were explained to


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each of them, and the appropriate consent was obtained. The hospital’s Ethics Committee approved the study, considering our experience with NOTES in pigs. Out of these six patients, we converted to a conventional laparoscopic appendectomy for the first three patients, due to technical difficulties experienced during the endoscopic procedure, and these were thus excluded from the study. In two patients, a 3-mm laparoscope in the umbilicus was used to aid the endoscopic appendectomy, while the third patient successfully underwent a totally endoscopic appendectomy. Patients with complicated appendicitis (mass, abscess, perforation) and lower abdominal scars were deemed unsuitable for this technique. All the patients were young, thinly built females, married with completed families, nonpregnant, and did not have pelvic inflammatory disease. Preoperative work up included blood and urine investigations, abdominal ultrasonogram, chest X-ray, and computed tomography (CT) scan. A gynecologist consulted all the patients as well. Prophylactic intravenous antibiotics were administered 1 hour prior to the operation (Fig. 1). Procedure The patient was placed in the lithotomy position with a 30° head-down tilt and abdomen and vagina were thoroughly sterilized and draped. The endoscopic monitor was kept at the head end of the patient, while the laparoscopic monitor was placed at the right side of the patient. The operating surgeon sat in between the patient’s legs, with the assistant surgeon and scrub nurse stood on either side. Under general anesthesia, pneumoperitoneum was created via a Veress needle in the umbilicus. A 3-mm trocar was introduced at the umbilicus to accommodate a 3-mm laparoscope. This was done to guide the incoming transvaginal endoscope, and assess the position of the appendix and the presence or

Fig. 1 Position of the patient and insertion of the endoscope into the vagina


absence of an inflammatory mass or extensive adhesions. This determined the feasibility of the endoscopic procedure in each individual patient. We utilized the help of the laparoscope for the first two patients only, while for the third patient a totally endoscopic appendectomy was performed. For this patient, the pneumoperitoneum was maintained and measured by a Veress needle in the umbilicus. Next, the gynecologist made a 15-mm incision in the posterior fornix and a double-channel endoscope was introduced into the peritoneal cavity. A rat-tooth biopsy forceps was introduced through the left working channel of the endoscope and the appendix was grasped and lifted up. A hot biopsy forceps was introduced through the right working channel and the mesoappendix was mobilized commencing from the proximal end with a monopolar cautery (Fig. 2). The cauterized tissue was cut using a needle knife and endoclips were used to secure the appendicular pedicle. As the mobilizing of the mesoappendix proceeded distally, we reapplied the rat-toothed forceps lower down on the appendix, at a level where the mesoappendix is to be dissected. This maneuver had to be done because both working channels are situated very near to each other on the endoscope, in the same axis. Once the appendix was entirely skeletonized, an endoloop was applied to the base, and the appendix divided with an endosnare (Fig. 3) (Fig. 4). The completely mobilized appendix was then snared and delivered through the vagina, by withdrawing the endoscope simultaneously

Fig. 2 Grasping the appendix and mobilizing the mesoappendix (arrow)

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Fig. 5 Specimen extraction


Fig. 3 Applying a VicrylTM endoloop (arrow)

Two female patients underwent a laparoscopy-assisted transvaginal endoscopic appendectomy, and one patient underwent a totally endoscopic appendectomy. The average age of the patients was 29.5 years (range, 25–34 years). The mean operating time was 103.5 min (range, 72–135 min). Liquids were commenced orally 12–24 h after surgery, and soft diet from the first postoperative day (POD) onward. Two patients complained of postoperative vaginal discomfort on the second POD, probably due to the colpotomy, which was relieved by oral analgesics. Only one postoperative dose of parenteral analgesics was administered for all patients for preemptive analgesia, followed by one dose of oral analgesics. Hemorrhage from the appendicular artery was seen in one patient, which was controlled endoscopically. There were no postoperative complications or mortality. Hospital stay was 1–2 days. The follow-ups were scheduled at 7 days, 30 days, 90 days, and 6 months. The first two cases were followed up for 30 and 90 days, respectively, while our last patient visited the outpatient room for the first follow-up, and is due for the other follow-ups. All the patients were advised to abstain from sexual intercourse for at least 30 PODs. The vaginal wound was examined by the gynecologist and found to have completely healed during the first and second follow-up. During the third follow-up, when questioned, none of the patients experienced pain during sexual intercourse. The patient was completely satisfied with the results and was thrilled to discover that no incisions were used. Histopathology of all the specimens showed evidence of appendicitis.

Fig. 4 Dividing the appendix using an endosnare (A) 3 mm above the VicrylTM endoloop applied at the base (B)

Discussion (Fig. 5). The incision in the posterior fornix of the vagina was closed with continuous sutures using 1.0 VicrylTM. A vaginal ‘pack’ dressing was applied.

NOTES refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic


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visualization. The basic concept of NOTES was first described in 1994 by Wilk, but was not popular until this decade [5]. In early 2001, it was described as a transgastric approach for liver biopsy in animals by researchers at Johns Hopkins University, though this work was not published until 2004 [6]. Recently, transgastric appendectomy in humans was presented (not published) for the first time in India [7]. Since then, numerous reports have been published describing different techniques and approaches in animal and now in human subjects [8, 9]. In 2007, Swanstrom et al. reported the first human transgastric cholecystectomy [10]. Other natural orifices, such as the anus or vagina, also allow access to the peritoneal cavity. Dr. Marescaux, from EITS-IRCAD Strasbourg, France, performed the first pure NOTES cholecystectomy (codenamed operation Anubis) in a patient in early April 2007 using a Veress needle as the only abdominal port [11]. Thus far, the use of this technique for diagnostic exploration, liver biopsy, cholecystectomy, splenectomy, and tubal ligation has been reported in animal models [12, 13]. Work on porcine models has been progressing for many years, and has now culminated in the successful endoscopic surgery in human subjects. In our institute, we first started performing NOTES (cholecystectomy) in pigs during the latter part of 2005. The hand instruments that we used were the conventional endoscopic instruments: needle-knife, hot forceps (for monopolar cautery), rat-toothed grasper, endosnare, and clips. Transabdominal insufflation for pneumoperitoneum was preferred in all cases, as we thought it was safer than transvaginal insufflation at least in the initial part of our learning curve. Initially in our series for the first three patients, a 3-mm laparoscope in an umbilical port was used to monitor the procedure by direct visualization of the endoscope and its instruments. In two cases, the appendix was situated in the retrocecal position and was cumbersome to mobilize. For the third case, the inflamed mesoappendix was short and thick, so the endoclip slipped and caused hemorrhage. Due to this problem, another two ports were placed transabdominally and the procedure was completed laparoscopically. A 3-mm laparoscope was used only for observing the operations in the next two patients, while the procedure was actually completed endoscopically. Once we gained confidence, the laparoscope was not used and the procedure was successfully completed endoscopically in one patient. The operative field in endoscopic surgery compared to laparoscopy is definitely less adequate. This is because the field changes according to the lateral movements of the instruments, but to and fro movements do not cause any change in the operative field. In laparoscopy, the instruments can be handled independently of the telescope. The operating times were obviously longer than the conventional procedures initially, though later we were able to reduce it.


Postoperative pain was less compared with our patients undergoing laparoscopic appendectomy. These patients usually complain of pain at the port sites, and as there are no trocars being used in NOTES, this pain is avoided. Hospital stay was the same as for patients undergoing laparoscopy, as we kept the patients in for observation to assess for possible leaks. This practice can be attributed to the paranoia of inexperience early in the learning curve. As expertise is accumulated, we are sure to reduce length of hospital stay, and even though it may not be much less than in laparoscopy, the other benefits of NOTES may apply. Recently, the transvesical and the transcolonic approaches have been advocated by some researchers as being more suited to access upper abdominal structures that are often more difficult to work with using a transgastric approach [14, 15]. The use of a transcolonic approach offers some advantages compared with a transgastric procedure. Surgeons in Portugal have used a combination of a transgastric and transvesical approach to increase the feasibility of procedures such as cholecystectomy [16]. In the transgastric approach, since the endoscope occupies most of the esophagus and the stomach, the length of the scope available outside the mouth for manipulation is only a few centimeters. Also, the original image of the target organ obtained through the endoscope is inverted, and cannot be reversed because the scope cannot be twisted. This is not a problem with the transvaginal approach. We found the transvaginal approach gave us the much-needed dexterity, which was otherwise quite cumbersome using endoscopic instruments. The concept of using the vagina as a gateway to the peritoneal cavity is not new. Tsin et al. have been using the transvaginal approach to perform various procedures and to retrieve specimens after resection [17]. Their group has also described a technique called minilaparoscopy-assisted natural orifice surgery (MANOS), in which they used rigid laparoscopic instruments to perform procedures transvaginally [18]. Bessler et al. have also performed hybrid endoscopic cholecystectomy using the transvaginal route, although they used three minitrocars as well [19]. There have been recent developments regarding instrumentation and optics, with better ergonomics offered by new-generation therapeutic endoscopes [20]. Another vital component of NOTES is closure of the access site. The consensus is that all access sites should be formally closed to avoid potentially fatal sepsis/peritonitis [21]. To aid this maneuver, there are several devices available in the market, although endoclips are the commonly used accessory [22]. The limitation of the endoclip is that it is primarily a hemostatic clip, and therefore its efficiency to close a gastrotomy or colotomy wound is questionable [23]. In the transvaginal approach, we could easily close the colpotomy wound in the conventional method using

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conventional suture materials from the outside. This is probably cheaper and safer than the other devices. The transvaginal access to NOTES seems to be safe and feasible for clinical application. Even though it carries fewer potential complications, the procedure has the disadvantage of being possible only in women. A new surgical device called the transdouglas endoscopic device (TED) is being developed by the New European Surgical Academy (NESA), and has recently been developed to carry out procedures in the pelvis. With all these new techniques and technologies being explored, we need a watchdog to monitor their progress, which is why the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) was created [24, 25].

Conclusion Although the promise of NOTES is exciting to both minimally invasive surgeons and endoscopists alike, several key issues need to be addressed prior to the incorporation of NOTES into routine surgical practice. Even though these concepts seem quite futuristic, it appears that the seeds of NOTES have been sown. This study shows the feasibility of the transvaginal approach for organ resection, although further studies are required to standardize techniques. Based on our report and early outcomes, the transvaginal appendectomy seems to be an effective approach to perform NOTES.

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8. Wilhelm D, Meining A, von Delius S, Fiolka A, Can S, Hann von Weyhern C (2007) An innovative, safe and sterile sigmoid access (ISSA) for NOTES. Endoscopy 39(5):401–406 9. Wagh MS, Merrifield BF, Thompson CC (2005) Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model. Clin Gastroenterol Hepatol 3: 892–896 10. Swanstrom LL (2007) Beyond endoluminal therapeutic endoscopy. Gastrointest Endosc 66(1):121–122 11. Marescaux J, Dallemagne B, Perretta S, Mutter D, Wattiez A, Coumaros D. ‘‘Operation Anubis’’, presented at the Japanese Congress of Surgery in Osaka on April 6th 2007 & at the Congress of the Society of American Gastrointestinal Endoscopic Surgery (SAGES) in Las Vegas 2007 12. Jagannath SB, Kantsevoy SV, Vaughn CA et al (2005) Peroral transgastric ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 61:449 13. Kantsevoy SV (2006) Transgastric endoscopic splenectomy: is it possible? Surg Endosc 20:522–525 14. Pai RD, Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006) Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 64(3):428–434 15. Lima E, Rolanda C, Peˆgo JM, Henriques-Coelho T, Silva D, Carvalho JL, Correia-Pinto J (2006) Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery. J Urol 176(2):802–805 16. Rolanda C, Lima E, Peˆgo JM, Henriques-Coelho T, Silva D, Moreira I, Macedo G, Carvalho JL, Correia-Pinto J (2007) Thirdgeneration cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video)’’. Gastrointest Endosc 65(1):111–117 17. Tsin DA, Colombero LT, Mahmood D, Padouvas J, Manolas P (2001) Operative culdolaparoscopy: a new approach combining operative culdoscopy, minilaparoscopy. J Am Assoc Gynecol Laparosc 8:438–441 18. Tsin DA, Colombero LT, Lambeck J, Manolas P (2007) Minilaparoscopy-Assisted Natural Orifice Surgery. JSLS 11:24–29 19. Bessler M, Stevens P, Milone L et al (2007) Transvaginal cholecystectomy laparoscopically assisted for gallstones: a human case (ET017). Proceedings of the annual meeting of the Society of American Gastrointestinal Endoscopy Surgeons, 2007, Las Vegas, Nevada. Las Vegas: The Society 318 20. Pasricha P et al (2005) A next generation therapeutic endoscope: development of a novel endoluminal surgery system with ‘‘birdseye’’ visualization and triangulating instruments. Gastrointest Endosc 61: AB106 21. Fong DG et al (2005) Transcolonic access to the peritoneal cavity using a novel incision and closure device. Gastrointest Endosc 63:AB233 22. Sclabas GM, Swain P, Swanstrom LL (2006) Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES). Surg Innov 13(1):23–30 23. Wallace M (2006) Take NOTES (natural orifice transluminal endoscopic surgery). Gastroenterology 131(1):11–12 24. Rattner D, Kalloo A et al (2006) ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery. Surg Endosc 20:329–333 25. Natural Orifice Surgery Consortium for Assessment and Research (NOSCARTM) International Conference on Natural Orifice Translumenal Endoscopic Surgery (NOTESTM) [http://www.]


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