Transvaginal Natural Orifice Transluminal Endoscopic Surgery Research Articles

Natural orifice transluminal endoscopic surgery in gynecology

Abstract Objective To present our initial experiences in transvaginal natural orifice transluminal endoscopic surgery (NOTES) for adnexal surgeries and hysterectomies. Materials and Methods From September 2010 to December 2010, a total of 15 patients with benign adnexal or uterine diseases who were eligible for laparoscopic surgeries were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results Transvaginal NOTES was successfully completed in five adnexal surgeries and 10 hysterectomies without complications, an ancillary port on the abdomen, or conversion to conventional laparoscopy or laparotomy. For the 10 hysterectomies, the surgical time was 93.4 ± 6.3 minutes (mean ± standard deviation), intraoperative estimated blood loss 245 ± 54.0 mL, uterine weight 440.1 ± 76.5 g, and the postoperative hospital stay 2.7 ± 0.3 days. No patients required intraoperative blood transfusion. The two tubal sterilizations were completed in 18 minutes and 30 minutes, respectively, with negligible blood loss. The two salpingectomies, including one ruptured ectopic pregnancy with 2000 mL hemoperitoneum, were completed in 62 minutes and 116 minutes, respectively. The enucleation was completed in 64 minutes with 20 mL estimated blood loss. Conclusion Our preliminary results indicate that transvaginal NOTES for adnexal surgeries and hysterectomies is feasible and safe. However, this procedure is still new and should only be used as an alternative for conventional laparoscopic surgery in highly selected cases.

A case of simultaneous transvaginal NOTES gastrectomy and vaginal hysterectomy in a patient with gastric submucosal tumor and uterine prolapse

A 5-cm gastric submucosal tumor was incidentally found through abdominal CT as a preoperative work-up for hysterectomy in a 62-year-old woman with uterine prolapse. NOTES using a flexible gastrointestinal endoscope via the transvaginal route was indicated to accomplish concomitant partial gastrectomy and hysterectomy. Perigastric dissection was performed, followed by stapled partial gastrectomy using transvaginal NOTES technique with two transabdominal ports. The specimen was delivered transvaginally by enlarging the initial vaginal entry site. Vaginal hysterectomy was then accomplished by utilizing the enlarged vaginal wound. The patient showed rapid and uneventful postoperative recovery without any narcotic need. No complication was noted, her cosmetic result was satisfactory, and there was complete resolution of preoperative gynecological symptoms. Female patients with concomitant gastrointestinal and gynecological conditions requiring large specimen retrieval would potentially be suitable candidates for the transvaginal NOTES approach.

The Role of Uterine Manipulator in Laparoscopic Hysterectomy without General Anesthesia

Study Objective: Preliminary advances in s natural orifice transluminal endoscopic surgery (NOTES) as applied to urologic and gastrointestinal surgery demonstrate that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills and optimal instrumentation are available. Vaginal hysterectomy is a procedure for small size or prolapsed uterus; but laparoscopic-assisted vaginal hysterectomy (LAVH) is for moderate size and non-prolapsed uterus. It is reasonable to perform vaginal NOTES hysterectomy for moderate size and non-prolapsed uterus. Design: Prospective clinical study. Setting: Teritary university teaching medical center. Patients: From August 2011 to March 2012, eight patients underwent transvaginal NOTES of hysterectomy in one single operative setting. Intervention: Transvaginal NOTES of hysterectomy and bilateral Salpingoovariectomy. Measurements and Main Results: Eight patients underwent transvaginal NOTES of hysterectomy. Five were identified as Female to Male (FtM) transsexuals. The transsexuals were younger (22-45 years. median 27 years), with no parity (P0).The operating times were 70-120minutes (median 80 minutes). Blood loss during surgery (100-650mL, median 200 mL). There was no complication after surgery. We also showed the video of vaginal NOTES surgery in this presentation. Conclusion: Transvaginal natural orifice transluminal endoscopic surgery (NOTES) hysterectomy and bilateral Salpingoovariectomy for female-tomale transsexuals seems a safe, feasible, and valuable procedure for FtM transsexuals.

How To Avoid Laparotomy during Hysterectomy

Study Objective: Preliminary advances in s natural orifice transluminal endoscopic surgery (NOTES) as applied to urologic and gastrointestinal surgery demonstrate that the techniques are feasible provided that both optimal surgical technical expertise with advanced skills and optimal instrumentation are available. Vaginal hysterectomy is a procedure for small size or prolapsed uterus; but laparoscopic-assisted vaginal hysterectomy (LAVH) is for moderate size and non-prolapsed uterus. It is reasonable to perform vaginal NOTES hysterectomy for moderate size and non-prolapsed uterus. Design: Prospective clinical study. Setting: Teritary university teaching medical center. Patients: From August 2011 to March 2012, eight patients underwent transvaginal NOTES of hysterectomy in one single operative setting. Intervention: Transvaginal NOTES of hysterectomy and bilateral Salpingoovariectomy. Measurements and Main Results: Eight patients underwent transvaginal NOTES of hysterectomy. Five were identified as Female to Male (FtM) transsexuals. The transsexuals were younger (22-45 years. median 27 years), with no parity (P0).The operating times were 70-120minutes (median 80 minutes). Blood loss during surgery (100-650mL, median 200 mL). There was no complication after surgery. We also showed the video of vaginal NOTES surgery in this presentation. Conclusion: Transvaginal natural orifice transluminal endoscopic surgery (NOTES) hysterectomy and bilateral Salpingoovariectomy for female-tomale transsexuals seems a safe, feasible, and valuable procedure for FtM transsexuals.

Evaluation of sexual function in sexually active women 1 year after transvaginal NOTES: a prospective cohort study of 106 patients

The primary objective of this prospective cohort study was to investigate sexual function, quality of life and patient satisfaction in sexually active women 1 year after transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES). This prospective single-centre cohort study included sexually active female patients after transvaginal hybrid NOTES cholecystectomy or anterior resection. Sexual life impairment and quality of life were assessed by the Gastrointestinal Quality of Life Index (GIQLI) prior and 1 year after surgery. Patient satisfaction was assessed as well as the sexual function 1 year postoperatively using the validated German version of the Female Sexual Function Index (FSFI-D). Between September 2008 and December 2009, 106 sexually active women after transvaginal hybrid NOTES cholecystectomy or anterior resection were identified. Sexual life significantly improved (GIQLI scores 3.2 ± 1.0 preoperatively vs. 3.7 ± 0.7 1 year postoperatively, P < 0.001), and painful sexual intercourse (3.3 ± 1.0 vs. 3.6 ± 0.7, P = 0.008) decreased post-surgery. The mean FSFI-D total score after transvaginal NOTES was 28.1 ± 4.6, exceeding the cutoff for sexual dysfunction defined as 26. Four (4.5 %) out of 88 patients who answered this question were not satisfied with the transvaginal hybrid NOTES procedure. This prospective cohort study of female sexual function after transvaginal NOTES provides compelling evidence that the transvaginal access is safe and associated with high satisfaction rate.

NOTES transvaginal hybrid cholecystectomy: the United States human experience

"Pure" NOTES and "hybrid" NOTES procedures have gained popularity during the past few years. However, most of these published series have been documented outside the United States. This is a prospective, nonrandomized series of patients. Female subjects who presented to the University of California at San Diego surgery clinic for elective cholecystectomy were offered participation in this study. Patients met the following criteria: aged 18-75 years; diagnosis of gallbladder disease that required cholecystectomy and American Society of Anesthesiology (ASA) class 1. Hybrid NOTES transvaginal technique was used for cholecystectomy. A total of 27 women underwent hybrid transvaginal NOTES cholecystectomy during a 43-month period. The median age was 40.1 (range 23-63) years. The mean body mass index was 25.2 (range 16.4-34.1). All patients had an ASA I-II classification. The mean operative time was 92 (range 38-165) min. There was no conversion to an open operation. The mean hospital stay was 1.07 (range 1-2) days. Patients were followed for a mean of 3.32 (range 0.06-12.2) months. There were no postoperative complications. No scars were visible on the abdominal wall. This study is the largest series of hybrid transvaginal cholecystectomy published in the United States. With our experience, we demonstrate that this technique is safe and clinically viable.

Transvaginal Single-Port Natural Orifice Transluminal Endoscopic Surgery for Benign Uterine Adnexal Pathologies

Transvaginal natural orifice transluminal endoscopic surgery (NOTES) with pneumoperitoneum has been used in cholecystectomies, appendectomies, and nephrectomies, but transvaginal NOTES using a single port in gynecologic procedures has not been described despite gynecologist familiarity with the vaginal approach. We performed transvaginal single-port NOTES in 10 women with benign uterine adnexal disease: oophorectomy in 3 patients, salpingostomy and salpingectomy in 2 each, and ovarian cystectomy, paratubal cystectomy, and ovarian wedge resection in 1 each. The patients were discharged at 1 or 2 days postoperatively, and were satisfied, with minimal pain, no abdominal scar, and no complications at 2-month follow-up. We conclude that transvaginal single-port NOTES to treat benign uterine adnexal disease is a feasible and attractive option.

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): Feasibility of an innovative approach

ObjectiveTo evaluate the feasibility and safety of performing a hysterectomy using the transvaginal natural orifice transluminal endoscopic surgery (NOTES). Materials and MethodsFrom May through December 2010, 16 patients with benign uterine diseases who were eligible for laparoscopic hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. ResultsAll of the included hysterectomies were completed via transvaginal NOTES without conversion to conventional laparoscopy. The mean (± standard error of mean (SEM)) uterine weight was 538.8±102.9g, the mean operative time was 122.7±17.6 minutes, and the mean blood loss was 379.4±95.4mL. The mean postoperative hospital stay was 2.8±0.2 days. No intraoperative or postoperative complications were noted in this series. ConclusionHysterectomy for the treatment of benign diseases can be feasibly carried out via transvaginal NOTES. However, prospective studies are needed to determine its full clinical applications.

Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250)

Natural orifice transluminal endoscopic surgery (NOTES) is a technique still in experimental development whose safety and effectiveness call for assessment through clinical trials. In this paper we present a three-arm, noninferiority, prospective randomized clinical trial of 1 year duration comparing the vaginal and transumbilical approaches for transluminal endoscopic surgery with the conventional laparoscopic approach for elective cholecystectomy. Sixty female patients between the ages of 18 and 65 years who were eligible for elective cholecystectomy were randomized in a ratio of 1:1:1 to receive hybrid transvaginal NOTES (TV group), hybrid transumbilical NOTES (TU group) or conventional laparoscopy (CL group). The main study variable was parietal complications (wound infection, bleeding, and eventration). The analysis was by intention to treat, and losses were not replaced. Cholecystectomy was successfully performed on 94% of the patients. One patient in the TU group was reconverted to CL owing to difficulty in maneuvering the endoscope. After a minimum follow-up period of 1 year, no differences were noted in the rate of parietal complications. Postoperative pain, length of hospital stay, and time off from work were similar in the three groups. No patient developed dyspareunia. Surgical time was longer among cases in which a flexible endoscope was used (CL, 47.04 min; TV, 64.85 min; TU, 59.80 min). NOTES approaches using the flexible endoscope are not inferior in safety or effectiveness to conventional laparoscopy. The transumbilical approach with flexible endoscope is as effective and safe as the transvaginal approach and is a promising, single-incision approach.

Comparison of short-term outcomes between transvaginal hybrid NOTES cholecystectomy and laparoscopic cholecystectomy

A natural orifice transluminal endoscopic surgery (NOTES) approach offers the potential of reducing pain and convalescence after intra-abdominal operations. We present a single-institution series of transvaginal hybrid NOTES cholecystectomies (TVC) and compare outcomes with patients undergoing standard laparoscopic cholecystectomy (LC). Patients had an indication for elective cholecystectomy and met the following institutional review board-approved inclusion criteria: female gender, age >18 years, body mass index ≤35, ASA Classification I or II, and absence of acute cholecystitis. TVC was performed by using one or two transabdominal ports to enable gallbladder retraction and clip application. Dissection was performed with a flexible endoscope through a posterior colpotomy using instrumentation from the NOTES GEN1 Toolbox (Ethicon Endo-Surgery, Inc.). Seven patients underwent TVC and seven patients underwent LC. Operative times were significantly longer for TVC (162 vs. 68 min; p < 0.001). All procedures were performed on an outpatient basis, except for one patient in each group who were discharged on POD#1. Three minor (grade I) complications occurred: two in the LC group and one in the TVC group. TVC patients required less narcotics in the postanesthesia care unit (1 vs. 8 mg morphine equivalents; p = 0.02). Visual Analog Scale pain scores (scale 0-10) were less in the TVC group at 30 min (1 vs. 5; p = 0.02) and 60 min (2 vs. 5; p = 0.02). TVC pain scores also were lower on postoperative days 1, 4, and 7 (2, 1, 0 vs. 6, 3, 2), although only significantly on POD#1 (p = 0.01). SF-36 scores were similar at 1 and 3 months postoperatively. This series adds to the existing evidence that transvaginal hybrid NOTES cholecystectomy using a flexible endoscope for dissection is a technically feasible and safe procedure. TVC requires a longer operative time than LC but may result in less pain in the immediate postoperative period with patients subsequently requiring fewer narcotics.

512 The Learning Curve for Transvaginal Hybrid Notes Cholecystectomy

Learning curves for Natural Orifice Transluminal Endoscopic Surgery (NOTES) have not been established so far. The German NOTES Registry (GNR) currently is the largest NOTES outcome database worldwide. 89% of all procedures in the GNR are transvaginal hybrid NOTES cholecystectomies (tvChole). The aim of this study was to examine the learning curve for tvChole.

852 COMPARISON OF TRANSRECTAL AND TRANSVAGINAL HYBRID NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) PARTIAL NEPHRECTOMY IN THE PORCINE MODEL

You have accessJournal of UrologyTechnology & Instruments: Laparoscopy - Malignant Disease1 Apr 2012852 COMPARISON OF TRANSRECTAL AND TRANSVAGINAL HYBRID NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) PARTIAL NEPHRECTOMY IN THE PORCINE MODEL Wassim M. Bazzi, Sean P. Stroup, Takayuki Dotai, Seth A. Cohen, Ryan P. Kopp, Omer Raheem, James Masterson, Suzanne Gudeman, Caroline Colangelo, Santiago Horgan, Christopher J. Kane, and Ithaar H. Derweesh Wassim M. BazziWassim M. Bazzi San Diego, CA More articles by this author , Sean P. StroupSean P. Stroup San Diego, CA More articles by this author , Takayuki DotaiTakayuki Dotai San Diego, CA More articles by this author , Seth A. CohenSeth A. Cohen San Diego, CA More articles by this author , Ryan P. KoppRyan P. Kopp San Diego, CA More articles by this author , Omer RaheemOmer Raheem San Diego, CA More articles by this author , James MastersonJames Masterson San Diego, CA More articles by this author , Suzanne GudemanSuzanne Gudeman San Diego, CA More articles by this author , Caroline ColangeloCaroline Colangelo San Diego, CA More articles by this author , Santiago HorganSantiago Horgan San Diego, CA More articles by this author , Christopher J. KaneChristopher J. Kane San Diego, CA More articles by this author , and Ithaar H. DerweeshIthaar H. Derweesh San Diego, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.944AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transrectal Natural Orifice Transluminal Endoscopic Surgery (NOTES) nephrectomy has recently been performed in the porcine model. We compared feasibility of porcine Transrectal (TR) and Transvaginal (TV) hybrid NOTES partial nephrectomy (NOTES-PN). METHODS 8 female pigs (45 kg) underwent TR (n=4) or TV (n=4) NOTES-PN. In both pneumoperitoneum was created by periumbilical 12-mm trocar, through which a laparoscope was advanced for intra-abdominal visualization. For TV-NOTES-PN: A gastroscope (Olympus, Center Valley, PA) was used to obtain transvaginal peritoneal access. For TR-NOTES-PN: horizontal incision was made 2-cm above the dentate line and a submucosal tunnel was created in the posterior rectal wall. Gastroscope was advanced through the submucosal tunnel and retroperitoneum to the kidney. A peritoneal window was created. For both TR- and TV-NOTES-PN, the gastroscope was exchanged for the SPIDER System (TransEnterix, Morrisville, NC) TR, Figure 1). Flexible dissecting instruments and hook cautery introduced through the SPIDER arms were used to mobilize kidney (TR, Figure 2) and hilum. Periumbilical-introduced harmonic scalpel (Ethicon, Cincinnati, OH) and scissors were used to excise a portion of the lower pole. Lapra-Ty secured (Ethicon) sutured renorrhaphy was performed, followed by completion nephrectomy, TR or TV specimen extraction and rectotomy/vaginotomy closure. RESULTS TR-and TV-NOTES-PN was successfully performed in all 8 pigs. Comparison of TR and TV approaches revealed no significant difference in mean: access time (33.5 vs. 30.8 min, p=0.626), operative time (212.5 vs. 197.5 min, p=0.561), estimated blood loss (68.8 vs. 66.3 mL, p=0.943), and volume of resected specimen (p=0.763). Necropsy did not demonstrate abdominal injuries. CONCLUSIONS We demonstrate proof-of-principle for TR and TV-NOTES-PN in swine, with comparable perioperative parameters. Preclinical survival studies are requisite to assess potential of TR NOTES to be an alternative to TV. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e347 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wassim M. Bazzi San Diego, CA More articles by this author Sean P. Stroup San Diego, CA More articles by this author Takayuki Dotai San Diego, CA More articles by this author Seth A. Cohen San Diego, CA More articles by this author Ryan P. Kopp San Diego, CA More articles by this author Omer Raheem San Diego, CA More articles by this author James Masterson San Diego, CA More articles by this author Suzanne Gudeman San Diego, CA More articles by this author Caroline Colangelo San Diego, CA More articles by this author Santiago Horgan San Diego, CA More articles by this author Christopher J. Kane San Diego, CA More articles by this author Ithaar H. Derweesh San Diego, CA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures

From August 2010 to June 2011, 10 consecutive patients underwent transvaginal NOTES of the adnexa, including tubal sterilization in 3, salpingectomy because of ectopic pregnancy in 3, and ovarian tumor enucleation in 4. The mean (SD; 95% CI) age of the patients was 34.8 (9.7; 27.9–41.8) years, and their body mass index was 21.6 (2.8; 19.4–23.8). In 9 of the 10 patients, the procedure was completed. The 3 tubal sterilization procedures were completed in 18 to 30 minutes, with negligible blood loss. Operative time for the 3 salpingectomies because of ectopic pregnancy was 62 to 116 minutes. One of these procedures included management of 2000 mL hemoperitoneum. Three of the 4 attempts at ovarian enucleation were successfully completed within 64 to 162 minutes, with estimated blood loss ≤50 mL. One NOTES procedure failed because of a misdiagnosed peritoneal mucinous tumor located anterior to the uterus and inaccessible, leading to subsequent conversion to transabdominal laparoscopy. Our preliminary results show that purely transvaginal NOTES is feasible and safe for use in performing uterine adnexal procedures in selected patients. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.

Measuring the quality of colonoscopy at a district general hospital in south east England: adenoma detection rates and withdrawal times

s / International Journal of Surgery 10 (2012) S1–S52 S21 ABSTRACTS Background: Congenital extrahepatic portosystemic shunt the Abernethy malformation is a rare anomaly. We present a 26 year old male with right upper quadrant pain also found to have an absent portal vein, double gallbladder, double spleen, right-sided pancreas and malrotation of the gut. Method: A search was made on Pubmed for literature on Abernethy malformation and these were examined for associated abnormalities similar to those found in our patient. Results: Abernethy malformation is extremely rare. Type I describes a complete absence of the portal vein as in our patient but is more common in females. It is also associated with other abnormalities including polysplenia, cardiac anomalies as well as malrotation . Type II is commoner in males, describing a partial shunt and rarely associated with other malformations. Hepatic neoplasms are a common finding in patients with CEPS. No case with associated double gall bladder was described. After routine imaging, no definite cause for the patient's abdominal pain was found. However, several liver lesions were noted and are currently being investigated. Conclusion: A very rare case of Abernethy malformation with associated polysplenia, malrotation and we report, to our knowledge, the first instance of an associated double gallbadder. 1089 WINNER OF IJS CASE REPORTS PRIZE (JOINT 1 PLACE): A TRANSRECTAL, RETROPERITONEAL PARA-AORTIC LYMPH NODE DISSECTION USING NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) IN A PORCINE MODEL A.M. Howell, M.H. Sodergren, J. Clark, D. Noonan, J. Teare, G.Z. Yang, A. Darzi. Imperial College, London, UK Background: Retroperitoneal lymph node dissection is employed in highrisk clinical stage 1 nonseminomatous germ-cell tumours to detect metastases. Current methods include open and laparoscopic approaches. Transvaginal NOTES para-aortic lymphadenectomy for gynaecological malignancy has been described. We present a novel trans-rectal approach. Methods: Under ethical approval and home office license, a para-aortic lymphadenectomy was performed in an anaesthetised 55kg pig in the supine position. A rectal port was placed and the retroperitoneum was accessed through a 2inch incision in the posterior rectal wall using a flexible endoscope. The retroperitoneal space was opened using blunt dissection and CO2 insufflation. The right kidney, right renal vein and inferior vena cava were easily identified. A para-aortic lymph node was removed using conventional flexible endoscopic instruments. Results: A para-aortic lymph node was successfully excised and the histology was confirmed microscopically. Operating time was 27mins without injury to other structures encountered. Subjectively, access was straightforward and the retroperitoneal structures clearly visualised. The animal was euthanized at the end as per the experimental protocol. Conclusion: It is feasible to obtain para-aortic lymph nodes using a transrectal, retroperitoneal NOTES approach in the porcine model. This approach could provide an alternative diagnostic option for patients with suspected retroperitoneal pathology.

Transvaginal NOTES cholecystectomy in my partner? No way!

IntroductionNatural orifice transluminal endoscopic surgery (NOTES) transvaginal cholecystectomy is being intensively studied. A few studies have been recently published evaluating patients’ attitude towards NOTES with its individual accesses. However, the choice of a transvaginal access with its potential influence on sex life and fertility is not restricted entirely to women. The sexual partner would at least give his opinion or decide together with the woman.AimThe aim of the study was to assess the attitude of male sexual partners of potential NOTES transvaginal patients towards the surgical access.Material and methodsHundred males were asked for their opinion in a specially designed instrument.ResultsThe general attitude of male sexual partners of potential NOTES transvaginal cholecystectomy patients is negative. With several possible problems and complications feared by the partners, they would mostly oppose or dissuade against NOTES transvaginal cholecystectomy. The cosmetic benefit seems not to justify undergoing a novelty procedure with potential complications threatening sexual life and procreation. This attitude was especially observed in young, sexually active males with high appreciation of sexual life.ConclusionsBoth scientific and educational efforts are required to prove safety and efficiency of NOTES transvaginal cholecystectomy beyond question.

Gastric Emptying is Delayed in Transgastric Notes: A Randomized Study in Swine

The aim of this study was to evaluate the restoration of gastrointestinal motility after NOTES using capsule endoscopy (CE). Twenty adult Yorkshire pigs were randomly assigned to four groups: transgastric NOTES (gNOTES), transrectal NOTES (rNOTES), transvaginal NOTES (vNOTES), and laparoscopy (LAP). At the end of a 30-min peritoneoscopy with identification of seven predetermined organs, an array of eight receivers and the recorder were attached to the abdominal wall. The CE was delivered into the antrum with the help of an endoscope and a polypectomy snare. Animals were kept alive for 14 d. Median time for surgery was longer in gNOTES (56 min, range 47-63) and vNOTES (54 min, range 44-79) than in LAP (32 min, range 32-33; P < 0.05 and P < 0.01) and in rNOTES (45.5 min, range 33-56) (P = ns). This increase was related to a larger incision and longer closure times. Images from the CE were successfully retrieved in 19 cases. The CE was retained in the stomach in all animals in gNOTES (459 min; range 360-600), but only in one animal in rNOTES and vNOTES and in none in the LAP group. Failure of passage of the CE beyond the stomach was associated with gNOTES and longer closure of the incision. Animals in the gNOTES group gained less weight than the others and this change was statistical significant when compared with vNOTES animals (1.7 kg, range -1.98 to 4.5 versus 8.4 kg, range 5.8 to 11.45; P < 0.01). Gastric emptying is delayed after gNOTES peritoneoscopy compared with rNOTES, vNOTES, and LAP and this effect is associated with less weight gain.

Comparison of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES®) and Laparoscopy for Elective Bilateral Ovariectomy in Standing Mares

To compare surgical trauma, perioperative pain, surgical time, and complication rate in mares undergoing standing bilateral ovariectomy by natural orifice transluminal endoscopic surgery (NOTES) or laparoscopy. Experimental study. Healthy mares (n = 12). Ovariectomy was performed with a vessel-sealing device by transvaginal NOTES (n = 6) using a flexible endoscope and specialized instruments or by bilateral flank laparoscopy (n = 6). Preoperative and postoperative complete blood count (CBC), plasma fibrinogen concentration, serum amyloid A concentration, peritoneal nucleated cell count, and total protein concentration were compared using repeated measures ANOVA. Surgical times were compared using an unpaired t-test. Mares were monitored for 2 weeks postoperatively and necropsy was performed at 3 weeks (n = 6) or 3 months (n = 6) to assess short- and medium-term effects of each procedure. Complication rate, necropsy, and bacteriology findings were compared using a Fishers exact test. Significance was set at P < .05. All surgical procedures were performed successfully and all but one laparoscopy mare were bright, alert, and maintained a good appetite until euthanasia. Mean ± SD surgical time was similar between groups (NOTES: 100 ± 40 minutes; laparoscopy: 107 ± 47 minutes). There were no significant temporal differences in vital parameters, CBC, plasma fibrinogen concentration, serum amyloid A concentration, peritoneal nucleated cell count, and total protein concentration between groups. Bilateral ovariectomy by transvaginal NOTES or laparoscopy resulted in minimal inflammation and surgical trauma.

Standing Ovariectomy in Mares Using a Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES®) Approach

To develop and assess the feasibility of standing transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES®) ovariectomy in the mare. Descriptive study. Mares (n=10). The technique was developed in 6 mares and then evaluated in a short-term study in 4 mares. Abdominal access was developed using controlled access vaginal cannula placement under endoscopic guidance. With viewing provided by a flexible endoscope, hemostasis, and transection of ovarian pedicles was performed using a customized bipolar vessel-sealing device. The ovaries were retrieved and the colpotomy was sutured. Surgical time, intra-, and postoperative complications were recorded. Necropsy was performed immediately after surgery in 6 mares and 15 days after surgery in 4 mares to assess short-term complications. After the instruments and techniques were developed, transvaginal NOTES® ovariectomy was successfully performed. Analgesia during the procedure was adequate in all cases. The visual field provided by the endoscope was acceptable. The customized 60 cm vessel-sealing device provided good hemostasis and a comfortable working length. Intraoperative complications included difficult viewing that prolonged operative time and inability to remove the second ovary in 1 mare. Postoperative recovery was excellent. Postmortem findings of 1 true positive microbial culture, elevated cell counts in abdominal fluid, and adhesion formation raise questions that must be addressed in future studies. Using specialized instruments, transvaginal NOTES® ovariectomy is technically feasible in mares.

Inflammatory impact of NOTES peritoneoscopy is not different from that of laparoscopy: a randomized comparative study in a survival porcine model

Inflammatory changes of different NOTES approaches remain unknown. The aim of this study was to compare the inflammatory effects of NOTES and laparoscopy. Forty female pigs were assigned to transgastric, transrectal, and transvaginal NOTES and laparoscopic peritoneoscopy groups. Antiseptic technique was utilized for NOTES whereas laparoscopy was performed sterile. Intraperitoneal pressures were monitored and maintained below 15 mmH(2)O. Pneumoperitoneum was maintained with CO(2) in all groups. Pre- and postoperative blood samples of IL-6, Il-1β, and TNFα, and peritoneal fluid collected at surgery were analyzed. Animals were followed daily for 14 days. At necropsy, peritoneal fluid was collected for cytokine analysis. Thirty-nine peritoneoscopies were successfully completed. The median procedure time was longer in the NOTES groups (57 min, range = 33-109) than in the laparoscopy group (33 min, range 32-36; P < 0.001); this was related to longer incision time and closure time. All 39 completed follow-up. Severe bleeding in the post-transrectal approach required early sacrifice of the remaining animal. Besides this, complications were similar among groups. At necropsy, adhesions were seen in four animals in the gastric group, five in the rectal group, two in the vaginal group, and two in the laparoscopic group (P = ns). There were no statistical differences in serum levels of TNFα among the groups. When serum TNFα values were expressed as the difference from the baseline, in the transvaginal group they were significantly lower than in the transrectal at 2 h [0.5 pg/ml (range = -14 to 59) vs. 60 pg/ml (range = -8 to 303); P = 0.041] and at 8 h [-5.5 pg/ml (range = -86 to 55] vs. 37 pg/ml (range = -30 to 62); P = 0.031]. The limitations of this study were that the analyses of IL-6 and Il-1β were not possible because most of the samples were below detectable levels, it was an animal model, and the sample size was small. Inflammatory parameters are similar between NOTES and laparoscopic peritoneoscopy despite longer surgery time in the NOTES group. The vaginal route seems to reduce the inflammatory stress.

Transvaginal rigid-hybrid natural orifice transluminal endoscopic surgery technique for anterior resection treatment of diverticulitis: a feasibility study

In laparoscopic anterior resection, minilaparotomy still is required. Recently, transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy have been described. Reports on operations that require removal of larger specimens, as in anterior resection, are scarce and limited primarily to small case series and case reports. The current study aimed to evaluate the feasibility and safety of transvaginal rigid-hybrid NOTES anterior resection (tvAR) for symptomatic diverticular disease. All female patients presenting with symptomatic diverticulitis of the sigmoid colon were candidates for inclusion in the study. The exclusion criteria specified failure to sign informed consent, previous colorectal resection, anesthesiologic contraindication for pneumoperitoneum, liver failure and coagulopathy, severe acute diverticular bleeding, internal fistula with abscess (Hinchey 2b), perforated diverticulitis with peritonitis (Hinchey 3 or 4), gynecologic or urologic contraindications, and absence of preoperative gynecologic examination. A preoperative and 2-week postoperative gynecologic examination was performed. Quality of life and sexual function were assessed preoperatively and 6weeks postoperatively. Of 70 patients, 45 (64.3%) were scheduled for tvAR. Five patients were withdrawn at the beginning of laparoscopy with no transvaginal access performed. Of the remaining 40 patients with attempted tvAR, 4 patients underwent conversion to a minilaparotomy (Pfannenstiel incision) and 2 patients were converted to a total median laparotomy. For 34 patients (85%), the operation was completed transvaginally. A total of 2 major complications and 10 minor complications occurred. No serious postoperative gynecologic morbidity was experienced. At 6weeks postoperatively, sexual function did not differ significantly from preoperative status. For symptomatic diverticular disease, TvAR is feasible, although the presented technique requires laparoscopic expertise and further refinement.