Transvaginal appendectomy: a systematic review

Acute appendicitis and its treatment: a historical overview

PURPOSE

Acute appendicitis (AA) is the leading cause of acute abdomen worldwide, with an incidence of 90-100 cases per 100,000 individuals annually and a lifetime risk of 7-12%. Despite its prevalence, historical accounts of AA are limited, particularly when compared to conditions like haemorrhoids, likely due to the appendix's internal location. This article traces the historical evolution of AA treatment from ancient times to the present, highlighting key contributions.

METHODS

A review of common research databases and relevant literature on AA was conducted.

RESULTS

Evidence from ancient Egypt suggests early recognition of the appendix, referring to it as the "worm of the bowel." However, detailed anatomical descriptions and treatment approaches for AA did not emerge until the Renaissance, particularly with contributions from Leonardo da Vinci and Berengario da Carpi. The article traces the progression of AA management, including the first autopsies and surgeries, the development of surgical techniques predating anaesthesia and antisepsis, and advancements achieved from the nineteenth to the twenty-first century. The shift from conservative to surgical approaches is discussed, alongside innovations such as laparoscopic appendicectomy, single-incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES), and endoscopic retrograde appendicitis therapy (ERAT). The impact of the COVID-19 pandemic on AA treatment, including adaptations in medical practices, is also explored.

CONCLUSIONS

This review highlights the significant historical developments in AA treatment and its pivotal role in advancing abdominal surgery.

Development of a Two Port Laparoscopic Appendectomy Technique at a Rural Hospital

Background

Laparoscopic appendectomy (LA) is most commonly performed using two 5-mm and one 10/12-mm ports. Various attempts to reduce the number and size of ports have been made and new technologies such as single port LA have been introduced. Appendix and mesoappendix are usually divided with a stapler or energy device with electrocautery, clips, and endoloop being cheaper options.

Patients and Methods

This study includes 51 consecutive LAs performed at a rural hospital. Patients were divided into 4 groups: group 1 was the standard technique group (n=12), group 2 served as a “try-out” (n=12), group 3 served as feasibility group (n=12), and group 4 was the final patient cohort in which the optimized technique was preferably used (n=15).

Results

Median age of the study cohort was 35.4 (range: 6.2-80.6) years, and 55% of patients were male. Whereas in G1 all patients had standard port placement (10/12-mm, 2x5-mm), in an increasing number of patients in G2-4 only two 5-mm ports and the 2.3-mm Teleflex minigrasper were inserted. Usage of staplers and/or energy devices was reduced from 100% in G1 to 20% in G4, and in the majority of cases both the appendix and the vascular pedicle were secured with an endoloop. The new technique did not add time to the procedure or total OR time. No stump-leaks or surgical site infections were encountered in this series, and there were no conversions to open surgery. Cost savings when not using a stapler or energy device are approximately 400$ per case; the minigrasper added approximately 200$ to the case.

Discussion

LA with use of two ports and a portless needle grasper is feasible in the majority of cases and was associated with high patient satisfaction and excellent cosmetic results. Avoiding energy devices and staplers is cost saving; the endoloop securely controls appendix and mesoappendix.

[Appendectomy: open versus laparoscopic versus single port : Evidence for choice of surgical procedure]

The treatment of choice in acute appendicitis is still the surgical removal of an inflamed vermiform appendix. There is still some disagreement regarding the optimal access route, i.e. conventional open or minimally invasive. The best available evidence is used to answer the question of the current optimal choice of procedure. For laparoscopic appendectomy there are evidence-based benefits in terms of access trauma, postoperative pain, wound infection rates and convalescence. For the alternative minimally invasive procedure single port appendectomy, mini-laparoscopic appendectomy or NOTES appendectomy, there is still a lack of scientific evidence to advocate the broad clinical use of these procedures. It is recommended that whenever the infrastructure permits, laparoscopic appendectomy should be the treatment of choice.

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.

Transgastric removal of a polycystic liver disease using mini-laparoscopic excision

Surgical treatment is often necessary for patients with symptomatic or complicated polycystic liver diseases (PLD). In this paper, we describe a 52-year-old female with symptomatic PLD that had resulted in the formation of liver cysts, the largest of which was 23 cm in diameter. The patient underwent mini-laparoscopic fenestration through 5-mm abdominal trocars. The walls of the cysts were unroofed using a harmonic scalpel. Four thickened rubber-like pieces of specimens (sizes ranged between 9 × 6 × 0.5 cm and 6 × 3 × 0.1 cm) were not suitable for extraction through the 5-mm trocars. A gastrotomy was performed, and the specimens were extracted through the stomach with the help of an endoscope. Transoral removal of the specimens was completed without any complications, and the gastrotomy was closed intracorporeally. The patient was permitted to take fluids on day one, and oral intake was gradually increased. She was discharged on day four and was asymptomatic after two months of follow-up. The combination of mini-laparoscopy and intraoperative endoscopic specimen extraction represented a minimally invasive surgical approach for the treatment of PLD. To the best of our knowledge, this was the first case report of the transoral extraction of a liver specimen.

Natural Orifice Translumenal Endoscopic Surgery: Review of Its Applications in Bariatric Procedures

This review aims to summarise clinical applications of natural orifice translumenal endoscopic surgery (NOTES) in bariatric surgery. A review of data, until December 2014, was carried out regarding techniques and outcomes of bariatric NOTES procedures. Nine publications were included in the final analysis, with another six papers describing endolumenal procedures included for comparison. All NOTES studies adopted a hybrid procedure. Hybrid NOTES sleeve gastrectomy (hNSG) was described in four humans and two porcine studies. In humans, six subjects (23.1 %) were converted to conventional laparoscopic methods, and one postoperative complication (3.8 %) was reported. Mean excess weight loss was 46.6 % (range 35.2–58.9). Transvaginal-assisted sleeve gastrectomy appears feasible and safe when performed by appropriately trained professionals. However, improvements must be made to overcome current technical limitations.

Total laparoscopic subtotal gastrectomy with transvaginal specimen extraction is feasible in advanced gastric cancer

PURPOSE

Natural orifice specimen extraction (NOSE) is an ever-evolving advanced laparoscopic technique. NOSE minimizes surgical injury, involving a low risk of wound complications, fewer incisional hernias, faster recovery and less postoperative pain. Laparoscopic gastrectomy combined with NOSE is a procedure that can potentiate the advantages of both minimal invasive techniques. We aim to demonstrate the feasibility of laparoscopic subtotal gastrectomy with transvaginal specimen extraction in advanced gastric cancer.

CASE

A 72-year-old woman with a 2cm adenocarcinoma in gastric antrum was treated by laparoscopic subtotal gastrectomy and lymph node dissection. A totally laparoscopic Roux-en-Y gastrojejunostomy was constructed. Specimen was extracted through the posterior fornix of vagina without difficulty. Histopathology confirmed pT3pN0 tumor. After a 10-month follow-up the patient was asymptomatic and getting adjuvant chemoradiotherapy.

CONCLUSIONS

Transvaginal specimen extraction after laparoscopic gastric resection for advanced gastric cancer is a feasible procedure. It is offered to selected patients and of course only to female patients. Natural orifice surgery may provide faster recovery and decrease the wound related complications which may cause a delay on postoperative adjuvant chemo-radio therapies. We have presented, as far as we know, the first human case of a transvaginal extraction of an advanced gastric cancer after laparoscopic gastrectomy.

Corrigendum to "Transvaginal Appendectomy: A Systematic Review"

[This corrects the article DOI: 10.1155/2014/384706.].