Transvaginally Adjustable Apical Suspension and Compartment-Specific Tensioning in Vaginal Natural-Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Cadaveric and Live Patient Experience

Objective

This article provides a systematic approach to performing a vaginal natural-orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy (SCP) to create an anatomically aligned vaginal axis, an intraoperatively adjustable apical suspension, and variable compartment tensioning.

Methods

The technique presented for vNOTES SCP focuses on: (1) retroperitoneal tunneling; (2) direct sacrum access below the S-1 level, using uterosacral-ligament guidance; (3) transvaginal tensioning of the mesh to ensure both adequate vaginal length and cuff elevation using the DZOH apical-suspension technique; (4) circumvention of intrapelvic laparoscopic suturing; and (5) near-total peritoneal coverage of the mesh arms.

Results

This detailed description of a successful novel technique to perform vNOTES SCP was based on cadaveric experience as well as in live patients that is reproducible on living patients.

Conclusions

This apical suspension technique for vNOTES SCP may be a viable, reproducible, safe, and efficient transvaginal alternative to the commonly practiced minimally invasive approaches that involve abdominal-port placements. (J GYNECOL SURG 40:116).

A comparison of the efficacy and safety of natural orifice specimen extraction and conventional laparoscopic surgery in patients with sigmoid colon/high rectal cancer

OBJECTIVE

This study aimed to investigate the efficacy and safety of natural orifice specimen extraction surgery (NOSES) compared to conventional laparoscopic radical resection in the treatment of patients with sigmoid colon/high rectal cancer.

METHODS

The control group (n = 62) underwent traditional laparoscopic radical resection, and the observation group (n = 62) underwent transanal NOSES laparoscopic radical resection. The operation length; amount of bleeding; number of lymph node dissections and days of hospitalization after surgery; visual pain scores on the first and third days after surgery; first leaving bed, anal exhaust, eating a liquid diet, and effective sleep times; and the postoperative complications (abdominal or incision infection or anastomotic fistula) of the two groups of patients were compared and analyzed.

RESULTS

The effective sleep time of the observation group on the first day after the operation was 12.3 ± 2.9 h, which was longer than that of the control group (10.6 ± 3.2 h), and the difference was statistically significant (p < 0.001). The pain degree of the two groups on the third day after the operation was lower than that on the first day, and the pain score of the observation group was lower than that of the control group (2.0 ± 1.0 vs. 3.2 ± 1.2, p < 0.001). The postoperative hospital stay in the observation group was significantly shorter than that in the control group (9.7 ± 2.3 vs. 11.2 ± 2.6, p < 0.001). The incidence of postoperative complications in the observation group was significantly lower than that in the control group (3.2% vs. 12.9%, p = 0.048). In addition, it was found that the first leaving bed, anal exhaust and liquid diet times in the observation group were significantly shorter than those in the control group (p < 0.001).

CONCLUSION

Laparoscopic radical resection NOSES in patients with sigmoid colon cancer or high rectal cancer leads to lower postoperative pain and longer sleep time than in patients who undergo traditional laparoscopic radical surgery. The complication rate of this procedure is low, and the curative effect is safe and positive.

Natural Orifice Specimen Extraction (NOSE) colorectal resection for deep endometriosis: A 50 case series: NOSE resection for DIE: 50 cases

STUDY OBJECTIVE

To describe our experience with the use of Natural Orifice Specimen Extraction (NOSE) technique for segmental bowel resection in patients with colorectal endometriosis.

DESIGN

Retrospective, observational study.

SETTING

Single tertiary referral centre PATIENTS: 50 consecutive patients undergoing NOSE colectomy for colorectal endometriosis in our centre, between March 2021 and November 2021.

INTERVENTIONS

NOSE colectomy for colorectal endometriosis with removal of the excised colorectal specimen through the vagina or the anus.

MEASUREMENT AND MAIN RESULTS

45 procedures were performed laparoscopically and 5 procedures were carried out robotically. All interventions were carried out by 3 endometriosis surgeons in a multi-disciplinary fashion, with involvement of a colorectal surgeon. There were no cases of conversion to laparotomy. Concomitant surgical procedures were performed in all cases. 11 patients had concomitant interventions on the digestive tract. 5 patients had concomitant interventions on the sacral plexus or sciatic nerve. All anastomoses were latero-terminal. The mean height of colorectal anastomosis was 12 centimetres (SD= +/- 4), and the mean length of the excised colorectal specimen was 9 centimetres (SD= +/- 4). In 29 cases, the specimen was extracted through the vagina and in 21 cases through the anus. 5 patients required a re-operation in the early post-operative period: We identified 1 case of anastomotic leak, 1 case of post-operative bowel obstruction, 1 case of haemorrhage and 2 cases of pelvic collection (no macroscopic evidence of pus). No patient received blood transfusion. The mean operative time was 158 minutes (SD=+/- 70) and mean hospital stay was 4 days (SD=+/- 1).

CONCLUSION

NOSE colectomy is a reproducible surgical technique for the management of colorectal endometriosis. The complication rate appears comparable with the conventional (mini-laparotomy) surgical approach. In experienced hands, this technique has a short learning curve, both in laparoscopy as well as in robotic surgery.

Robotic NICE Procedure Using Handsewn Technique

INTRODUCTION

In 2018, we described a robotic natural orifice-assisted left-sided colorectal resection with intracorporeal anastomosis and transrectal extraction of the specimen and termed it the natural orifice intracorporeal anastomosis with transrectal extraction procedure. More recently, we have explored the feasibility, safety, and utility of performing total handsewn intracorporeal anastomosis. We present a technical video and initial experience depicting the unique steps to accomplish this procedure with colorectal end-to-end handsewn anastomosis.

TECHNIQUE

Twenty natural orifice intracorporeal anastomosis with transrectal extraction procedures with end-to-end handsewn intracorporeal anastomosis were performed. A video depicting the essential steps with 2 variations of the handsewn techniques is presented along with short-term outcomes.

RESULTS

The most common indication was complicated diverticulitis followed by rectal cancer and deep infiltrative endometriosis of the rectum. The mean operative time was 235 minutes (99-294 min), and there were no intraoperative complications or conversions. Handsewn end-to-end intracorporeal anastomosis was successful in all patients. Natural orifice transrectal extraction was successful in 17 of 20 (85%) patients. The mean postoperative length of stay was 2.1 days (±1.05 SD). There were 3 major complications. One patient developed a deep surgical site infection, and another patient had an organ space abscess. Both patients required readmission and were treated with antibiotics alone. One patient, who had a diverting ileostomy performed at the time of the index procedure, developed subclinical dehiscence of the anastomosis, which healed without intervention but resulted in a delay in ileostomy reversal. There were no additional readmissions and no reoperations or mortalities.

CONCLUSIONS

Robotic natural orifice intracorporeal anastomosis with transrectal extraction procedure and colorectal end-to-end handsewn anastomosis was feasible and safe in this initial series. This technique can be successfully performed in a total intracorporeal manner without the need for an abdominal wall extraction incision or any circular stapling devices.

Natural Orifice-Assisted Laparoscopic Meckel Diverticulectomy Incidentally Found During Para-Aortic Mass Resection

STUDY OBJECTIVE

To show a surgical video in which an incidentally found Meckel diverticulum was resected with a natural orifice-assisted laparoscopic approach during para-aortic resection of a retroperitoneal schwannoma.

DESIGN

Case report (Canadian Task Force classification III).

SETTING

Tertiary referral center in New Haven, Connecticut.

INTERVENTIONS

This is a step-by-step illustration for resection of a retroperitoneal para-aortic schwannoma and of an incidentally found Meckel diverticulum. The patient was a 39-year-old white woman diagnosed with stage IV choriocarcinoma with metastasis to the lungs and left para-aortic area. She received chemotherapy in the form of etoposide, methotrexate, actinomycin-D, cyclophosphamide, oncovine (EMA-CO) and had an excellent clinical response with resolution of all metastatic disease except for the para-aortic mass. Therefore, she was taken to the operating room for laparoscopic resection of the persistent left para-aortic mass. After placement of four 5-mm abdominal ports, the pelvis and abdomen were explored and revealed an incidental Meckel diverticulum as well as the 5 cm left para-aortic mass. The peritoneum overlying the para-aortic mass was incised and the retroperitoneum explored. Given the proximity to the mass, left ureterolysis was performed. The retroperitoneal attachments were resected, and the left para-aortic mass was removed without any complications. At this point attention was turned to the Meckel diverticulum. In order not to extend the abdominal incisions, a posterior colpotomy was performed in the cul-de-sac equidistant from the uterosacral ligaments. Endo-GIA (Covidien, New Haven CT) was introduced through the 10-mm port site at the posterior colpotomy. Meckel diverticulum was resected without narrowing the lumen of the distal ileum. The specimen was removed in a contained manner through posterior colpotomy.

MEASUREMENTS AND MAIN RESULTS

The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 0. Pathology revealed a retroperitoneal schwannoma with negative margins and benign Meckel diverticulum without ectopic gastric or pancreatic tissue. The patient has been disease-free since the completion of surgery.

CONCLUSION

Laparoscopic resection of the retroperitoneal schwannoma and Meckel diverticulum were successfully performed in this patient with history of stage IV choriocarcinoma. To our knowledge, this is the first report describing a natural orifice-assisted laparoscopic approach for resection of Meckel diverticulum. Natural orifice-assisted laparoscopy should be considered when the surgeon needs to remove a large specimen and/or to introduce >5-mm diameter instruments into the peritoneal cavity without having to extend the abdominal incisions.

Transanal natural orifice specimen extraction in colorectal surgery: bacteriological and oncological concerns

INTRODUCTION

Natural orifice techniques have been developed to reduce incision-related morbidity in laparoscopic colorectal surgery. We describe our method of performing transanal specimen extraction in laparoscopic colorectal surgery, addressing bacteriological and oncological concerns in its implementation.

METHODS

Data of consecutive patients undergoing natural orifice specimen extraction (NOSE) laparoscopic colorectal surgery in our institution were retrospectively analysed. All specimens were extracted transanally via a wound protector, followed by intracorporeal end-to-end colorectal anastomosis. Perioperative details, microbiological and oncological findings were reviewed.

RESULTS

Between November 2014 and February 2015, five patients underwent NOSE laparoscopic colorectal procedures in our institution. All cases were completed laparoscopically and specimens were extracted transanally via a wound protector. There were no cases of post-operative anastomotic leaks, wound infections, intra-abdominal sepsis or faecal incontinence. Oncological margins and lymph node harvest were adequate for malignant cases. Transanal specimen extraction did not result in a malignant yield on peritoneal fluid cytology.

CONCLUSIONS

Early bacteriological, oncological and functional results show that NOSE is safe and feasible. Follow-up is required to establish that long-term oncological outcome is not compromised.