title: Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient.
abstract: BACKGROUND
  Standard sleeve gastrectomy for the morbidly obese is feasible and safe using the hybrid transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS) with available laparoscopic/endoscopic instruments and technology as illustrated by this technical report on a female patient.
  
  
  METHODS
  The intervention was a transvaginal sleeve gastrectomy in a 67-year-old woman who was hypertensive, noninsulin-dependent with diabetes with morbid obesity (BMI, 37). Operative field view was maintained at all times with a gastroscope introduced through a transvaginal trocar. The surgeon positioned himself at the right side of the patient using a 2-mm needle port/mini-grasper placed in the left upper quadrant for traction of the greater curvature of the stomach. A 12-mm umbilical trocar was used as the port for insertion of the LigaSure device used for division of the short gastric vessels and the Endo-GIA stapler for creation of the gastric tube. The first assistant used a second mini-grasper for liver retraction and stomach positioning. The resected stomach was retrieved through the vagina. There were no intraoperative complications. The operative time was 150 minutes.
  
  
  RESULTS
  The advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All component steps of a laparoscopic sleeve gastrectomy (LSG) were reproduced. The patient was discharged on the third postoperative day.
  
  
  CONCLUSIONS
  Transvaginal hybrid MA-NOS sleeve gastrectomy is both feasible and safe. The hybrid technique ensured safety during the performance of the procedure. MA-NOS is a potential option to avoid abdominal incisions and related complications for the laparoscopic resection of large intra-abdominal organs. Combined hybrid laparoscopic NOS for humans is currently a safe and reliable approach for major surgery through the NOS approach in female patients. Hybrid surgery allows controlled implementation of NOS techniques in clinical practice, providing a stepwise progression to the pure NOS approach once the appropriate technology has been developed. Additionally, it is the best way to stimulate the active development and evaluation of the underpinning technologies and instruments for these novel endoscopic surgical approaches. Appropriate clinical indications for these new procedures are yet to be defined. LSG is associated with short-term excess weight loss and resolution of comorbidities comparable to those obtained with other restrictive procedures. The performance of sleeve gastrectomy is an option in selected patients undergoing bariatric surgical treatment, particularly in the super obese and those who are considered high risk because of comorbid disease.
authors.affiliation: Department of Gastrointestinal Surgery, Centro de Investigaciones Biomédicas Esther Koplowitz, IMDiM, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain. alacy@clinic.ub.es
authors.forename: Antonio M
authors.initials: AM
authors.lastname: Lacy
authors.forename: Salvadora
authors.initials: S
authors.lastname: Delgado
authors.forename: Oscar A
authors.initials: OA
authors.lastname: Rojas
authors.forename: Ainitze
authors.initials: A
authors.lastname: Ibarzabal
authors.forename: Gloria
authors.initials: G
authors.lastname: Fernandez-Esparrach
authors.forename: Pilar
authors.initials: P
authors.lastname: Taura
mesh_terms: D000368:Aged; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D009767:Obesity, Morbid / Q000601:surgery*; D014621:Vagina / Q000601:surgery