title: Transvaginal rigid-hybrid natural orifice transluminal endoscopic surgery technique for anterior resection treatment of diverticulitis: a feasibility study.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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 6 weeks postoperatively.
  
  
  RESULTS
  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 Five patients were withdrawn at the beginning of laparoscopy with no transvaginal access performed.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 6 weeks postoperatively, sexual function did not differ significantly from preoperative status.
  
  
  CONCLUSIONS
  For symptomatic diverticular disease, TvAR is feasible, although the presented technique requires laparoscopic expertise and further refinement.
authors.affiliation: Department of Surgery, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland. Ignazio.tarantino@kssg.ch
authors.forename: Ignazio
authors.initials: I
authors.lastname: Tarantino
authors.forename: Georg R
authors.initials: GR
authors.lastname: Linke
authors.forename: Jochen
authors.initials: J
authors.lastname: Lange
authors.forename: Ikbale
authors.initials: I
authors.lastname: Siercks
authors.forename: René
authors.initials: R
authors.lastname: Warschkow
authors.forename: Andreas
authors.initials: A
authors.lastname: Zerz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004239:Diverticulitis, Colonic / Q000601:surgery*; D017558:Elective Surgical Procedures; D019723:Endoscopes; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D011788:Quality of Life; D012008:Recurrence; D014621:Vagina