Transvaginal hybrid-NOTES appendectomy in routine clinical use: prospective analysis of 13 cases and description of the procedure.
BACKGROUND
Access-related abdominal wall injury is part of the operative trauma in laparoscopic appendectomy and accounts for complications. Minimizing this trauma by entering the abdominal cavity by means of natural orifice transluminal surgery (NOTES) may be achieved by a hybrid-appendectomy procedure using the transvaginal route plus a single transumbilical trocar.


METHODS
Thirteen patients were prospectively analyzed following transvaginal-hybrid NOTES appendectomy. For the procedure, rigid instruments are used with the patient in lithotomy position. The procedure is performed with two transvaginal and one transumbilical access-points. The specimen is retrieved transvaginally.


RESULTS
All procedures were performed without additional trocars. No conversions to standard laparoscopy or open surgery were necessary. All procedures were performed in acceptable time (mean 52 min). No intraoperative complications and two (15%) postoperative complications, an infected hematoma and an abscess, occurred. They were smoothly treated with standard techniques including one laparoscopic reoperation (8%). Drain placement or resection of a Meckel's diverticulum was easily managed without conversion. Gynecological short-term follow-up revealed one complication, which was vaginal fungal infection. It occurred after a 7-day course of antibiotics.


CONCLUSIONS
This method is found to be feasible intraoperatively and early postoperatively in terms of possibility to manage a variety of intraoperative findings that may occur during planned appendectomy, low intraoperative complications, and management of postoperative complications using established concepts. We, therefore, consider the procedure safe and continue to offer hybrid-NOTES appendectomy to suitable patients.
Department of Abdominal, Vascular & Transplant Surgery, Witten/Herdecke University, Medical Center Cologne-Merheim, Cologne, Germany, jurgen.knuth@gmx.net.
Jurgen
J
Knuth
Markus Maria
MM
Heiss
Dirk Rolf
DR
Bulian
D000328:Adult; D000368:Aged; D001062:Appendectomy / Q000009:adverse effects / Q000379:methods*; D001064:Appendicitis / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D013525:Surgical Instruments; D014621:Vagina; D055815:Young Adult