title: Minimizing the Access Trauma of Laparoscopic Sleeve Gastrectomy: the Transoral Specimen Extraction Technique.
abstract: BACKGROUND
  Laparoscopic sleeve gastrectomy has become a popular stand-alone procedure among bariatric surgeons. Recently, Natural Orifice Specimen Extraction laparoscopic surgery has been introduced to avoid minilaparotomy, possibly reducing postoperative pain, hospital stay, and improving QoL and cosmetics. Operative steps and preliminary results of NOSE sleeve gastrectomy are described and reported.
  
  
  METHODS
  Five patients underwent NOSE LSG from November 2014 to March 2015. Selection criteria were as follows: age <60 years, ASA score ≤III, BMI <50. Operative steps are the same of standard LSG, but the stomach transection that starts higher on the greater curvature. A 2–3 cm width opening is created on the exceeding antrum and the resected stomach sutured to the calibration probe tip, which is pull back allowing transoral specimen extraction. The exceeding antrum is stapler-trimmed, allowing breach closure and completion of tubulization.
  
  
  RESULTS
  Mean age was 41.6 years (median 43), average weight was 123.6 Kg (median 114), mean BMI 43.6 Kg/m2 (median 44). Mean operation time was 72 min (median 75). Mean and median postoperative stay were 4.6 and 5. No intraoperative nor postoperative complications occurred. Postoperative day 1 mean and median VAS pain score at were 1.4 and 1, respectively. Follow-up ranged 1–5 months (mean and median 3), average weight loss was 19.8 Kg (median 19), and excess weight loss 36.2 % (median 32 %).
  
  
  CONCLUSIONS
  NOSE LSG potential advantages are as follows: improved cosmetics, decreased postoperative pain, possible incisional hernia rate reduction. No objective data are available to confirm these theoretical benefits; larger observational studies and RCTs are mandatory before clinical validation.
authors.forename: Marco Maria
authors.initials: MM
authors.lastname: Lirici
authors.forename: Valentina
authors.initials: V
authors.lastname: Romeo
authors.forename: Luigi
authors.initials: L
authors.lastname: Simonelli
authors.forename: Simone
authors.initials: S
authors.lastname: Tierno
authors.forename: Carlo Eugenio
authors.initials: CE
authors.lastname: Vitelli
mesh_terms: D000328:Adult; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009055:Mouth; D057605:Natural Orifice Endoscopic Surgery; D009767:Obesity, Morbid / Q000601:surgery*; D061646:Operative Time; D010149:Postoperative Pain / Q000517:prevention & control; D064232:Visual Analog Scale