Gastrointestinal Surgery: 2016

A new and novel technique of ‘scar less’ laparoscopic surgery for gallbladder & appendix - Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Dr. Sanjoy Mandal
MBBS (AIIMS), MS(AIIMS), DNB, MRCS(Ed), MCh

Contact: +91-9836066320

Email: drsanjoymandal@gmail.com

Over the years, laparoscopic surgery for gallbladder stone or appendicitis has been performed with three or four small incisions on the abdominal wall. This results in visible scars and some degree of pain. NOTES or hybrid NOTES is an upcoming procedure where surgery is being performed by a novel technique in which the abdominal cavity is entered through natural orifices like the mouth, vagina or anal canal. The surgery is performed with special instruments and once completed the specimen is removed through the concerned natural orifice.

In the Department of Gastrointestinal Surgery at Medica Superspecialty Hospital Kolkata, we have performed the first NOTES procedure on 6^th July 2014 on a female patient by accessing the peritoneal cavity via the vagina and doing an appendectomy for acute appendicitis. The patient did not have any abdominal scar. Since then we have preformed a number of such procedures for appendectomy and cholecystectomy. This is done with an idea to decrease the number of scars, improve the cosmesis, decrease post operative pain and decrease the incidence of port site hernias.

Methods

We have been doing this procedure on female patients, wherein access to peritoneal cavity is obtained through the posterior fornix of the vagina (fig 1& 2) as a result of which there is either no incision or a single (5mm) incision at the umbilicus (for cholecystectomy). All the patients were symptomatic for the disease. There was a selection criteria, wherein married female patients in the reproductive and peri-menopausal age group were selected. An informed consent was taken explaining in detail about the procedure and its possible complications.

During surgery patient were positioned in a low lithotomy position. Once we have access to the abdominal cavity through an opening in the posterior fornix of the vagina, the surgery is carried out with certain specialized equipments. Gallbladder traction is done by externally placed sutures (fig 3). The surgery is performed and the gallbladder or appendix is then extracted through the vagina. The vaginal opening is subsequently closed. The resultant effect is that that the patient does not have any visible scar or a single 5 mm scar at the umbilicus (fig 4).

Results

In a preliminary feasibility study 16 patients were operated by this technique. 13 underwent cholecystectomy and 3 patients appendectomy.

Mean age of our patients was 34.5 years (range 23 to 48 years). All were married and had at least one child birth (either normal delivery or C-section).

Operative time was a mean of 85 minutes (range 65 to 120 minutes), blood loss a mean of 34 ml (range of 25 to 120 ml). Time to discharge was mean of 1.2 days (range of 0 to 3 days). The post-operative pain was subjectively less and none of the patients’ required any injectable analgesic in the post operative period. All patient received only oral diclofenac in the postoperative period. There were no postoperative complications except for in one patient who had minimal bleeding per vagina for the 10 days. There were no long-term complications.

Discussion

Since our study has been only to assess feasibility we are unable to comment on the actual advantages of the procedure vis-à-vis standard laparoscopic cholecystectomy or appendectomy. However we are able to say that though it is a technically more difficult procedure, it is possible to perform it satisfactorily and safely with minimal morbidity. 3 of our patients were discharged on the day of surgery, 8 of them on day 1 and 4 of them on day 2. Only one of our patients stayed longer (3 days) because she was from out of the city and required certain extra workup from the rheumatological point of view. We felt that the pain is less and recovery is quicker. There are no significant side effect or complications with this procedure. It is however a more technically difficult procedure to perform than a standard laparoscopic surgery.

Conclusion

Our results have shown that NOTES and hybrid NOTES are feasible and appears to have favorable short and long term results but more studies are required with regards to whether its is significantly better than standard laparoscopic surgery and whether it can be routinely recommended for all patients.

Currently we are offering this surgery to certain selective female patients.