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
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 6th 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-Ã -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.