Trans-Vaginal Organ Extraction: Potential for Broad Clinical Application

Juan S Barajas-Gamboa, MD, Alisa M Coker, MD, Joslin Cheverie, MD, C. Aitor Macias, MD, MPH, Bryan J Sandler, MD, FACS, Garth R Jacobsen, MD, FACS, Mark A Talamini, MD, FACS, Santiago Horgan, MD, FACS

UCSD Center for the Future of Surgery

Introduction
Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedures evolved over the past few years. A trans-vaginal approach is a promising alternative for intraperitoneal procedures. Our objective was to evaluate the safety and feasability of trans-vaginal organ extraction.

Methods and Procedures
This IRB-approved protocol involved retrospective review of an on-going prospective study. Female subjects who presented to our hospital for elective cholecystectomy, appendectomy, or sleeve gastrectomy were offered participation in the study. Eligible patients met the following criteria: ages between 18 and 75, diagnosis of gallbladder disease, acute appendicitis, or morbid obesity who desired surgical treatment. A hybrid natural orifice approach was used in this series. This involved a conventional laparoscopic surgical approach to the disease, followed by trans-vaginal organ extraction at the completion of the procedure. Vaginal access was performed under direct laparoscopic visualization. After dilating the cervix and placing a uterine mobilizer, a 15-mm trocar was placed in the posterior cul-de-sac of the vagina under direct view. An endoscope was then placed through the vaginal trocar with an endoscopic snare for organ extraction. At the conclusion of the case, a single figure-of-eight absorbable stitch was used to close the defect.

Results
Thirty-four women underwent trans-vaginal organ extraction between March 2008 and January 2012. The mean age was 40 years (+/- 12.1) (range 23-63). The mean body mass index (BMI) was 27 (+/- 6.4) (range 16-43). All patients had an ASA classification of 2 or below. The mean operative time for cholecystectomy, appendectomy, and sleeve gastrectomy was 90, 71, and 135 minutes respectively. There were no conversions to open operation and no intraoperative complications. The mean hospital stay was 2 days for all cases. Patients were followed for a mean of 24 months (range 1 – 61). There were 2 pregnancies and 2 successful vaginal deliveries. Six patients (18%) had minor complaints of spotting or heavy menses in the immediate post-operative period that resolved with conservative measures. There were no abdominal wall complications. There were no long-term complications and no mortalities.

Conclusions
This initial experience suggests that this surgical approach is safe, does not increase length of stay, and has no long-term vaginal complications. Given this attractive profile, a trans-vaginal approach may prove to be a superior mode of organ extraction, although randomized studies and long-term follow-up are needed.

Session: Podium Presentation

Program Number: S104