Transvaginal NOTES Partial Gastrectomy for Gastric Submucosal Tumors: Early Experience in Humans

Introduction: Transvaginal endoscopic gastric surgery is one of the cutting edge procedures in the field of natural orifice translumenal endoscopic surgery (NOTES). Its feasibility has been shown sporadically in bariatric cases, however, not in oncologic conditions. We report our early experience with hybrid transvaginal NOTES gastrectomy for gastric submucosal tumors (SMTs).
Methods: Two female patients with SMTs (Case #1: 30mm bleeding tumor; Case #2: 40mm asymptomatic tumor; both located in the distal stomach) participated in this IRB approved study. Surgical indication was determined according to NCCN sarcoma guidelines. By our study protocol, a minimum of 2 laparoscopic ports was required to ensure procedure safe and oncologically appropriate. Under laparoscopic guidance, a transvaginal route was created and secured with flexible overtube. A gastrointestinal endoscope was introduced, and the perigastric dissection was performed using IT-knife/needle knife. This process was assisted with laparoscopic graspers. After perigastric mobilization, the transvaginal endoscope was replaced with a digital stapling device, and partial gastrectomy was accomplished in accordance with following oncologic principles: 1) no direct handling of the lesion, 2) full thickness resection, and 3) reasonable surgical margins. The resected specimen was isolated and delivered through the vagina. The vaginal wound was closed under direct vision. Outcomes measurements included surgical results, pain scoring and clinical outcomes.
Results: Both operations were completed successfully in compliance with above oncologic principles. The operating time was 365 min in Case #1 and 170 min in #2. EBL was negligible. Two ports were necessitated, however mini-laparotomy for specimen delivery was totally eliminated. Minimal vaginal incision was added in Case #2 at retrieval. Both showed rapid and uneventful recovery. Pain scaling demonstrated virtually no pain. Final diagnosis was lipoma (#1) and GIST (#2).
Conclusion: Our initial experience with human transvaginal NOTES gastrectomy showed it to be feasible and safe for gastric SMTs. It is a complex but promising surgical alternative for female oncologic patients undergoing gastric resection.

Session: Video Channel

Program Number: V054

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