Feasibility and Technique for Transvaginal Natural Orifice Transluminal Endoscopic Surgery Liver Resection: A Porcine Model

Abstract

Introduction:Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR).Materials and Methods:Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures.Results:Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver.Conclusions:Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.

Postoperative outcomes of natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy and conventional laparoscopic-assisted vaginal hysterectomy: a comparative study

“…NOTES was used not only for hysterectomy but also for adnexectomies [ 6 7 8 9 ], ectopic pregnancies [ 10 11 ], appendectomies [ 12 13 14 15 ], and cholecystectomies [ 16 17 18 ]. Recently, feasibility and technique for transvaginal NOTES liver resection was studied in a porcine model [ 19 ]. Nevertheless, NOTES is not widely performed and has not been extensively studied in Korea.…”

Gasless transvaginal natural orifice transluminal endoscopic surgery for hysterectomy and salpingectomy on a robot platform with flexible devices in a porcine model

“…To the best of our knowledge, the study may be the first to describe the technique of gasless V-NOTES for hysterectomy and salpingectomy in the porcine model on a robot platform with flexible devices. In 2013 and 2017, Bazzi and Katagiri described a case of V-NOTES for partial nephrectomy and liver resection in a porcine model respectively 8 , 9 . However, it is not necessary to do the intricate dissection of para-cervical and para-uterine tissues in both cases.…”

Endoscopic trans-esophageal submucosal tunneling surgery: A new therapeutic approach for diseases located around the aorta ventralis

“…In 2006, Rao et al[7] made the first attempt of transgastric NOTES in human. Subsequently, a number of scholars used NOTES to simulate a variety of intraperitoneal surgeries including cholecystectomy, colectomy, liver resection, and thyroidectomy in experimental animals[8-11]. A significant and hybrid model of NOTES was proposed for abdominal surgeries using transcutaneous rigid laparoscopes in combination with a flexible endoscope passing through a visceral incision[12,13].…”