Transvaginal Appendectomy in Morbidly Obese Patient

Abstract

Introduction. Laparoscopic appendectomy has significant benefits in obese patients. However, morbid obesity can be accepted as an exclusion criterion for natural orifice transluminal endoscopic surgery (NOTES). Here, we present a transvaginal appendectomy in a 66-year-old morbidly obese (BMI 36 kg/m2, ASA III) patient. Case and Technique. Acute appendicitis was suspected based on history, physical examination, laboratory tests, and ultrasound findings. During laparoscopic surgery, a 5 mm trocar was inserted through the umbilicus and a 5 mm telescope was placed. A 12 mm trocar and a 5 mm grasper were inserted separately through the posterior fornix of the vagina under laparoscopic guidance. The appendix was divided with an endoscopic stapler through the transvaginal 12 mm trocar and removed from the same trocar. The operating time was 75 minutes with minimal blood loss (<10 mL). The patient was discharged 16 hours after surgery uneventfully and she did not require any analgesic administration. Conclusion. To the best of our knowledge, this is the first clinical case that focuses on the transvaginal appendectomy at morbid obesity. We can say that morbid obesity does not constitute an obstacle for treatment of acute appendicitis by transvaginal endoscopic surgery.

Transvaginal laparoscopic appendectomy using innovative submucosal tunnels: a conducive modification for improving hybrid NOTES access and its critical appraisal

“…In effect, this discourages scissor-configuration of working instruments, an oft-reported difficulty of traditional transvaginal NOTES (Figure 2). 13,16,33 These tactical adaptations offer an enormous ergonomic advantage, while manipulating two vaginal working ports, to dissect the appendix and prevent unwarranted pelvic bowel injuries, not infrequently reported in the literature. 33 Though the entry points for the vaginal trocars remain at the same level, one of them occupies a deeper position than the other to create an intentional intra-corporal length mismatch.…”

“…Natural orifice transluminal endoscopic surgery (NOTES) has been predicted to replace conventional laparoscopy in the near future. [1][2][3][4][5][6][7][8][9][10] In addition, the transvaginal route, having typical physical and physiological benefits, [1][2][3][4][5][6][11][12][13][14][15][16] makes it the safest, as well as an immensely popular method. [1][2][3]6,[11][12][13][14][15][17][18][19][20][21][22][23][24][25][26] However, even a decade after its inception, it continues to be fraught with diverse technical hurdles such as spatial constraints, inadvertent vaginal gas-leak, compelling requirements for complex instrumentation, scarce availability and affordability, and a steep learning curve, to name a few.…”

“…[1][2][3]6,[11][12][13][14][15][17][18][19][20][21][22][23][24][25][26] However, even a decade after its inception, it continues to be fraught with diverse technical hurdles such as spatial constraints, inadvertent vaginal gas-leak, compelling requirements for complex instrumentation, scarce availability and affordability, and a steep learning curve, to name a few. 7,[13][14][15][16][17][18][19][20] Gas leaks from the vaginal port-rents fail to maintain adequate pneumoperitoneum and often necessitates tamponade by wet compresses. This hinders a smooth performance, leading to extended surgical times.…”

Transvaginal Laparoscopic Appendectomy: A Systematic Review

“…Women were excluded if they had retrocecal appendix, were pregnant, had past abdominal or gynecological surgery, had complicated appendicitis like appendicular abscess, were virgins, had gynecological infections, aged <18 or >65, had pelvic adhesions, had prior malignancy, chemotherapy, or BMI >35 kg/m 2 [ 13 , 16 - 20 , 22 ]. Despite the BMI limitations, two publications performed surgery on women with a BMI over 35 kg/m 2 to test whether it is a true contraindication [ 23 , 25 ]. Another two publications only performed TVA in patients undergoing laparoscopic vaginal hysterectomy as they were already performing a vaginal surgery [ 19 , 21 ].…”

Natural Orifice Translumenal Endoscopic Surgery of the GastroIntestinal Tract

“…German registry showed that more than 6% [182 cases] of human NOTES procedure was appendicectomy done by Tg and Tv routes. Not only slim patients but also morbidly obese patients benefited from NOTES appendicectomy [124]. A 5-mm trocar was inserted through the umbilicus and a 5-mm telescope was placed.…”