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Figure 20.15 Endoscopic view of the right ovary. The endoscope has
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been retrofl exed and is shown with the ovary suspended from the dorsal
(posterior) abdominal wall.
CHAPTER 20 NOTES Applications in Veterinary Medicine
Figure 20.17 Endoscopic view of gastric incision following placement
of two pairs of T -fasteners secured with clips.
Figure 20.16 Endoscopic view of gastric closure. A second pair of
T-fasteners has been applied and the guidewire removed.
correctly located. The scope is then withdrawn and a second
T-fastener is applied on the opposite side of the incision
(Figure 20.16). The two free ends of the suture exit the
endoscope working channel. Outside the body, the two
suture strands are captured in a loop threaded through the
suture clip. The clip is positioned against the tissue and
the inside plug is advanced to trap the sutures and appose
the gastric incision. Endoscopic scissors are used to cut the
sutures. The guidewire is removed. After two pairs are
placed, the stomach is infl ated with air (Figure 20.17) and
the abdomen is monitored for tympany. Any residual air in
the abdominal cavity is evacuated by a 16 gauge catheter.
Outcomes
A feasibility and technique development study was undertaken in 10 research dogs. The mean operative time was
about 2.5 hours and no animals died. The ovaries were
incompletely excised in three animals and inadequate access
to the right ovary required conversion to an open procedure
in one [4]. Necropsy at two weeks revealed uneventful
healing of the surgical sites with no signifi cant damage to
surrounding organs, no signifi cant growth on bacterial cultures, and no evidence of peritonitis. A prospective comparison study was then conducted in 30 dogs that underwent
NOTES, laparoscopic, or open oophorectomy [29]. Surgical
times for the NOTES procedure were longer, but the animals
demonstrated less evidence of pain in the postoperative
period [29]. Since then, NOTES oophorectomy has been
attempted in 19 additional dogs. Ten of them were performed under inhalant anesthesia and nine were performed
with propofol sedation (Video 20.1) [19] There were
fi ve operative failures with no difference between the anesthetic methods used [19]. Four were related to inadequate
hemostasis of the ovarian pedicle due to incorrect power
setting of the electrosurgical device, and there was one conversion to an open procedure due to an unusually large
uterus. The surgical time for the last group of animals was
about 2 hours, which is longer than open or laparoscopic
methods. Time to close the gastric incision remains the
longest operative step [14].
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Transvaginal -assisted laparoscopic oophorectomy
or ovariohysterectomy
Hybrid techniques have been performed by veterinarians in
Iran and Brazil. In these studies, a laparoscope is placed at
the umbilicus and a 5 mm trocar is introduced through the
vagina under direct vision. Standard laparoscopic instruments are then introduced through the vaginal port for
ligation and transection of the ovarian pedicle, and the
laparoscope provides visualization during the procedure.
The ovary and uterine horns are extracted through the
vaginal port and the uterine body is ligated externally. No
attempt is made to close the colpotomy. Comparative studies
with traditional laparoscopy and open ovariohysterectomy
suggest that the animals undergoing the hybrid NOTES procedures suffer less pain than those undergoing traditional
surgery. The operative times in the hybrid studies were
similar to the laparoscopic approach [3].
Abdominal exploration via a transvaginal
approach in mares
Indications
An experimental study was conducted in eight mares to
identify the abdominal structures that can be visualized with
a fl exible or rigid endoscope following a transvaginal
approach [30]. The transvaginal approach could theoretically be used when the surgeon desires exploration of the
left and right compartments of the dorsal aspect of the
abdomen.
Anesthesia and pre-operative preparation
Food was withheld for 48 hours. Animals were given peri operative antibiotics and fl unixin meglumine 30 minutes
before surgery. Sedation was provided with detomidine and
butorphanol with additional doses given to effect. The perineal region was prepared with surgical scrub and the vagina
was fl ushed with dilute iodine solution. A urinary catheter
was placed. A lidocaine -soaked sponge was placed into the
vagina at the intended colpotomy site for 5 minutes.
Technique
The authors chose to pursue either a left -side or a right -side
approach to the caudal abdomen. For the left -side approach,
the colpotomy incision was made at 11 o ’clock. This approach
permitted examination and evaluation of the left ovary and
uterine horn, spleen, left kidney, diaphragm, liver, stomach,
and caudal peritoneal refl ection. For the right side, the colpotomy incision was made at 1 o ’clock. The right ovary,
uterine horn, base of the cecum, duodenum, diaphragm,
and caudal peritoneal refl ection were examined. Curved
mosquito hemostatic forceps were held in the surgeon ’s
hand and bluntly inserted through the vaginal wall about
3 cm lateral to the cervix. The forceps were opened, and then
retracted to create a 2 cm opening. A fi nger was then inserted
into the opening to confi rm entry into the abdominal cavity.
The endoscope was inserted and a systematic exploration of
the dorsal abdomen was performed. The colpotomy incision
was not closed. The animals were monitored clinically for 7
days postoperatively.
Outcomes
The mares in this study tolerated the procedure well and the
approach permitted examination of the structures on that
side of the abdomen. The fl exible endoscope allowed visualization of more structures than the rigid laparoscope
because it was not limited by the vaginal walls; however,
because of lack of support, it was diffi cult to direct the distal
end of the endoscope. The technique required two operators
with a stated learning curve associated with manipulation
of the endoscope inside the abdomen. Because of the midline
position of the colon and rectum, the authors were not able
to consistently view both sides of the abdomen through one
incision. Although no positive pressure insuffl ation was
given, two mares developed perineal emphysema, apparently due to entry of air into the abdomen during the procedure, which resolved without treatment. The colpotomy
incisions healed as expected. One mare demonstrated signs
of colic on day 5.
Application
The authors suggested that this technique has the potential
for shorter recovery time and an earlier return to athletic
use. The transvaginal approach may offer a cosmetic benefi t
in show mares since there are no external incisions.
NOTES oophorectomy in standing mares
Indications
Bilateral oophorectomy is performed in mares to assist in
modifying estrus behavior, when the mare is to be used as
an embryo -transfer recipient or as a mount mare for collecting semen, or when there are recurrent episodes of colic
during estrus. Unilateral ovariectomy is performed to remove
ovarian tumors. Older techniques using a blind colpotomy
approach were abandoned due to complications with hemorrhage, peritonitis, and evisceration through the colpotomy
site [31]. Current oophorectomy techniques utilize a ventral
midline celiotomy under general anesthesia or laparoscopic
ovariectomy in a standing mare. Laparoscopic bilateral
oophorectomy requires three skin incisions in each paralumbar fossa to gain access to both ovaries, and wound
complications occur in up to 50% of horses following ovariectomy [32]. The NOTES procedure performed in standing
mares eliminates the need for general anesthesia and skin
incisions, requiring only a single incision in the vaginal wall.
Pre-operative preparation
Hay is withheld for 3 days and pelleted feed is removed 24
hours before surgery. Mares are given peri -operative antimicrobials and fl unixin meglumine prior to surgery. Restraint
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CHAPTER 20 NOTES Applications in Veterinary Medicine
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and sedation are performed as described above. The perineal
area is clipped and cleaned and prepared for aseptic surgery.
The vulva and vagina are prepared with surgical scrub of
chlorhexidine gluconate. A urinary catheter is passed and
the perineal region is draped (Figure 20.18).
Technique
The operative set -up and position of the instruments are
shown in Figure 20.19. Transvaginal access to the abdominal
cavity is made at the 11 o ’clock position about 4 cm lateral
to the cervix with the 15 mm optical trocar using the fl exible
Figure 20.18 Operative preparation for the mare for standing NOTES
oophorectomy.
endoscope through the center of the trocar to provide visualization of each tissue layer as it is encountered. When the
abdomen is entered, the obturator is removed and a 10 mm
exchange rod is inserted. The cannula is removed and
exchanged for the 33 mm port (Figure 20.6). The large port
has a dilating tip that gradually stretches the opening in the
vagina to accept the cannula. The obturator and exchange
rod are then removed. The endoscope is inserted and each
ovary is visualized. Lidocaine (2%, 35 ml) is injected through
the needle in the working channel of the endoscope into the
mesovarium to provide local anesthesia. Long laparoscopic
grasping forceps elevate the ovary while a bipolar sealing
device is positioned and fi red across the ovarian pedicle
(Figure 20.20). The ovary is removed and the procedure is
repeated on the opposite side. The colpotomy is closed with
a single cruciate suture and examined with the endoscope
to ensure secure closure (Figure 20.21).
Outcomes
The technique was developed initially in ten horses (six
acute, four with 15 -day survival). Visualization was considered excellent and the mares tolerated the procedure well.
The bipolar sealing device worked well; however, modifi cation in design is required for future studies. The learning
curve was steep, operative times were long; however, the
surviving mares recovered well. One of them had a positive
microbiological culture but there was no evidence of infection on cytology and the mare remained clinically normal.
Figure 20.19 Operative set -up for NOTES oophorectomy in mares showing the position of the patient, endoscopic tower, surgical instruments, and
handler.
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SECTION 3 Perspectives on NOTES
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2
2
1
6
Figure 20.20 Endoscopic view of the right ovary of the mare
(1). Grasping forceps (2) are used to elevate and apply caudal traction
while the bipolar vessel sealing system (3) is applied to the mesovarium
(4). The uterus (5) and mesocolon (6) are also seen.
4
3
5
Three of the mares demonstrated a mild to moderate infl ammatory response but no evidence of signifi cant adhesion
formation [33].
The refi ned techniques were then used for a comparative
study with laparoscopy in 12 horses, with six animals in
each study arm. Surgical times were similar for the two
procedures (mean time NOTES = 100 ± 40; mean time
laparoscopy = 107 ± 47) and there were no differences in
postoperative pain or infl ammation when the two approaches
were compared. In the laparoscopy group, 33% of the
animals developed an incisional infection. Both methods
provided a satisfactory outcome (Video 20.2) [34].
Application
The technique is currently being used clinically in client owned horses; however, widespread adoption is limited by
the lack of commercially available long bipolar vessel sealing
devices.
Canine NOTES gastropexy
Indications
Prophylactic gastropexy is performed to prevent gastric volvulus in large breeds of dogs that may be predisposed to
developing gastric dilatation volvulus (GDV) syndrome. The
condition may be fatal if not treated promptly, and veterinarians frequently advise owners of Great Danes, Rottweilers, Irish Setters, and other large deep -chested breeds of dogs
to pursue prophylactic gastropexy. The goal is to create a
permanent adhesion between the stomach and right lateral
1
4
3
Figure 20.21 Endoscopic view of a single cruciate suture (1) being used
to close the colpotomy in the mare. The dorsal (2) and ventral (3) wall of
the vagina and the cervix (4) are also seen.
body wall to prevent twisting of the stomach that follows
gastric dilation in these animals. We considered that a
NOTES approach to endoscopic gastropexy might offer an
advantage in lessening the invasiveness of this surgical
procedure over open or laparoscopic -assisted approaches;
however, the NOTES procedure introduced new questions
that had to be addressed before the technique could be seriously considered. A previous study had shown that a PEG
tube technique for gastropexy did not produce adhesions
that were as strong as those with an incisional gastropexy
[35]. Additional concern arose when gastropexy was proposed as a method to close the gastric incision following
NOTES procedures [36]. The technique used three percutaneous stay sutures placed in a triangular pattern around the
gastric incision in 15 pigs, which were followed for 2 to 4
weeks before necropsy. One of the pigs died from peritonitis
resulting from a gastric leak when the incision extended
beyond the stay sutures [36]. For these reasons, we performed an experimental study in 10 research animals, which
was then followed by a clinical study in client -owned
animals.
Technique
Anesthesia and pre -operative preparation are similar to
canine oophorectomy. Studies involving client -owned
animals used laparoscopic monitoring for safety with a port
and laparoscope placed just caudal to the umbilicus.
The therapeutic endoscope was passed into the stomach
and the proposed gastrotomy site was identifi ed in the antral
portion of the stomach midway between the greater and
lesser curvature on the ventral (anterior) aspect of the
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CHAPTER 20 NOTES Applications in Veterinary Medicine
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stomach. The site was adjacent to the incisura angularis,
a narrow fold that divides the pyloric antrum from the
gastric body.
A 19 gauge 5” stylet -loaded catheter was inserted through
the right lateral body wall just inferior to the 13th rib and
directed into the antral portion of the stomach with laparoscopic visualization (Figure 20.4). The stylet was removed
and a 0.035” guidewire was inserted and pulled through the
scope using a standard 11 mm snare. A through -the-scope,
sequential dilating balloon was used to directly dilate the
gastrostomy to 20 mm. Alternatively, a Huibregtse
®
Triple
Lumen Needle -Knife can be used to create the gastrotomy
around the guidewire, which can be subsequently dilated if
needed. The guidewire was advanced and looped in the
peritoneal cavity. The endoscope was then passed through
the gastrotomy into the peritoneal cavity. Insuffl ation was
provided via air insuffl ation through the endoscope or
through CO
connected to the trocar at the umbilicus if
2
laparoscopic monitoring was used.
The site of guidewire penetration through the abdominal
musculature, which marks the location of the gastropexy,
was identifi ed. A needle -knife electrode or wire loop cautery
device was then used to create one or several incisions in
the abdominal musculature surrounding the guidewire. A
generous incision or a series of incisions, approximately
50 mm long, was made (Figure 20.8). Monopolar electrocautery was used to coagulate and cut the peritoneum
and abdominal musculature. The site was examined to
ensure adequate hemostasis and touched up with cautery if
needed.
Keeping the guidewire in place, the endoscope was
removed and reinserted into the stomach beside the
guidewire. To obtain adequate insuffl ation of the stomach
to permit dilation of the stomach to the body wall, it was
necessary to fi rst close the gastric incision around the
guidewire. The T -fastener suturing device was used to place
one or two sutures through the gastric mucosa to close the
incision. The intra -abdominal pressure was lowered to
46 mmHg to permit the stomach to move closer to the
abdominal wall. A series of sutures were placed through the
gastric mucosa into the abdominal wall to secure the gastropexy for 360 degrees around the incision in the abdominal wall. During placement of each suture, the abdominal
wall was palpated until the tip of the T -fastener was felt
within the subcutaneous tissue before deployment. Digital
palpation caused the tip of the fastener to toggle and remain
in the subcutaneous tissue just beneath the skin. Approximately six sets of sutures were placed and joined with surgical clips to secure an intact gastropexy (Figures 20.22 and
20.23). The laparoscope was used to monitor the needle
penetration into the body wall to ensure that no other
organs become entrapped in the gastropexy site. Following
fi nal examination, excess air was removed from the stomach
and the endoscope was removed from the stomach. The
abdomen was desuffl ated and the laparoscope and trocar
were removed and the site closed with sutures.
Figure 20.22 Schematic view of pairs of T -fasteners placed through
the gastric and abdominal wall.
Outcomes
Ten research dogs initially underwent the procedure without
laparoscopic monitoring and fi fteen client -owned dogs have
undergone the procedure with laparoscopic monitoring. The
Figure 20.23 Laparoscopic view of the fi nal result of the NOTES
endoscopic gastropexy.
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SECTION 3 Perspectives on NOTES
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median procedure time was 75 minutes in the fi rst study
and there were no deaths or signifi cant complications in the
peri-operative period. Animals undergoing the procedures
took approximately 3 days to recovery to their pre -surgical
activity levels. Animals were examined laparoscopically four
to six months after surgery and two of them had no adhesion remaining, two had minor adhesions, and six had
extensive fi brous adhesions. The technique for performing
the gastopexy was modifi ed to include multiple incisions in
the abdominal wall and placement of multiple pairs of
T-fasteners under laparoscopic visualization. With these
changes, a clinical study in 15 client -owned Collie dogs was
performed. Each of the dogs in the clinical study had a fi rst or second -degree relative that died from GDV. The mean
surgical time was slightly longer than in the research animals;
however, none of the animals died or had signifi cant complications. To date, ten of them have been evaluated 12
months after surgery with endoscopy and ultrasound examination. The gastropexy sites appear to be intact and there is
no evidence of gastritis from the suture clips inside the
stomach (Video 20.3). The study is ongoing.
Application
Although the results of the study to date appear promising,
additional work will be required to reduce procedure time
and cost before the technique will be clinically applied in
veterinary medicine.
Acknowledgments
We are deeply grateful for the gastroenterologists and surgeons at the Indiana University School of Medicine, and to
the Veterinary Clinical Sciences department at Purdue University School of Veterinary Medicine, and to NOSCAR, the
Collie Health Foundation, American College of Veterinary
Surgeons, and the Indiana Equine Research Foundation for
funding our basic research. Cook Endoscopy and Boston
Scientifi c provided disposable endoscopic products used in
our studies. Without these groups, this work would not have
been possible.
Chapter video clips
Video 20.1 Endoscopic video demonstrating the technique for
NOTES oophorectomy in dogs under propofol sedation. Video provided by Dr Daniel McKenna.
Video 20.2 Movie demonstrating the technique for performing
transvaginal oophorectomy in standing mares.
Video 20.3 A combination endoscopic and laparoscopic video
demonstrating the technique for performing NOTES
endoscopic gastropexy in dogs.
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15 Sodergren MH, Coomber R, Karimyan V, et al. What are the
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17 Eickhoff A, Vetter S, von Renteln D, et al. Effectivity of current
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NOTES and Pregnancy: Where We Are
and Where We Could Go
Nicolas Bourdel & Janyne Althaus
Johns Hopkins University, Baltimore, MD, USA
Introduction
Between 1 in 500 –635 pregnant women will be operated on
for non -obstetric indications [1,2]. These classical rates are
based on studies performed more than 15 years ago and
have certainly increased with widespread use of prenatal
ultrasound and accuracy in imaging adnexal masses and
other pathologies [3]. Kuczkowski estimates the rate now
lies between 1% and 2% [4], with the most common etiologies being appendicitis, cholecystitis, ovarian torsion, and
symptomatic or suspicious adnexal masses.
Although laparoscopy has become the gold standard in
the treatment of numerous gynecologic pathologies, this
minimally invasive surgery is still controversial in pregnant
women and does not cancel the risks of surgery. Every
surgical procedure during pregnancy regardless of level of
invasiveness requires weighing the benefi t and the risk to
both the mother and the fetus. Risks include both classical
surgical complications (e.g., hemorrhage, infections, injury
to internal organs, etc.) and specifi c pregnancy -associated
risks (e.g., miscarriage, preterm labor, preterm premature
rupture of membranes [PPROM], intrauterine death, intrauterine fetal compromise, etc.). Moreover, anesthesia risks
remain for both the mother (pulmonary edema, failed intubation, aspiration, increased supine hypotension, thromboembolic risk) and the fetus (potential teratogenicity of
anesthetic and analgesic agents, fetal hypoperfusion and
hypoxemia).
Over the past 20 years, there has been a rise in surgeries
performed for specifi cally obstetric indications, such as in utero repair or amelioration of fetal birth defects, or treatment of pathological obstetric conditions, as will be discussed
below. Thus, it is reasonable to assume that the rate of
surgery in pregnant females may increase as indications for
surgery increase. During pregnancy unique physiological
and anatomical changes require all procedures be adapted
to pregnancy (access, techniques, devices, energy, etc.) to
lower the risk. Moreover, pregnancy is a fl uid condition:
access to the peritoneal cavity and the intrauterine cavity
changes and could be challenging, especially during the last
trimester of the pregnancy. Natural orifi ce translumenal
endoscopic surgery (NOTES) could be the next step in the
improvement of surgical treatment of pregnant women, providing us with a new way to treat maternal, placental, or
fetal pathologies.
NOTES could potentially provide a solution not only to
improve surgical access to the uterus and the placenta but
also to reduce invasiveness of the surgical procedure. To
evaluate the potential benefi t of NOTES during pregnancy,
we distinguish between three general categories of surgery
performed on pregnant patients:
• Maternal surgery (for maternal pathology)
• Intrauterine surgery (for placental pathology)
• Fetal surgery (for fetal pathology).
Maternal surgery (for maternal pathology)
Risks of minimally invasive surgery during
pregnancy
Every surgical procedure during pregnancy, in addition to
the standard material risks, carries risks for miscarriage,
intrauterine hemorrhage, premature rupture of membranes,
preterm labor, intrauterine death, or intrauterine fetal
hypoxemia [5]. None of these complications is linked to a
specifi c technique or surgery and can occur after or during
any surgical procedure performed during pregnancy. Cur-
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
232
CHAPTER 21 NOTES and Pregnancy
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rently, there are no randomized control studies comparing
laparoscopy and laparotomy during pregnancy [6,7].
Laparoscopy, with its faster recovery time, reduced postoperative pain, and decreased rates of blood loss, postoperative ileus, and thromboembolic events described in the
general population, seems perfectly applicable to pregnancy.
However, its use is still controversial [6,8]. Technical risks of
laparoscopy during pregnancy include uterine injury during
blind trocar placement [9]. Improvement of laparoscopic
techniques during the past two decades [10] and an open
guided approach to insure safe trocar placement have not
eliminated this risk [11].
Another technical issue of laparoscopy is the use of gas to
create the operative fi eld. Gasless laparoscopy during pregnancy has been reported only as case reports [12–17]. Larger
series in general populations failed to prove any advantage
of gasless surgery versus carbon dioxide (CO
) laparoscopy,
2
and showed an increase in the time to create pneumoperitoneum and technical issues [18]. The used of CO
has been
2
questioned primarily because of its consequences on blood
gas acidity on the maternal side, and potential risk of
decreased uteroplacental blood fl ow due on the fetal side to
decreased maternal cardiac output [4,19–25]. CO
has been
2
widely used in animal and human procedures, with very
low rates of complication due to the gas itself [4]. If gas is
used, CO
is recommended for insuffl ation during pregnancy
2
until other experimental and clinical studies on other gases
have been reported.
In addition to the type of gas, intra -abdominal pressure
used during surgery can also have an impact on morbidity
[26,27]: lower pressures are recommended to minimize the
effect of CO
on maternal or fetal status [28]. During surgery,
2
especially during pregnancy, the goal should be to use low
pressures (8 –12 mmHg). This will also impact anesthesia
since the majority of CO
used for pneumoperitoneum is
2
evacuated by ventilation. Regional anesthesia is not amenable to intraperitoneal surgery during pregnancy despite its
better safety profi le compared to general anesthesia. There
are two major drawbacks to regional anesthesia for intraperitoneal minimally invasive surgery. The fi rst is the necessity to monitor and adapt ventilation to end -tidal level of
CO
(good approximation of arterial CO 2 in the pregnant
2
women) [4], which is usually possible only with mechanical
ventilation [29]. The other drawback is the necessity to have
a high regional anesthesia block to perform laparoscopic
surgery, which can increase the risk of hypotension and
reduced placental perfusion, and decrease the possibility of
self-patient adaptation to a high level of CO
(risk of paralyz-
2
ing respiratory muscles) [30]. Meanwhile, general anesthesia, however, has its own risks, including potential diffi cult
access to airway during pregnancy and aspiration risk due
to gastric emptying.
Thromboembolic risk increases with pregnancy, and
surgery further increases this risk even if laparoscopy lowers
the incidence compared to laparotomy [31]. The decreased
risk may be due to a faster recovery, but this must be balanced against longer operative times, a factor that increases
the risk.
Regardless of the method of surgery, fetal monitoring can
be technically diffi cult if not impossible during abdominal
surgery, but must be available in the operative room. After
24 weeks of gestation, ability to continuously monitor the
fetus and availability for emergency Cesarean section must
be considered.
Endoscopy and pregnancy
The literature on endoscopy and pregnancy only shows
small studies and case reports, with no large controlled trials
[32]. The American Society for Gastrointestinal Endoscopy
(ASGE) published guidelines for endoscopy (upper and
lower endoscopy) in pregnant women in 2005 [33]. These
recommendations include a strong indication for the procedure, to defer endoscopy to the second trimester whenever
possible, to minimize procedure time, to position pregnant
patients in left pelvic tilt or left lateral position to avoid vena
cava or aortic compression, and to assess the presence of
fetal heart sounds before sedation is begun and after the
endoscopic procedure. Obstetric support should be available,
and endoscopy is contraindicated in the presence of obstetric
complications such as placental abruption, imminent delivery, ruptured membranes, or eclampsia.
For colonoscopy or sigmoidoscopy, the data in the literature is also sparse, with 144 reported cases [34]. A report on
colonoscopy in 20 pregnant women demonstrates that
despite the presence of a gravid uterus, a complete colonoscopy is often feasible [34].
Invasive procedures that include a transgastric “passage”
during pregnancy have been reported, with good postoperative results. Twelve placements of percutaneous endoscopic
gastrostomy (PEG) have been reported [35–37] with favorable fetal outcomes and no maternal complication. Senadhi
et al. reported specifi c advice for care before and during PEG
placement during pregnancy [35]:
• Ultrasound to defi ne the dome of the uterus before the
procedure.
• Ultrasound indentation and transillumination displaying
PEG can be separated from the ribcage and the uterus.
Only three case reports have been published so far
on endosonographic cystogastrostomy [38–40]. Use of endosonography was successful, and there were no sequelae
of fetal irradiation compared to classical fl uoroscopic
location.
Finally, bipolar devices are preferred over monopolar
devices to minimize stray electric current. If use of a monopolar device is necessary, then placement of the grounding
pad should avoid positioning the uterus between the electrical device and this grounding pad.
233
SECTION 3 Perspectives on NOTES
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Lateral
wall
Uterine
fundus
Small bowel
Figure 21.1 Transgastric view of the uterus and small bowel.
NOTES for maternal pathology during pregnancy
Review of the literature
No human studies and only one animal study have been
reported so far [41] using NOTES during pregnancy. In this
study on pregnant ewes performed by our team at Johns
Hopkins, the goal was to assess the feasibility of NOTES for
diagnostic and therapeutic intrauterine fetal interventions.
Two natural orifi ce translumenal access sites were used: one
animal was operated on in a transgastric manner, one by the
transvaginal route, and one used both. A needle -knife was
used to perform the vaginal vault puncture, followed by
dilation using an 18 mm hydrostatic dilation balloon (the
same technique was used for transgastric access). The endoscope was then advanced into the peritoneal cavity. The
vagina was closed with a T -bar anchoring system (Cook
Medical, Inc.) and endoscopic clips. Transgastric access was
achieved in the fi rst of the sheep ’s four stomach chambers
because it was the easiest to lavage clear. No closure of
transgastric access was done (non -survival model).
In all three animals, peritoneoscopy (Figure 21.1, Video
21.1) was achieved with good visualization of the wall of
the gravid uterus and other intraperitoneal organs. No intraoperative complications were observed. Two animals were
euthanized immediately after the procedures. During the
necropsy of the non -survival animals no complication was
found. The one with the exclusive transvaginal access (survival model) showed no postoperative complication over the
next four weeks, and necropsy did not reveal any damage
to the uterus or intraperitoneal organs. This experiment
demonstrated the feasibility and the safety of transvaginal
and transgastric access in an animal model. The routes
allowed a good examination of intraperitoneal organs (peritoneoscopy), and allowed thorough access to the uterus,
including the posterior wall, which is rarely, if ever, accessible by laparoscopy or laparotomy. From just one entry
Transvaginal
entry
Uterus
Figure 21.2 Lateral transvaginal access, with perfect view of the wall of
the uterus.
point, all sides of the uterus were reached. The transvaginal
route (Figure 21.2) allowed a straight access to the adnexa,
the appendix, and the gallbladder, sites of the most common
surgical pathologies that occur during pregnancy.
Pitfalls and perspective
Because NOTES in pregnant patients has not been reported
in the literature, the following are the theoretical and philosophical advantages and challenges to consider.
The fi rst challenge will be the inherent learning curve.
With any new device, technique, or access route, surgery
times are initially increased, and NOTES procedures are no
exception [42]. Since in most cases, surgical procedures performed during pregnancy are emergency procedures, the
team and material must be ready in a few hours. This could
be an issue if the surgical team does not perform NOTES
routinely and cannot mobilize as quickly. The learning curve
of NOTES during pregnancy will automatically increase
operative time, which may negate any advantage laparoscopy has over open surgery in regard to thromboembolic
events.
The increased risk of regurgitation, nausea, and vomiting
must still be addressed, as well as postoperative nausea and
vomiting. NOTES with its faster recovery time could decrease,
but not eliminate, this risk as compared to laparoscopy.
Advantages of NOTES
Since pain has been proposed as a contributing mechanism
in preterm delivery [43], lowering postoperative pain with
NOTES could be an advantage [44].
Disadvantages for NOTES
Tocolysis would continue to be required (particularly during
the third trimester); thus, collaboration with obstetricians
familiar with NOTES is crucial.
234
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