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the peritoneum was incised along the line of
Toldt, and the colon was mobilized and retracted
medially. The ureter was identified proximal to
the iliac vessels and ligated using 5- or 10-mm
Hem-o-lok clips (Teleflex Medical China,
Shanghai, China). Proximal mobilization of the
ureter up to level of the ureteropelvic junction
was performed. The mobilized ureter was used
for the retraction of the kidney and the lower pole
of the kidney was mobilized, followed by pos-
terior dissection. The lower pole was lifted lat-
erally to define the renal hilum. After the hilum
was identified, it was dissected using the ultra-
sonic dissector or pre-bent instruments and flex-
ible forceps. The Hem-o-lok applier was used to
control the artery, and then the vein. In cases of
severe hydronephrosis, the collecting system was
drained, as needed, to achieve better exposure to
the renal pedicle. If dense adhesions around the
renal artery precluded skeletonizing it, the renal
artery was doubly clipped with its surrounding
fibrous tissues, and the kidney was mobilized
outside Gerota’s fascia. Remaining attachments
of the upper pole of the kidney medially, supe-
riorly, posteriorly, and laterally were progres-
sively freed using straight, flexible, or pre-bent
instruments to retract the dissected kidney, and
the kidney was released. A homemade bag was
introduced into the abdominal cavity through the
10-mm working channel of the transvaginal
Zou-port. The specimen was placed inside the
bag and removed through an extended incision at
the posterior vaginal fornix (Fig. 23.4a, b). For
hybrid transvaginal NOTES nephrectomy, one or
no drain was placed at the renal bed, and one was
placed at pelvic cavity through the vagina. We
placed the intra-abdominal drain through the
umbilical incision in order to remove the
abdominal fluid, which can also help us early
find postoperative problems. However, in the
first 10 cases, we found that the postoperative
drainage from intra-abdominal drains was little
(less than 20 ml each day). Furthermore, the fluid
may flow out of the pelvic drain when the patient
is in the semi-recumbent position. Therefore, we
consider that it is not necessary to place an
intra-abdominal drain. There was no intra-
abdominal drain in later patients. For pure
transvaginal NOTES nephrectomy, the drain tube
was placed at pelvic cavity throu gh the vagina.
The vaginal wound and the 10-mm umbilical
fascial defect were closed using a 2-0 absorbable
suture. Final ly, a vaginal tamponade with a
sterile vaginal pack dressing was applied in all
the patients. Complete sexual abstinence lasting
3 months was advised for all cases.
Postoperative Care
• Patients received intravenous fluid until
recovery of bowel sounds.
• Intravenous broad-spectrum antibiotic (cef-
triaxone) and injection tramadol on patient
demand were administered.
• The drainage tube output, if less than 30 ml in
24 h, was removed.
• Patients can resume their normal daily activ-
ities as soon as they are comfortable doing
them.
Fig. 23.3 Diagrammatic representation of the use of
extra-long pre-bent instruments during pure transvaginal
NOTES nephrectomy. Reprinted with permission from
Elsevier. Yijun Xue, Xiaofeng Zou, Guoxi Zhang,
Yuanhu Yuan, Rihai Xiao, Yunfeng Liao, Xin Zhong,
Bo Jiang, Ruiquan Xu, Yuhua Zou, Gang Xu, Kunlin Xie,
Xu Zhang. Transvaginal Natural Orifice Translumenal
Endoscopic Nephrectomy in a Series of 63 Cases:
Stepwise Transition From Hybrid to Pure NOTES, Euro-
pean Urology 2015;68(2):302–310
23 Transvaginal NOTES Nephrectomy 285
• Fluid intake was encouraged to prevent
constipation.
• Some light vaginal bleeding is expected and
may continue for several days following the
procedure. Occasionally (during the first
week), patients may have an episode of heavy
bleeding when the patients stand up or after
urinating. If the bleeding is excessive (more
than a menstrual period or completing soaks a
large pad in 1 h), the patient should contact
the physician. To promote healing and reduce
the risk of infection, patients should not put
anything in their vagina for the first 8–
12 weeks until the tissues have had time to
completely heal. This includes tampons and
douches that involve the vagina. Complete
sexual abstinence lasting 3 months was
advised for all patients.
• Showers are permitted, but tub baths and
swimming should be avoided until the inci-
sions are healed.
• Patients are instructed to notify the doctor or
go to the emergency department if any of the
following happens: abdominal distention or
pain;increased or bright red bleeding from the
vagina;foul smelling vaginal flow;redness,
Fig. 23.4 a Specimen extraction through the vagina.
b Intact excised specimen shows the lower-pole tumor.
c Three-month postoperative appearance of posterior
colpotomy incision. d Three-month postoperative appear-
ance of umbilical incision. Reprinted with permission
from Elsevier. Yijun Xue, Xiaofeng Zou, Guoxi Zhang,
Yuanhu Yuan, Rihai Xiao, Yunfeng Liao, Xin Zhong, Bo
Jiang, Ruiquan Xu, Yuhua Zou, Gang Xu, Kunlin Xie, Xu
Zhang. Transvaginal Natural Orifice Translumenal Endo-
scopic Nephrectomy in a Series of 63 Cases: Stepwise
Transition From Hybrid to Pure NOTES, European
Urology 2015;68(2):302–310
286 X. Zou et al.
pus-like (yellow or green) discharge or
swelling from the cuts;fever/chills with tem-
perature over 38.5 °C.
Results
For hybrid transvaginal NOTES nephrectomy,
the mean operative time was 105 min (range:
70–280 min), and the mean estimated blood loss
was 80 ml (range: 30–800 ml). There were 19
intraoperative complications. Five patients were
converted to open surgery. There were 15 post-
operative complications:14 minor complications
(Clavien 1–2) and 1 major complication (Clavien
3b, postoperative bleeding). The patient subse-
quently underwent exploratory laparotomy
revealing a clip dislodgment from the gonadal
vein. For pure transvaginal NOTES nephrec-
tomy, the procedures were successfully per-
formed in all patients without additional trocars
except for one patient who experienced a rectal
injury caused by a forceps during the placement
of the Zou-Port, and immediate repair was per-
formed. The patient was converted to
suprapubic-assisted laparoendoscopic single-site
surgery (SA-LESS) nephrectomy in which 5- and
10-mm trocars were inserted at the medial mar-
gin of the umbilicus through two separate inci-
sions and a 10-mm trocar was inserted into the
abdominal cavity below the pubic hairline. The
technique for the SA-LESS is similar to that of
the standard laparoscopy, with conventional
instruments placed in the abdominal trocars,
under direct vision achieved by a 5.4-mm
flexible-tip laparoscope placed through the tro-
car below the pubic hairline [35]. The kidney
specimen was removed after the incision below
the pubic hairline was enlarged. Postoperative
major complications included a right external
iliac artery thrombosis on postoperative day 2,
which was successfully treated by thrombus
removal. This complication may be related to the
patient’s poor vascular condition, and the
long-time compression and repeated friction
injury of the vascular intima. There was no other
intraoperative abdominal and pelvic organs
injury. The mean operative time was 190 min
(range: 160–320 min), and the mean estimated
blood loss was 170 ml (range: 100–500 ml).
At a mean range follow-up of 51.8 (10–69)
months, all the patients were in good condition.
The posterior colpotomy incision healed well
(Fig. 23.4c). The scars were nearly invisible on
the abdominal wall (Fig. 23.4d). There were no
infections, umbilical hernias, or uterine prolapse.
All patients who underwent nephrectomy for
malignant suspicion were alive without evidence
of tumor recurrence or metastasis. One hundred
and sixty eight patients completed the female
sexual function index (FSFI) questionnaire, and
analysis did not show any difference in FSFI
scores before and after surgery.
Stepwise Transition from Hybrid
to Pure Transvaginal NOTES
Nephrectomy
Our transvaginal NOTES nephrectomy schedule
has evolved as a stepwise process [36]. Prior to
proceeding with NOTES in humans, we under-
went extensive training in the animal laboratory
to investigate operative safety and to prepare for
transition to human clinical application. Different
methods of peritoneal access were evaluated, and
the transvaginal route was finally determined to
be an ideal approach for nephrectomy. For our
initial human experience, we performed five
cases of transumbilical, multiport laparoscopic
nephrectomy with intact specimen extraction
through the vagina [37]. We think that this
method is an effective technique by itself and an
ideal way to train for the hybrid transvaginal
NOTES technique. In our hybrid NOTES series,
vaginal access was used to insert a laparoscope,
and two umbilical trocars were used as main
working ports. We then transitioned to a single
umbilical trocar used for the laparoscope, with
the transvaginal approach used for the majority
of the dissection. Working toward pure
transvaginal NOTES nephrectomy, we firstly
performed pure transvaginal NOTES renal cyst
decortication in 5 patients using extra-long
pre-bent instruments [38]. Finally, we moved to
23 Transvaginal NOTES Nephrectomy 287
a pure transvaginal NOTES nephrectomy. Based
on our experience, we o ffer the following
recommendations:
• This relatively slow and graded introduction
of pure transvaginal NOTES nephrectomy
into clinical practice is pragmatic, so this
procedure can be explored safely.
• Highly judicious patient selection (thinner
patients [BMI < 30] with limited prior
abdominal surgery and favorable disease
processes) is of utmost importance in the
early phase of NOTES skill acquisition, to
minimize complications and optimize surgical
outcomes.
• In situations where there is lack of progres-
sion or other concerns about patient safety,
the transition to at least standard laparoscopy
is advisable.
• Triangulation is one of the fundamental con-
cepts of laparoscopic surgery. NOTES seeks
to decrease morbidity and improve cosmesis
by placing all surgical instrum ents through a
single transvisceral incision. This “in-line”
placement of instruments invariably results in
clashing, imprecise tissue handling, and
retraction. We strongly recommend starting
NOTES with regular and extensive practice in
standard laparoscopy.
Conditions Necessary for Progression
to Pure Transvaginal NOTES
Nephrectomy
• Placement of a transvaginal port is a crucial
first step.
• Gradually increasing the use of the
transvaginal port for actual intraoperative
steps, including mobilize/dissect colon and
ureter, individually dissect/control renal
artery and vein with clips, respectively, and
mobilize kidney completely, must be
performed.
• Preoperative mechanical bowel preparation is
recommended for intestinal repair in case of
an intestinal injury.
• The dissection of the cephalad aspect of the
hilum and the upper pole is very challenging,
because it is difficult to obtain the correct
working angles. An additional problem is the
considerable distance between the introitus
and the upper pole of the kidney; the use of
extra-long pre-bent or flexible instruments is
required. Pre-shaped, rigid instruments with
different profiles were introduced with the
aim of minimizing instrument clashing out-
side the port, providing triangulation in the
operative field and better force application at
instrument tip during dissection. They are
also cost-effective, because they are reusable
compared to the single-use disposable flexible
instruments.
Instrumentation
The flexible-tip laparoscope provided excellent
visualization, even considering the atypical
transvaginal perspective. This scope has a dis-
tally mounted image capture chip and a built-in
light cable which gives the handle a streamlined
profile compared to a typical rod-lens scope with
a light cable connected at a 90° angle and a bulky
image capture coupler which can interfere with
the instrument handles being used in close
proximity to the scope (Fig. 23.5a). The flexible
forceps help with intracorporeal instrument tri-
angulation and proper tissue retraction. The
introduction of extra-long pre-bent instruments
has the advantage of minimizing instrument
clashing, providing triangulation in the operative
field and better force distribution during dissec-
tion (Fig. 23.5b). Although these instruments
have facilitated our pure transvaginal NOTES
approach, they are still relatively laborious, with
suboptimal ergonomics. Continuing refinement
of instrumentation and, most importantly,
development of purpose-specific robotic plat-
forms may overcome current limitations of
NOTES.
We developed a three-channel port for pure
transvaginal NOTES nephrectomy procedures
(Fig. 23.6a, b). Several aspects of the port
288 X. Zou et al.
deserve a special mention. It was long enough to
bypass the pelvic organs once it was inserted
transvaginally. This characteristic precluded the
chance of pelvic organ injury during passag e of
the instruments toward the target organ. More-
over, the port material is elastomeric, and the
original length is 25 cm, which can be trimmed
with a knife depending on the individual
anatomy.
Complications
Although the vagina seems to be an ideal portal
of entry for NOTES nephrectomy, several reports
have indicated that considerable morbidity can
accompany this approach. In one case series of
102 transvaginal NOTES procedures [39], three
major complications occurred, specifically rectal
injury, omental bleeding, and abscess formation.
In an international multicenter trial on NOTES
(IMTN) registry [40], an overall complication
rate of 6.9% (grade I–II: 5.33%; grade III–IV:
1.57%) was reported for 319 transvaginal
NOTES patients. There were 40 complications
(22.47%) in our NOTES nephrectomy, including
13 major complications (7.3%), which was sim-
ilar to that of reported standard laparoscopic
nephrectomy [41].
Postoperative Sexual Function
The effect of transvaginal NOTES on postoper-
ative sexual function is a major concern. How-
ever, current literature suggests that sexual
dysfunction is a rare event after vaginal surgery
[39, 40]. Our experience confirmed this, because
the satisfaction of the patients with the result of
the operation was high, and no patient reported
Fig. 23.5 a A flexible-tip
5.4-mm 0° laparoscope.
b Extra-long flexible and
pre-bent instruments for
pure transvaginal NOTES
nephrectomy. Reprinted
with permission from
Elsevier. Yijun Xue,
Xiaofeng Zou, Guoxi
Zhang, Yuanhu Yuan,
Rihai Xiao, Yunfeng Liao,
Xin Zhong, Bo Jiang,
Ruiquan Xu, Yuhua Zou,
Gang Xu, Kunlin Xie, Xu
Zhang. Transvaginal
Natural Orifice
Translumenal Endoscopic
Nephrectomy in a Series of
63 Cases: Stepwise
Transition From Hybrid to
Pure NOTES, European
Urology 2015;68(2):302–
310
23 Transvaginal NOTES Nephrectomy 289
dyspareunia by a standardized questionnaire.
This finding is consistent with a recently pub-
lished study evaluating the short-term sexual
function with the same FSFI questionnaire after
transvaginal NOTES nephrectomy [42]. A previ-
ous study by Solomon et al. [43] may explain
why female sexual function is not affected by a
transvaginal procedure. These investigators
showed that somatic vaginal innervation is con-
centrated distally and anteriorly along the vaginal
walls, leaving the posterior fornix with sparse
sensory innervations.
Recommendations and Conclusions
NOTES nephrectomy using the vagina as an
entry point to the peritoneal cavity is very
promising. With the development of new
instruments and platforms that facilitate handling
and stabilization of flexible endoscopes, the sur-
gical approach has the potential to have broad
clinical applications in the future.
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Index
A
Abdominoperineal resection (APR), 243, 244, 245, 246,
253, 262, 263
Achalasia, 35, 36, 72, 82
EGJOO, 88, 89
endoscopic myotomy, 35
GERD after treatment, 96
Heller myotomy, 93
POEM of esophagus, 88
spastic achalasia, 89
Type III achalasia, 90f, 93
Acute appendicitis, 212
Acute pancreatitis, 152, 162
American Society of Gastrointestinal Endoscopy (ASGE),
2
Anastomosis
cystojejunal anastomosis, 162
transoral anastomosis, 169
Anti-reflux mucosectomy (ARMS), 34, 34f
efficacy, 35
indications, 34
safety, 34
technique, 34
Aspiration therapy, 134
AspireAssist, 134–136, 135f
B
Body mass index (BMI), 122–123
Botulinum, 114
C
Cholecystectomy, 202
techniques, 204–205
Circumferential rectal mucosectomy, 262
Clonidine, 114
Colorectal surgery, evolution of NOTES for, 243
–245
alternatives, 262
complications, 263–264
future directions, 265
limitations, 264
NOSE, 244, 246
postoperative care, 263
training, 264
Cosmetic result, 207, 218, 222, 280
Cough pressure, 17
Culdocentesis, 235–236
Culdolaparoscopy, 236
Culdoscopy, 236
diagnostic culdoscopy, 238–239
knee-chest position for, 237f
laparoscopic port, 237–238
site determination, 237f
Culdotomy, 236
Cystojejunal anastomosis, 162
D
Diagnostic endoscopy, 174
Diaphragm pacing (DP), 144
history of, 145–146
NOTES DP in ICU patients, 146–149
diaphragm electrodes, 149f
percutaneous retrieval of electrodes, 148f
permanent and temporary DP electrode, 147f
Direct endoscopic necrosectomy (DEN) procedures, 153
air embolism, 158
LAMS, 155
Distal esophageal spasm (DES), 88, 89
LES myotomy in, 95–96
Domperidone, 114
Dopamine D
2
receptors, 114
Duodenal mucosal resurfacing, 136, 137f
E
Elipse gastric balloon, 130–131, 130f
En bloc resection, 49, 57. See also Endoscopic submu-
cosal dissection (ESD)
EndoBarrier duodenal-jejunal bypass liner, 134
Endoluminal suturing, 133
Note: Page numbers followed by f and t indicate figures and tables respectively
© Springer International Publishing AG 2017
J.R. Romanelli et al. (eds.), NOTES and Endoluminal Surgery,
Clinical Gastroenterology, DOI 10.1007/978-3-319-50610-4
293
Endoscopic bariatric therapies (EBTs), 123–124
aspiration therapy, 134
AspireAssist, 134–136, 135f
categories, 124
future frontiers in, 136
combination of endoscopic and adjunctive medical
bariatric therapies, 138
cost-effectiveness research, 138
frameshift, 138
insurance coverage, 138
personalized endobariatrics, 136–138
goals of, 125
intragastric balloons, 126
Elipse, 130–131, 130f
Obalon, 129–130
Orbera, 126–128, 127f
Reshape Duo, 128–129, 129f
Spatz3 Adjustable Balloon System, 131
patient selection, 125–126
procedures, 124t
restrictive procedures and devices, 131
OverStitch for endoscopic sleeve gastroplasty, 131,
132f, 133
POSE procedure, 133–134, 133f
Revita duodenal mucosal resurfacing, 136, 137f
self-assembling magnets, 136
small-bowel bypass devices and procedures, 134
EndoBarrier duodenal-jejunal bypass liner, 134
space-occupying devices, 126
Endoscopic drainage, 153, 157
, 170
Endoscopic full-thickness resection (EFTR). See
Full-thickness endoscopic resection
Endoscopic mucosal resection (EMR), 30
efficacy
colon and rectum, 31
esophagus, 31
stomach, 31
EMR-C, 30–31
EMR-L, 30
en bloc resection, 30
indications, 30
safety, 31
Endoscopic pseudocystgastrostomy, 170
Endoscopic retrograde cholangiopancreatography
(ERCP), 124, 156
Endoscopic sleeve gastroplasty, 131, 132f, 133
Endoscopic submucosal dissection (ESD), 17, 32, 33f, 48,
65
classifications of mucosal layer depth, 50t
efficacy
colon and rectum, 33
esophagus, 33
stomach, 33
history, 48
indications of, 32, 48–49, 50t
colorectal, 51
esophageal, 50
gastric, 50–51
instruments and devices used
clips and closure devices, 54
Coagrasper, 52, 52f
contrast agents, 52–53
dyes, 52
–53
electrosurgical units, 53–54
endoscopy caps, 52
gas insufflation, 53
HookKnife, 51, 52f
hybrid knife, 51, 52f
injection needle catheters, 51
injection solutions, 52–53
IT knife, 51, 52f
management of complications, 56–57
Paris classification, 49, 49t
post-procedure management, 56
practice in West, 57
purpose-built knives, 32
safety
colon and rectum, 33
esophagus, 32–33
stomach, 33
submucosal tunneling, 32
techniques of, 54–56
esophageal ESD, example, 55f, 56f
Vienna classification, 49
Endoscopic suturing
device, 64
overstitch device, 67f
methods, 21–22
g-Prox device, 21f
ShapeLock overtube, 21f
Endoscopic therapy, for pancreatic necrosis
outcome, 156–157
procedural technique, 153–156
timing of intervention,
152–153
Endoscopic ultrasound (EUS), 91–92, 154, 163
Esophageal motility disorders, 88
Esophagogastric junction outflow obstruction (EGJOO),
88, 89
Extended gastric myotomy, 77
External pulse generator (EPG), 145
F
Failure to wean (FTW), 144
Fimbriectomy, 238
Flexible endoscopy, 62. See also Transvaginal
cholecystectomy
Flexible transgastric peritoneoscopy, 2
Fluoroscopy, 78
Full-thickness endoscopic resection
“closed” technique of, 63
over-the-scope clip, 63
“open” technique of, 63–64
with DualKnife, 66f
en bloc resection, 66f
laparoscopic resection, 64
294 Index