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184
D.N. Reddy et al.
goal is to perform abdominal surgery safely through the body’s natural ori fi ces,
some even outside the operating room setting, and to avoid complications associ-
ated with abdominal incisions, such as wound infection, pain, herniation, and adhe-
sions. The work of Kalloo et al. in the transgastric abdominal approach using
endoscopy in animal experiments reported in 2004 sparked the current heavy inter-
est in NOTES [
9 ] . NOTES has been attempted worldwide and has improved tre-
mendously in a short time. Work on porcine models has been progressing for many
years and has now culminated in successful endoscopic surgery in human subjects
[ 10 ] . Rao et al. (the senior authors of the chapter) presented the fi rst clinical case,
their work on the fi rst transgastric appendectomy, at the World Congress of
Gastroenterology in 2005 [ 11 ] . Since then, appendectomy has become the second-
most common surgery, reported in peer-reviewed journals, performed through the
NOTES approach [ 12 ] . World experience in human NOTES appendectomy,
restricted to ethically approved studies, is growing, particularly in the fi eld of trans-
vaginal and transgastric access (Table 14.1 ).
NOTES Nomenclature
While ideally, a “pure NOTES” procedure entails no incision on the abdominal
wall, the safety of this method has not been established enough to be used routinely
in human subjects. Most of the NOTES appendectomy procedures performed are
“hybrid NOTES,” which involves inserting one or two trocars in the abdominal area
and using laparoscopic equipment. These transabdominal instruments are used for
assistance in retraction and visualization, while the main dissection is done with
fl exible endoscopes. Also, when the operation is performed by laparoscopy with a
low natural ori fi ce instrumentation contribution (retraction or visualization), it has
been termed “NOTES-assisted laparoscopy” [ 12 ] .
Table 14.1 NOTES appendectomies performed in humans to date
Authors Route
Number of successful operations/
number of attempted operations
Year of
publication
Palanivelu et al. [
13 ] Transvaginal 3/6 2008
Rao et al. [
14 ] Transgastric 8/10 2008
Bernhardt et al. [
15 ] Transvaginal 1 2008
Tabutsadze
and Kipshidze [
16 ]
Transvaginal 2 2009
Horgan et al. [
17 ] Transvaginal 1 2009
Transgastric 1
Zorron et al. [
12 ] Transvaginal 37 2010
Transgastric 14
Park and Bergstrom [
18 ] Transgastric 1/3 2010
Noguera et al. [
19 ] Transvaginal 2 2010
Shin et al. [
20 ] Transvaginal 1 2010
185
14 NOTES: Appendectomy
Preprocedure Preparation
Before embarking on the performance of any NOTES procedure, a well-trained multi-
disciplinary team is required with advanced laparoscopic and endoscopic skills. It is
important to invest time in gathering extensive experience on animal models [
21 ] . This
is not only for the surgeon/gastroenterologist who is to perform the procedure, but also
for the operating room staff, scrub nurses, and anesthetists [ 18 ] . IRB approval and a
detailed informed consent from the patient are other crucial requisites [ 22 ] . Close con-
sultation with a gynecologist is essential if the transvaginal approach is chosen.
Patient Selection
The proper patient selection is required for the successful completion of appendec-
tomy through the NOTES approach. Advanced and emergency procedures should
be avoided in the early phase of technological development. The patient should not
have “complicated” appendicitis. Preferably, a patient with pain of less than 48 h’
duration and no history of recurrent pain in the past is chosen. A nonobese, non-
pregnant patient not in the extreme age groups with no major medical comorbidity/
bleeding disorder is favored. There should preferably be no previous history of
abdominal surgery. For the transvaginal approach, a history of pelvic in fl ammatory
disease, of severe endometriosis, of hysterectomy, of ectopic pregnancy, or of vagi-
nal trauma; vaginal infection; pregnancy, and virgin patients constitute contraindi-
cations. Before surgery, a bimanual pelvic examination is essential. Because of the
unresolved concern of the effect of the transvaginal route on fertility, women who
had completed their family were chosen by some groups for this approach [ 12 ] .
Sterilization of Equipment
Normally, endoscopes used for conventional purposes undergo bacteriostatic steril-
ization. However, for intraperitoneal use, bactericidal sterilization is required.
Sterilization with ethylene oxide as per the guidelines of the Minimal Access
Therapy Decontamination Working Group is recommended for a NOTES appen-
dectomy procedure [ 20 ] .
Patient Preparation and Anesthesia
For the transvaginal approach, disinfection of the vagina is achieved by topical
iodopovidone or chlorhexidine solution, and a urinary catheter is installed after
anesthesia [ 14 ] . For the transgastric approach, disinfection of the gastric lumen is
186
D.N. Reddy et al.
achieved by intraoperative gavage with clorohexidine solution. Some centers have
used no special cleaning besides aspiration [ 18 ] .
Prophylactic antibiotic use is recommended by all centers. Usually, a single dose
of an intravenous bolus of either 2 g of cefalexin or a combination of 400 mg of
metronidazol and 400 mg of cipro fl oxacin is given at the induction of anesthesia.
The procedure is carried out under general anesthesia with a transnasal endotracheal
intubation in a Lloyd–Davies/lithotomy position.
Creation of Pneumoperitoneum
The pneumoperitoneum can be created by insuf fl ation through the transabdominal
port, usually in the vicinity of the umbilicus, or through the endoscope. Translumenal
endoscopic insuf fl ation was obtained usually by attaching a laparo fl ator to a work-
ing channel of the endoscope or by tying an insuf fl ation tube to the endoscope.
Creating the pneumoperitoneum through endoscopic insuf fl ation has been found to
be more dif fi cult to measure and maintain [ 23 ] . A wider variation in pressure has
been observed than with laparoscopic insuf fl ation. Hence, most of the groups have
used the laparoscopic insuf fl ation system, which ensures that any excess insuf fl ation
is noted and quickly addressed. CO
2
was the gas of choice to insuf fl ate NOTES
surgery, and pressures of 5–15 mmHg have been used.
Approach
Transrectal, transesophagic, and transurethral accesses have been described in ani-
mal experiments [ 24, 25 ] . But they are not suitable yet for clinical studies, due to a
lack of suf fi cient experimental data and technical development for its safe use in
trials. Silberhumer et al. described the design and development of devices that
enable the inversion of the appendix through colonoscopy [ 26 ] . Such an inverted
appendix has been excised akin to a colonoscopic polypectomy. All the other
NOTES appendectomy described to date in humans have used the transvaginal and
transgastric approaches.
Transvaginal Approach
The transvaginal access has become the preferred route for NOTES appendec-
tomy in most clinical series. The use of the vaginal route for endoscopic proce-
dures is not new. Ventroscopy was described as early as in 1901, followed by
reports of culdoscopy and colpolaparoscopy [ 27 ] . Bueno described in 1949 the
187
14 NOTES: Appendectomy
fi rst successful performance of incidental vaginal appendectomy at the time of
vaginal hysterectomy, and Reiner, in 1980, presented his experience with 100
consecutive appendectomies done incidentally at the time of vaginal surgery [ 28 ] .
Culdolaparoscopy regained popularity at the end of the twentieth century when
ports inserted transvaginally were used in the assistance of laparoscopic gyneco-
logic procedures for the introduction of operative instruments and the extraction
of specimens.
The peritoneum can be accessed transvaginally via two methods [
12 ] . In the
more common method, the laparoscopic port is inserted fi rst in the periumbilical
region. A pneumoperitoneum is created. The pelvis is visualized through a laparo-
scopic camera/needloscope to rule out adhesions. Under laparoscopic guidance, the
posterior cul-de-sac is punctured in the avascular area between the two uterosacral
ligaments with one or more trocars. Alternately, the incision in the center of the cul-
de-sac is done via the mini-laparoscopy at a point stretched by an atraumatic plastic
rod placed transvaginally. The trocar(s) is subsequently placed through this inci-
sion. A fl exible endoscope introduced through this trocar(s) is used for the
appendectomy.
In the second method, opening of the posterior vaginal sac is done with conven-
tional instruments. A Sims speculum is inserted in the vagina, and two lateral retrac-
tors are used to retract the vaginal walls. The posterior fornix is stretched with a
Pozzi clamp grasping the posterior lip of the cervix. A uterine manipulator can be
utilized to assist in the procedure. The vaginal mucosa in the posterior cul-de-sac is
opened at the cervicovaginal junction by a semilunar 2.5-cm incision. With a sharp
dissection performed with scissors, the posterior cul-de-sac peritoneum is identi fi ed
and opened.
Transgastric Approach
Transgastric appendectomy begins with the insertion of a two-channel gastroscope
into the stomach, which is distended with carbon dioxide. Esophageal overtubes
have been used by a few groups to prevent esophageal trauma caused by repeated
passages of the endoscope. A needle-knife is used to incise the gastric wall, choos-
ing a spot in the anterior wall midway between the vascular arcades along the cur-
vatures. The needle-knife is withdrawn, and a guidewire is threaded through the
incision. This hole is then dilated using a balloon dilator, threaded over the guide-
wire (Fig. 14.1 ). The scope is then advanced into the peritoneal cavity along with
the dilator balloon through the gastrotomy [ 14 ] . The alternate way of gastrotomy
with a sphincterotome is less favored as it leaves behind a larger incision in the
stomach wall than the balloon-dilated puncture, which collapses as the uncut mus-
cle contracts after withdrawal of the scope. The “needle-knife/guidewire/balloon”
technique used to introduce the endoscope into the peritoneal cavity is easy, quick,
and reliable [ 18 ] .
188
D.N. Reddy et al.
Procedure
The regular dual-channel gastroscope is used. Alternately, the colonoscope is used
[ 20 ] . The procedure is carried out with standard endoscopic accessories, such as a
grasper, hot biopsy forceps, needle-knife, snare, and endoloop passed through the
accessory channel of the endoscope. Rigid instruments passed through the laparo-
scopic port have been used by different groups for various activities, including visu-
alization, retraction, dissection, ligation, and gastrotomy closure. Two monitors are
usually utilized, one for the laparoscopic view and another for the endoscopic
view.
After passing the endoscope into the peritoneal cavity, it is directed toward the
anterior abdominal wall for orientation. Visualization of the abdominal cavity is
simpli fi ed by tilting the patient into different positions, just as in traditional laparos-
copy. However, tilting the table will result in not only the organs but also the scope
falling to that side by gravity [ 18 ] . Platforms or fl exible overtubes that can be made
rigid in different positions might be helpful [ 29, 30 ] .
The tip of the scope is then positioned in the right lower abdomen and the appen-
dix is located. Even when the transvaginal route is used, this has been accomplished
by most workers without the need for retro fl exion. Endoscopic graspers are used to
Fig. 14.1 Balloon dilation of
anterior gastrotomy
189
14 NOTES: Appendectomy
separate the appendix from adjacent tissues. The appendix is then luxated outward
and moved into an optimal position. A rat-toothed biopsy is used to grasp and lift
the appendix and stretch the mesoappendix. A hot biopsy forceps with monopolar
cautery is used to dissect the mesoappendix from the appendix (Fig. 14.2 ). Cauterized
tissue is cut with the needle-knife. Endoclips can be used to secure the appendicular
artery pedicle. Once the appendix is entirely skeletonized, an endoloop is applied to
the base, and the appendix is divided with an endosnare (Fig. 14.3 ). Because of
concerns of the reliability of endoloops for this purpose, some groups have utilized
laparoscopic loop ligatures to ligate the appendix base [ 20 ] . The endoscopic linear
cutter has also been used to divide the base of the appendix along with the mesoap-
pendix. The transected appendix is then extracted through the natural ori fi ce along
with the endoscope (Fig. 14.4 ). The use of an endoscopic bag in the extraction of the
specimen has been advocated to restrict contamination. Irrigation and suction of the
peritoneal cavity is then performed. A thorough exploration of the abdominal cavity
is performed to look for injuries before withdrawal of the ports.
Fig. 14.2 Division of the
mesoappendix with hot
biopsy forceps
Fig. 14.3 Division of the
appendix after application of
loop at the base
190
D.N. Reddy et al.
Closure
The vaginal incision closure is straightforward and is done externally under direct vision
using conventional instruments and a single layer of absorbable sutures. However, there
are serious concerns related to the closure of the gastric puncture, as anything other than
a 0 % leak rate cannot be acceptable in practice. Because of these concerns, many cen-
ters have adopted a policy of routine laparoscopic closure of the gastric puncture [ 12 ] .
Others have used T-tags, endoclips, g-Prox sutures, and other newly designed endo-
scopic closure devices with and without laparoscopic reinforcements [ 12, 17, 18, 31 ] .
Operative Time
Operative time, as expected, is longer for NOTES appendectomy, at usually more
than 100 min, than conventional appendectomies. The time was longer when the
procedure was performed by the “pure NOTES” technique than the “hybrid” tech-
nique. Also, if the entry and closure time were excluded, the operation was per-
formed faster through the transgastric approach than through the transvaginal
approach [ 32 ] . This has been ascribed to the more direct approach of the scope to
the appendix by the transgastric approach when compared to the transperineal
approach. A learning curve could be demonstrated whereby the operating time
decreased as experience increased [ 32 ] . However, when the closure time was
included, the transvaginal approach was faster than the transgastric approach [ 12 ] .
Postoperative Care
Patients are allowed a liquid diet 12–24 h after surgery. On the fi rst postoperative
day, solid meals are started. Antibiotics have been continued for 2–3 days by most
[ 14 ] . Though the patient has been fi t for discharge earlier, most of the patients have
been kept in the hospital for 3 days as a precautionary measure.
Fig. 14.4 Transoral
extraction of the appendix
191
14 NOTES: Appendectomy
If the transvaginal route has been used, the vaginal dressing is changed on the
fi rst postoperative day. Similar to the wound care after obstetrical gynecological
surgery, antibiotic suppositories are inserted for 1 week. Abstinence from sexual
intercourse is advised for 1 month. Regular follow-up in the fi rst month is advised.
Transgastric Versus Transvaginal Approach
The transgastric approach was the fi rst approach used in NOTES surgery both in the
animal model and in humans [ 9, 14 ] . Also, it gives a more direct approach to the
appendix [ 32 ] . However, more complications have been noted with the transgastric
approach than with the transvaginal approach. Additionally, the issue of lack of reli-
able instruments to achieve a safe closure deters many workers from preferring this
route.
The transvaginal route, though it can be applied to only 50 % of the population,
has become the approach of choice. The closure is simple and the orientation prob-
lem is easily overcome with experience. Unlike the transgastric approach, where a
long length of the scope is used up in transversing the esophagus and stomach and
very little of the scope is available outside to work with, the transvaginal route is
shorter, giving more freedom for manipulation of the scope [ 13 ] . Also, it allows
larger instruments to be introduced, and larger specimens to be extracted, than the
transgastric route. Despite these advantages, the sensitive and private nature of this
approach makes it controversial. Fertility concerns and the risk of dyspareunia are
other apprehensions that need to be addressed.
Complications
Reported complications have been few and of minor consequence. In the series
reported by Rao et al., one patient who underwent a pure NOTES appendectomy
sustained a needle-knife injury to the anterior abdominal wall during transgastric
access. Another patient from the same series experienced postoperative ileus [ 14 ] .
In the series from Palanivelu et al., two patients complained of postoperative vaginal
discomfort on the second postoperative day, probably due to the colpotomy, which
was relieved by oral analgesia. Hemorrhage from the appendicular artery was seen
in one patient, which was controlled endoscopically [ 13 ] . In the series from Park
et al., a T-tag used to close the gastrotomy had anchored the stomach wall to the left
lateral thoracic wall and had penetrated the pleural cavity, resulting in a pneumotho-
rax [
18 ] .
In the IMTN NOTES Study, four patients (three transvaginal and one transgas-
tric) had bleeding of the appendicular vessel intraoperatively, which was managed
with endoscopic or laparoscopic hemostasis. One other patient had abdominal wall
injury during transgastric access that was managed conservatively. Postoperatively,
one patient who underwent transgastric appendectomy had prolonged ileus, which
was managed conservatively [ 12 ] .
192
D.N. Reddy et al.
There was no reported wound complication, pelvic pain, or urinary dif fi culty and
no mortality. None of the groups using the transvaginal approach reported postop-
erative dyspareunia in any of their subjects.
Bene fi ts and Hurdles
Studies comparing laparoscopic with open surgeries have demonstrated lower
pain scores and fewer analgesic needs for laparoscopic surgery. Laparoscopic sur-
gery has also shown to have a lower stress response and less impaired immune
functions when compared with open surgery [ 33 ] . NOTES surgery is likely to
further these advantages by achieving a “scarless” status. Lesser or no pain, no
wound-related complications, including wound infection and hernia, a shorter
convalescence, and better cosmesis are the suggested advantages of a NOTES
procedure.
Postoperative pain is less compared with patients undergoing laparoscopic
appendectomy [ 13 ] . The NOTES IMTN Study has shown the lack of need for
postoperative analgesia in a signi fi cant proportion of patients after NOTES proce-
dures [ 12 ] . Also, a trend toward a lower end tidal CO
2
has been shown in the same
study. Unpublished reports suggest that NOTES appendectomy has been per-
formed with lesser insuf fl ation pressures, 5–6 mmHg CO
2
, than required for con-
ventional laparoscopy, possibly because of less need for exposure and
insuf fl ation.
The physical restraints of operating exclusively through an endoscope with
limited dexterity and rudimentary instrumentation compared with laparoscopy
and traditional minimally invasive techniques remain the main hurdle to the uni-
versal acceptance of NOTES procedures. A limited operating fi eld, lack of trian-
gulation, disorientation, dif fi cult navigation, and accessories with a high elasticity
and low hardness incapable of exerting an adequate force are some of the impedi-
ments that need to be addressed before we see universal acceptance of this tech-
nique [ 10 ] .
Conclusion
NOTES appendectomy is feasible with the available instruments, taking possibly
longer operative times than laparoscopy until new endoscopic technology arises.
Transvaginal and transgastric appendectomies can be performed safely with limited
complications when performed by skilled operators with extensive training in vet-
erinary NOTES surgery. Using a laparoscope for assistance in the initial experience
appears to be a useful adjunct in improving safety. The initial studies have focused
on feasibility and safety. The ultimate aim should be of conducting blinded, ran-
domized controlled trials using comparisons with the current gold standard of open/
laparoscopic appendectomy.
193
14 NOTES: Appendectomy
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