Surgical Endoscopy

, Volume 25, Issue 9, pp 3034–3042 | Cite as

Transvaginal rigid-hybrid natural orifice transluminal endoscopic surgery technique for anterior resection treatment of diverticulitis: a feasibility study

  • Ignazio TarantinoEmail author
  • Georg R. Linke
  • Jochen Lange
  • Ikbale Siercks
  • René Warschkow
  • Andreas Zerz



In laparoscopic anterior resection, minilaparotomy still is required. Recently, transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques for cholecystectomy have been described. Reports on operations that require removal of larger specimens, as in anterior resection, are scarce and limited primarily to small case series and case reports. The current study aimed to evaluate the feasibility and safety of transvaginal rigid-hybrid NOTES anterior resection (tvAR) for symptomatic diverticular disease.


All female patients presenting with symptomatic diverticulitis of the sigmoid colon were candidates for inclusion in the study. The exclusion criteria specified failure to sign informed consent, previous colorectal resection, anesthesiologic contraindication for pneumoperitoneum, liver failure and coagulopathy, severe acute diverticular bleeding, internal fistula with abscess (Hinchey 2b), perforated diverticulitis with peritonitis (Hinchey 3 or 4), gynecologic or urologic contraindications, and absence of preoperative gynecologic examination. A preoperative and 2-week postoperative gynecologic examination was performed. Quality of life and sexual function were assessed preoperatively and 6 weeks postoperatively.


Of 70 patients, 45 (64.3%) were scheduled for tvAR. Five patients were withdrawn at the beginning of laparoscopy with no transvaginal access performed. Of the remaining 40 patients with attempted tvAR, 4 patients underwent conversion to a minilaparotomy (Pfannenstiel incision) and 2 patients were converted to a total median laparotomy. For 34 patients (85%), the operation was completed transvaginally. A total of 2 major complications and 10 minor complications occurred. No serious postoperative gynecologic morbidity was experienced. At 6 weeks postoperatively, sexual function did not differ significantly from preoperative status.


For symptomatic diverticular disease, TvAR is feasible, although the presented technique requires laparoscopic expertise and further refinement.


Anterior resection Diverticulitis Hybrid NOTES 



The authors thank Armin Schlegel, Spital Rorschach, Rorschach, Switzerland, for his support in the daily operative routine.


Ignazio Tarantino, Georg R. Linke, Jochen Lange, Ikbale Siercks, René Warschkow, and Andreas Zerz have no conflicts of interest or financial ties to disclose.


  1. 1.
    Giday SA, Kantsevoy SV, Kalloo AN (2006) Principle and history of natural orifice translumenal endoscopic surgery (NOTES). Minim Invasive Ther Allied Technol 15:373–377PubMedCrossRefGoogle Scholar
  2. 2.
    Rattner D, Kalloo A (2006) ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005. Surg Endosc 20:329–333PubMedCrossRefGoogle Scholar
  3. 3.
    Zornig C, Emmermann A, von Waldenfels HA, Mofid H (2007) Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach. Endoscopy 39:913–915PubMedCrossRefGoogle Scholar
  4. 4.
    Zornig C, Mofid H, Siemssen L, Emmermann A, Alm M, von Waldenfels HA, Felixmuller C (2009) Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases with midterm follow-up. Endoscopy 41:391–394PubMedCrossRefGoogle Scholar
  5. 5.
    Ramos AC, Murakami A, Galvao Neto M, Galvao MS, Silva AC, Canseco EG, Moyses Y (2008) NOTES transvaginal video-assisted cholecystectomy: first series. Endoscopy 40:572–575PubMedCrossRefGoogle Scholar
  6. 6.
    Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007) Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 66:1243–1245PubMedCrossRefGoogle Scholar
  7. 7.
    Decarli LA, Zorron R, Branco A, Lima FC, Tang M, Pioneer SR, Sanseverino JI, Menguer R, Bigolin AV, Gagner M (2009) New hybrid approach for NOTES transvaginal cholecystectomy: preliminary clinical experience. Surg Innov 16:181–186PubMedCrossRefGoogle Scholar
  8. 8.
    Decarli L, Zorron R, Branco A, Lima FC, Tang M, Pioneer SR, Zanin I Jr, Schulte AA, Bigolin AV, Gagner M (2008) Natural orifice translumenal endoscopic surgery (NOTES) transvaginal cholecystectomy in a morbidly obese patient. Obes Surg 18:886–889PubMedCrossRefGoogle Scholar
  9. 9.
    Noguera J, Dolz C, Cuadrado A, Olea J, Vilella A, Morales R (2009) Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series. Surg Endosc 23:876–881PubMedCrossRefGoogle Scholar
  10. 10.
    Pugliese R, Forgione A, Sansonna F, Ferrari GC, Di Lernia S, Magistro C (2009) Hybrid NOTES transvaginal cholecystectomy: operative and long-term results after 18 cases. Langenbecks Arch Surg 395:241–245PubMedCrossRefGoogle Scholar
  11. 11.
    Ghezzi F, Raio L, Mueller MD, Gyr T, Buttarelli M, Franchi M (2002) Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc 16:1691–1696PubMedCrossRefGoogle Scholar
  12. 12.
    Ebert AD, Burkhardt T, Parlayan S, Riediger H, Papadopoulos T (2009) Transvaginal-laparoscopic anterior rectum resection in a hysterectomized woman with deep-infiltrating endometriosis: description of a gynecologic natural orifice transendoluminal surgery approach. J Minim Invasive Gynecol 16:231–235PubMedCrossRefGoogle Scholar
  13. 13.
    Ghezzi F, Cromi A, Ciravolo G, Rampinelli F, Braga M, Boni L (2008) A new laparoscopic-transvaginal technique for rectosigmoid resection in patients with endometriosis. Fertil Steril 90:1964–1968PubMedCrossRefGoogle Scholar
  14. 14.
    Breitenstein S, Dedes KJ, Bramkamp M, Hess T, Decurtins M, Clavien PA (2006) Synchronous laparoscopic sigmoid resection and hysterectomy with transvaginal specimen removal. J Laparoendosc Adv Surg Tech A 16:286–289PubMedCrossRefGoogle Scholar
  15. 15.
    Abrao MS, Sagae UE, Gonzales M, Podgaec S, Dias JA Jr (2005) Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy. Int J Gynaecol Obstet 91:27–31PubMedCrossRefGoogle Scholar
  16. 16.
    Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22:1717–1723PubMedCrossRefGoogle Scholar
  17. 17.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6.336 patients and results of a survey. Ann Surg 240:205–213PubMedCrossRefGoogle Scholar
  18. 18.
    Eypasch E, Wood-Dauphinee S, Williams JI, Ure B, Neugebauer E, Troidl H (1993) The Gastrointestinal Quality of Life Index: a clinical index for measuring patient status in gastroenterologic surgery. Chirurg 64:264–274PubMedGoogle Scholar
  19. 19.
    Shafik A, Mostafa RM, Shafik AA (2002) Electrophysiological study of the rectosigmoid canal: evidence of a rectosigmoid sphincter. J Anat 200:517–521PubMedCrossRefGoogle Scholar
  20. 20.
    Guller U, Jain N, Hervey S, Purves H, Pietrobon R (2003) Laparoscopic vs open colectomy: outcomes comparison based on large nationwide databases. Arch Surg 138:1179–1186PubMedCrossRefGoogle Scholar
  21. 21.
    Guller U, Rosella L, Karanicolas PJ, Adamina M, Hahnloser D (2010) Population-based trend analysis of 2,813 patients undergoing laparoscopic sigmoid resection. Br J Surg 97:79–85PubMedCrossRefGoogle Scholar
  22. 22.
    Klarenbeek BR, Veenhof AA, Bergamaschi R, van der Peet DL, van den Broek WT, de Lange ES, Bemelman WA, Heres P, Lacy AM, Engel AF, Cuesta MA (2009) Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 249:39–44PubMedCrossRefGoogle Scholar
  23. 23.
    Martel G, Boushey RP (2006) Laparoscopic colon surgery: past, present, and future. Surg Clin N Am 86:867–897PubMedCrossRefGoogle Scholar
  24. 24.
    Nelson H, Sargent DJ, Wieand H (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059CrossRefGoogle Scholar
  25. 25.
    Winslow ER, Fleshman JW, Birnbaum EH, Brunt LM (2002) Wound complications of laparoscopic vs open colectomy. Surg Endosc 16:1420–1425PubMedCrossRefGoogle Scholar
  26. 26.
    Boni L, Benevento A, Rovera F, Dionigi G, Di Giuseppe M, Bertoglio C, Dionigi R (2006) Infective complications in laparoscopic surgery. Surg Infect (Larchmt) 7(Suppl 2):S109–S111Google Scholar
  27. 27.
    McGee MF, Rosen MJ, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J (2006) A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Innov 13:86–93PubMedCrossRefGoogle Scholar
  28. 28.
    Grande M, Tucci GF, Adorisio O, Barini A, Rulli F, Neri A, Franchi F, Farinon AM (2002) Systemic acute-phase response after laparoscopic and open cholecystectomy. Surg Endosc 16:313–316PubMedCrossRefGoogle Scholar
  29. 29.
    Karayiannakis AJ, Makri GG, Mantzioka A, Karousos D, Karatzas G (1997) Systemic stress response after laparoscopic or open cholecystectomy: a randomized trial. Br J Surg 84:467–471PubMedCrossRefGoogle Scholar
  30. 30.
    Burpee SE, Kurian M, Murakame Y, Benevides S, Gagner M (2002) The metabolic and immune response to laparoscopic versus open liver resection. Surg Endosc 16:899–904PubMedCrossRefGoogle Scholar
  31. 31.
    Holmdahl L, Eriksson E, Eriksson BI, Risberg B (1998) Depression of peritoneal fibrinolysis during operation is a local response to trauma. Surgery 123:539–544PubMedCrossRefGoogle Scholar
  32. 32.
    Swank DJ, Van Erp WF, Repelaer Van Driel OJ, Hop WC, Bonjer HJ, Jeekel H (2003) A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain. Surg Laparosc Endosc Percutan Tech 13:88–94PubMedCrossRefGoogle Scholar
  33. 33.
    Milingos S, Kallipolitis G, Loutradis D, Liapi A, Mavrommatis K, Drakakis P, Tourikis J, Creatsas G, Michalas S (2000) Adhesions: laparoscopic surgery versus laparotomy. Ann N Y Acad Sci 900:272–285PubMedCrossRefGoogle Scholar
  34. 34.
    Redwine DB, Koning M, Sharpe DR (1996) Laparoscopically assisted transvaginal segmental resection of the rectosigmoid colon for endometriosis. Fertil Steril 65:193–197PubMedGoogle Scholar
  35. 35.
    Zornig C, Emmermann A, von Waldenfels HA, Felixmuller C (1994) Colpotomy for specimen removal in laparoscopic surgery. Chirurg 65:883–885PubMedGoogle Scholar
  36. 36.
    Linke GR, Tarantino I, Hoetzel R, Warschkow R, Lange J, Lachat R, Zerz A (2010) Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation in routine clinical practice. Endoscopy 42:571–575PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Ignazio Tarantino
    • 1
    Email author
  • Georg R. Linke
    • 2
  • Jochen Lange
    • 1
  • Ikbale Siercks
    • 3
  • René Warschkow
    • 1
  • Andreas Zerz
    • 4
  1. 1.Department of SurgeryKantonsspital St. GallenSt. GallenSwitzerland
  2. 2.Department of General, Abdominal and Transplant SurgeryUniversity of HeidelbergHeidelbergGermany
  3. 3.Department of GynaecologyKantonsspital St. GallenSt. GallenSwitzerland
  4. 4.Department of SurgeryKantonsspital BruderholzBruderholzSwitzerland

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