Transvaginal Assisted Totally Laparoscopic Single-Port Right Colectomy

Introduction

Apparent advantages of laparoscopic surgery have encouraged surgeons to try more sophisticated methods such as natural orifice transluminal surgery (NOTES), which are already attractive scarless surgical methods in the surgical armamentarium.^1,2 Although technological improvement could not sufficiently support the surgeons in NOTES, as it did in laparoscopic procedures, surgeons have tried to improve their surgical skills prior to NOTES. Umbilicus was used as an access for a scarless surgery. ³ First, Remzi et al. ⁴ and Bucher et al. ⁵ published their single-port laparoscopic right colectomy cases with extracorporeal anastomoses for cancer. Meanwhile, Ramos-Valdez et al. have published the single-port right colectomy series. ⁶ Leroy et al. ⁷ published a single-access laparoscopic sigmoidectomy case for a benign disease. Here, we have presented a totally laparoscopic transumbilical single-port (SP) right colectomy, assisted by vaginal access, performed for Crohn's disease (CD). To our knowledge, this is the first case report describing the totally laparoscopic SP right colectomy, assisted by vaginal access.

Patient and Method

A 29-year-old woman was admitted to our clinic, complaining of abdominal pain and distention. She had received medical therapy for CD for 7 years. However, she had three symptomatic intestinal obstruction episodes and was able to manage with liquid diet. We could not cannulate the terminal ileum because of intestinal wall thickening observed on the cecum and the ascending colon. Her biochemical parameters and tumor marker levels were normal. In computed tomography, thickened area on the wall of the terminal ileum and cecum and a few enlarged lymph nodes were observed beneath the wall of the cecum. Her American Society of Anesthesiologists (ASA) score was I and the body mass index was 27.5 kg/m², preoperatively. For the diagnosis and treatment of diseases causing symptomatic obstruction in the terminal ileum, an operation was decided on.

The patient fully consented to the operation and also signed a detailed information consent form. She was aware of being our initial case for this specific procedure. We explained to the patient that, as an initial procedure, this technique would bring her no benefits, but it would relatively reduce the wound size. Further, she was fully aware that we would need to use an additional port or could convert the operation to open surgery in the case of intraoperative difficulties or complications.

The patient was allowed to take a clear-fluid diet without bowel preparation before the surgery. A day prior to the operation, a povidone–iodine suppository was inserted vaginally. After the induction of general anesthesia, a prophylactic antibiotic was given. The patient was positioned in the modified lithotomy, with legs slightly separated from each other with the help of stirrups. The patients' arms were tucked at the side and the shoulders were supported with the help of iron bars, to prevent sliding of the patient's body during positioning. The patient was placed in supine position with the sacrum at the edge of the table and the two legs abducted on the boards were fixed to the operating table. The surgeon and the camera assistant stood on the patient's left side. The second assistant stood between the patient's legs. After preparation of the skin and the vagina with a povidone–iodine solution, the SP (SILS^™ Port 12 mm; Covidien AG) was inserted into the abdomen through the umbilicus. The insufflator was set to a pressure of 12 mm Hg. A 5-mm flexible laparoscope with an integrated camera (EndoEYE LS; Olympus^®), using the HD-TV EXERA 2 System (LTF-VH; Olympus), was utilized, in preference to other equipment to achieve proper visualization. After a laparoscopic exploration, the patient was positioned to a 30-degree Trendelenburg and a 15-degree left lateral tilt position. With the help of this maneuver, the small intestines were placed to the left paracolic space to expose the operative field.

Posterior colpotomy was performed with a 12-mm trocar to prevent the loss of gas from the abdomen, under laparoscopic vision. An articulating endograsper (Roticulator Endo Grasp^™ with Lock; Covidien AG) instrument was inserted through the vaginal port to achieve traction. A medial to lateral (vascular approach) technique was used. While pulling the transverse colon upward by using an atravmatic grasper, the dissection was begun by using ultracision (Harmonic Scalpel Ace^®; Ethicon Endo-Surgery). Peritoneal incision was made below the ileocolic pedicule. After the retroperitoneum was entered, the dissection was continued over Toldt's fascia. The posterior sheath of the right mesocolon was dissected sharply through the anatomic avascular plans to ligate ileocolic vessels safely. The ileocolic vessels were clipped with endo clips (Hem-O-Lok; Weck Closure Systems). The terminal ileum was also mobilized in all patients from the lateral and caudal peritoneal attachments. The right colonic flexure was freed downwards. As the medial dissection was finished, the right colon was fully mobilized after separating lateral peritoneal attachments.

The transverse colon and the ileum (7 cm proximal to the ileocecal valve) were prepared for division. The terminal parts of the colon and the ileum had been checked for viability before an endoscopic linear stapler (Echelon™ 60 ENDOPATH^®; Ethicon Endo-Surgery) was used for division. The 12-mm port in the vagina was exchanged with a 15-mm port. The specimen was put into an Endobag (Endocatch II ENDO CATCH™ II 15 mm; Covidien), which was inserted through the vaginal port to prevent possible contamination. The Endobag remained within the abdomen until the intracorporeal anastomosis was finished. Ileocolic anastomosis was performed in an isoperistaltic fashion. First, the ileum and the colon were sutured together with 2/0 silk stitches by using a needle holder. This stitch was used for the traction of the bowel segments laterally to do a safe anastomosis. The stitch was tied and cut in a distance of 5 cm. The traction was performed with the help of the endograsper, which was inserted through the vaginal port. Small full-layered incisions were created on both the colon and ileum for the insertion of the endoscopic linear stapler jaws. The endoscopic linear stapler was used to perform a side-to-side ileocolic anastomosis. The intestinal opening was closed by using continuous 2/0 polyglactic acid sutures with the help of the needle holder intracorporeally. A 3-cm-long transvaginal colpotomy was performed under laparoscopic visualization. After the specimen had been extracted, the vagina was irrigated with a povidone–iodine solution. The colpotomy was closed using a continuous 2/0 polyglactic acid suture. The colpotomy incision was inspected by laparoscopy for bleeding and the possibility of any injury during the closure. No drain was used. The umbilical incision was closed with absorbable sutures. A povidone–iodine-soaked vaginal pack was placed into the vagina for 12 hours. The naso-gastric tube was removed at the end of the operation. The summary of the surgery could be watched in the video. The operation time was 140 minutes. The blood loss was 20 mL. The patient was allowed to drink fluids and a soft oral diet on the first day postoperatively. Neither intraoperative nor postoperative complications were observed. The patient was discharged on postoperative day 4. The wound size was 2.5 cm. The umbilical scar was almost invisible on postoperative day 7.

Discussion

Although laparoscopic colectomy is a minimally invasive procedure, it has a few disadvantages, including multiple small incisions for port access and a minilaparotomy for extracting the specimen. The minilaparotomy incision is smaller (usually 4–7 cm) than it would be in open surgery, but the size of the specimen sometimes requires a longer incision. All of these increase complications such as pain, infection, hematoma, and incisional hernia. Additionally, cosmetic appearence after laparoscopic surgery is better than in open surgery, but it is not perfect.

SP laparoscopic surgery is one of the newest branches of advanced laparoscopy, which would make up for the limitations of traditional laparoscopic surgery, by reducing the number of trocars and the length of the incision required for specimen extraction.

Complex colorectal resections have been performed with SP laparoscopic surgery.^4–10 But there are some limitations in SP right colectomy, such as limitations of movement due to the clashing of instruments, the difficulty to perform anastomosis, and awkward ergonomics for surgeons. Transvaginal minilaparoscopic assisted NOTES is a new development in minimally invasive surgery. ¹¹ We had the aim of describing an innovative technique for SP right colectomy, assisted by vaginal access.

Vaginal access provides many advantages: first, vaginal access allows retraction, manipulating, clipping, stapling, and sutures. Effective traction is one of the most important factors during laparoscopic SP right colectomy, as otherwise it can become harder to reach the area of the surgery, to make manipulations and to visualize. The manipulation of the colon and other structures are very easy via vaginal access. Intracorporeal anastomosis in SP laparoscopic right colectomy requires more advanced laparoscopic skills. There is only one access and the use of the instruments may complicate the continuing of the operation. For these kinds of difficult surgical interventions, surgeons have developed some techniques, which make the operation safe and easy. In this case, the authors used vaginal access for totally laparoscopic right colectomy. Intracorporeal anastomosis can be performed safely, assisted by vaginal access. We think that performing intracorporeal anastomosis is less difficult with SP surgery, assisted by vaginal access, compared with conventional laparoscopic surgery.

Second, the vaginal route offers an alternative for specimen extraction. ¹² Vaginal access is not a new method in gynecological surgery,^13,14 but most surgeons are not familiar with surgical access via the vaginal route. Transvaginal extraction of the specimen after total laparoscopic right colectomy has been previously described, but the vaginal route was only used for specimen extraction. ¹⁵ Vaginal extraction elimimates the need to enlarge the abdominal incision to extract the specimen. ¹⁶ It is very important in patients who have large phlegmonose disease and those who are obese. It potentially decreases pain and wound problems such as infections, hematomas, or hernias.

Third, this method offers excellent cosmetic body image. It may be especially important for a young woman suffering from a benign disease such as CD. The patient feels less traumatized and feels as if she/he is not ill because they do not have any scars on their abdomen. Because of this, the patient feels better about the procedure from the first moment.

Finally, vaginal access has a positive effect on the operation time in SP colectomy. One of the limitations of SP colectomy is the longer operation time. Current surgical devices of SP surgery and the experience of laparoscopic surgeons are not sufficient to perform these procedures as fast as the conventional laparoscopic colectomy. We believe that vaginal access has shortened the operation time.

There are two major limitations of SP colectomy. One of them is the incisional hernia risk. However, there has been no published data regarding increased incisional hernia risk in transumbilical SP laparoscopic surgery. The second limitation is the risk of complication due to vaginal access. However, vaginal access is a safe procedure for benign and malign disease.^12,14,17,18 The major complications in this procedure are dyspareunia, infection, bleeding, trauma to pelvic structures, and risk of pelvic adhesion. ¹² A review of the literature showed that the risk of infections and noninfectious complications following colpotomy for the removal of the specimen is extremely low. ¹²

Conclusion

Transvaginal assisted totally laparoscopic transumbilical SP right colectomy is a feasible technique for the surgical treatment of ileocecal CD. It has advantages such as scarless surgery, shorter hospitalization, protecting the body image, and better postoperative recovery period. Using vaginal access to perform SP right colectomy has allowed specimen extraction and also it has been used as an additional port, which may help the manipulation of structures in the operative field. Transvaginal access might improve the comfort of the surgical team. We believe that this technique allows extension of SP laparoscopic right colectomy.