Perioperative management - Hybrid-NOTES - Sigmoid Resection

NOTES ("natural orifice transluminal endoscopic surgery") has the potential to further optimize minimally invasive surgeries.

The majority of NOTES ("natural orifice transluminal endoscopic surgery") procedures are transvaginal procedures.

The transvaginal approach to the abdominal cavity has long been routinely used by gynecological colleagues. Instruments are introduced into the abdominal cavity under vision via colpotomy. Due to the stretchability of the vaginal wall, instruments with a larger diameter can also be introduced, and larger specimens can be retrieved.

True NOTES procedures are considered experimental, while the hybrid procedure presented here, with transvaginal specimen retrieval and intracorporeal anastomosis preparation, has been included in the Sk2 guideline Diverticular Disease/Diverticulitis of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society for General and Visceral Surgery (DGAV).

The intra-abdominal, laparoscopic sigmoid preparation requires additional access through the abdominal wall, which in the example is further minimized using 5mm trocars and a 5mm optic.

Compared to conventional laparoscopic surgery, less pain, fewer wound infections, and hernias are expected. The cosmetic result is better in any case.

In the present case, sigmoid resection in hybrid NOTES technique is indicated by a stenosing sigmoid diverticulitis.

• General contraindications for laparoscopic procedures (e.g., intolerance to pneumoperitoneum, extreme positioning, or presence of ileus).
• Generalized peritonitis
• Previous abdominal surgeries or adhesions are not contraindications for a laparoscopic approach per se, but they may justify conversion to an open procedure.

Emergency Diagnostics

• Clinical examination: A typical nearly pathognomonic symptom constellation for diverticulitis includes age >50, previous episodes, increased pain with movement, localization, and tenderness in the left lower abdomen DD irritable bowel syndrome.
• Laboratory tests (inflammatory markers), follow-up within 48 hours, as inflammatory values in complicated courses rise later.
• Imaging: Imaging techniques (US, CT) are crucial and indispensable for diagnosing diverticular disease. Sonography is equivalent to CT, thus it is the first choice in imaging. In cases of discrepancy or inadequate US representation, CT of the abdomen with rectal contrast application.

Additional Diagnostics for Elective Surgery

• Complete colonoscopy: Not required for diagnosing diverticulitis, but highly recommended before elective sigmoid resection to exclude other relevant findings. Early examination (12-24 hours) in diverticular bleeding for bleeding localization and possible interventional treatment.
• Optional sphincter manometry
• Pneumocolon CT in case of frustrating/impossible colonoscopy

• orthograde bowel lavage
• shaving of the abdominal wall
• marking the optimal location for a potential stoma on the abdominal wall

in the OR:

• insertion of an indwelling catheter
• single-shot antibiotic prophylaxis (e.g., 2nd generation cephalosporin + metronidazole)
• trial positioning after attachment of the supports

• Bleeding/postoperative bleeding with administration of donor blood and possibly surgical revision
• Anastomotic insufficiency with local or generalized peritonitis leading to sepsis, reoperation, discontinuity resection, and creation of a stoma.
• Intra-abdominal abscess formation
• Injury to the left ureter, iliac vessels, spleen, kidney, pancreas
• Specific complications from transvaginal access such as injury to the rectum/bladder/adnexa during insertion of the trocar/retrieval bag or protective sheath
• Primary creation of a protective ileostomy or primary discontinuity resection
• Conversion
• Change in bowel habits
• Trocar hernia
• Risk of injury to the sphincter apparatus by stapler