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

Intubation anesthesia for pneumoperitoneum placement epidural catheter for postoperative pain therapy

• Lithotomy position
• Adduction of both arms
• Adequate padding of the knees and proximal lower legs
• Fixation of the legs in the leg holders
• Legs adjustable via the operating table control
• Shoulder supports on both sides
• Trial positioning

Abdominal part:

• Surgeon and assistant stand to the right of the patient
• Surgeon stands at the headward right of the assistant
• Instrumental surgical nurse at the right foot side
• MIC tower on the patient's left side.

Transvaginal part:

• Surgeon sits between the legs
• Assistant stands headward right

ERGO 310D- the BOWA sealing instrument in combination with the HF generator ARC400.

Basic Instruments for Laparoscopy:

• 11 scalpel
• Dissection scissors
• Suction system
• Needle holder
• Suture scissors
• Forceps
• Gas system for pneumoperitoneum
• Compresses
• Compresses, abdominal towels
• Swabs
• Purse-string suture (0-0, monofilament, non-absorbable)
• Suture for colpotomy closure (0-0, braided, absorbable)
• Absorbable monofilament skin suture (3-0)

Trocars:

• 1 optical trocar (5mm)
• 3 working trocars (5mm)
• Transvaginal trocar (13mm)
• Camera system (5mm) with 30-degree optics

Additional Instruments for Sigmoid Resection:

• 2 atraumatic holding instruments
• Bipolar scissors
• BOWA sealing instrument
• Suction-irrigation system
• Linear articulating stapler
• Transluminal circular stapler
• Clip applier with vessel clips
• 27 silicone drainage with suture and drainage bag
• 19 Blake drainage
• Vaginal specula
• Transvaginal protective sheet with introduction instruments for specimen retrieval
• Purse-string suture (0-0, monofilament, non-absorbable)
• Suture for colpotomy closure (0-0, braided, absorbable)

Postoperative Analgesia

• Continue epidural anesthesia postoperatively for 2 – 5 days

Follow the link here to PROSPECT (Procedure specific postoperative pain management) or to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up Treatment

• Remove urinary catheter preferably on the day of surgery
• If inserted, remove abdominal drainage between the 2nd and 3rd postoperative day
• If non-absorbable, remove skin suture material around the 12th postoperative day

Thrombosis Prophylaxis

In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30 minutes duration), in addition to physical measures, low molecular weight heparin should be administered in prophylactic, possibly weight- or disposition risk-adapted dosage until full mobilization is achieved. Note: Renal function, HIT II (history, platelet control).

Follow the link here to the current Guidelines for Thromboembolism Prophylaxis

Mobilization

• Immediate mobilization
• Gradual resumption of physical activity until full load

Physiotherapy

• Breathing exercises for pneumonia prophylaxis

Dietary Progression

• Drinking on the day of surgery
• On the 1st postoperative day, tea, soup, yogurt
• From the 2nd postoperative day, light diet

Bowel Regulation

• Laxatives from the 2nd postoperative day
• In case of intestinal paralysis, 3×0.5 mg Neostigmine as a short infusion

Discharge

• Possible from the 4th postoperative day

Incapacity for Work

• Individually, depending on the profession, between 3 and 6 weeks