Department of Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka 565-0871, Japan.
Surg Endosc. 2009 Dec;23(12):2650-5. doi: 10.1007/s00464-009-0474-7. Epub 2009 Apr 9.
Transvaginal endoscopic gastric surgery is one of the cutting edge procedures in the field of natural orifice translumenal endoscopic surgery (NOTES). Its feasibility has been shown sporadically in bariatric cases but not in oncologic conditions. The authors report their early experience with hybrid transvaginal NOTES gastrectomy for gastric submucosal tumors (SMTs).
Two female patients with SMTs in the distal stomach participated in this institutional review board (IRB)-approved study. Surgical indication was determined according to the National Comprehensive Cancer Network (NCCN) sarcoma guidelines, and the study adhered to the following oncologic principles: no direct handling of the lesion, full-thickness resection, and reasonable surgical margins. The study protocol required a minimum of two laparoscopic ports to ensure procedural safety and aforementioned oncologic appropriateness. Under laparoscopic guidance, a transvaginal route was created and secured with a 50-cm flexible overtube. A gastrointestinal endoscope was introduced, and the perigastric dissection was performed using an insulation-tipped diathermy knife (IT knife) and needle knife. This process was assisted with two laparoscopic graspers. After perigastric mobilization, the transvaginal endoscope was replaced with a digital stapling device, and partial gastrectomy was accomplished. The resected specimen was isolated and delivered through the vagina, and the vaginal wound was closed under direct vision. Outcomes measurements included surgical results, pain scoring, and clinical outcomes.
Both operations were completed successfully in compliance with the aforementioned oncologic principles. The operating time was 365 and 170 min, respectively. The estimated blood loss was negligible. A minilaparotomy for specimen delivery was successfully avoided in both cases. A minimal vaginal incision was added for one patient at retrieval. Postoperatively, both patients reported no pain and recovered rapidly. The final diagnosis was hemorrhagic lipoma and gastrointestinal stromal tumor (GIST), respectively.
Our initial experience with human transvaginal NOTES gastrectomy showed it to be feasible and safe for gastric SMTs. It is a complex but promising surgical alternative for female oncologic patients undergoing partial gastric resection.
经阴道内镜胃手术是经自然腔道内镜外科（NOTES）领域的前沿手术之一。在减肥病例中，其可行性已零星显示，但在肿瘤病例中尚未显示。作者报告了他们在经阴道 NOTES 胃部分切除术中治疗胃黏膜下肿瘤（SMT）的早期经验。
两名患有远端胃 SMT 的女性患者参与了这项机构审查委员会（IRB）批准的研究。手术适应证根据国家综合癌症网络（NCCN）肉瘤指南确定，研究遵循以下肿瘤学原则：不直接处理病变、全层切除和合理的手术切缘。研究方案要求至少有两个腹腔镜端口，以确保程序安全和上述肿瘤学适宜性。在腹腔镜引导下，创建经阴道入路并用 50cm 柔性外套管固定。引入胃肠内镜，使用隔热电刀（IT 刀）和针刀进行胃周围解剖。这个过程由两个腹腔镜抓钳辅助完成。在胃周围游离后，经阴道内镜更换为数字吻合器，并完成部分胃切除术。切除标本通过阴道隔离和输送，阴道伤口在直视下关闭。结果测量包括手术结果、疼痛评分和临床结果。
两次手术均成功完成，符合上述肿瘤学原则。手术时间分别为 365 分钟和 170 分钟。估计出血量可忽略不计。两种情况下均成功避免了用于标本输送的小开腹手术。一种情况下，为一名患者增加了最小的阴道切口进行取出。术后，两名患者均无疼痛，恢复迅速。最终诊断分别为出血性脂肪瘤和胃肠道间质瘤（GIST）。
我们对经阴道 NOTES 胃切除术的初步经验表明，该术式对胃 SMT 是可行和安全的。对于接受部分胃切除术的女性肿瘤患者，这是一种复杂但有前途的手术替代方法。
