Totally laparoscopic gastrectomy with natural orifice (vagina) specimen extraction in gastric cancer: Introduction of a new technique.

Radical excision by surgery is the main treatment method for gastric cancer and as the surgery develops, the laparoscopic treatment effect on gastric cancer is gradually being verified. The totally laparoscopic gastrectomy (TLG) with natural orifice specimen extraction surgery (NOSES) for gastric cancer has attracted people's attention by avoiding abdominal incision and further reducing surgical injury and provides ideas for the further development of minimally invasive surgical treatment on the basis of laparoscopy. Surgical technique of TLG with natural orifice (vagina) specimen extraction is detailed in the text. We have employed NOSES in 4 cases of TLG in the past year. The visual analogue scale score was low, and all patients had no complications during and after the operation. No recurrence or metastasis was found in the short-term follow-up. TLG with NOSES is feasible and has many advantages such as aesthetics, light post-operative pain.

INTRODUCTION

NOSES was first named by Palanivelu et al. in 2008.[1] It refers to the surgery without auxiliary incision which use laparoscopic, Da Vinci robots or soft endoscopy to complete various conventional abdominal pelvic surgery operation (resection and reconstruction) and extract specimens through the body's natural orifices (rectum or vagina mouth). It avoided the additional incision, which provides a new direction for minimally invasive treatment of gastric cancer. This operative technique adopted by us is described below.

METHODS

Standard Radical Gastrectomy

Operating procedures for gastric cancer were classified into open gastrectomy (OG) and laparoscopic gastrectomy (LG). Conventional OG was the first choice for patients undergoing gastric surgery. But now, several large-scale studies have confirmed that LG has comparable survival outcomes with OG, and it has some advantages include shorter wound length, shorter hospitalisation duration, decreased complication rates and faster recovery.[2]

The 2 versions of LG include laparoscopic-assisted gastrectomy (LAG) and TLG. Specimen extraction and digestive reconstruction with LAG are similar to OG while gastrectomy and D2 lymph node dissection are completed laparoscopically. In contrast, anastomosis with LTG is performed intracorporeal, but it still needs an incision for removal the post-operative specimens.

Both OG and LG require the incision in the abdomen for removal the post-operative specimens, which greatly compromises the advantages of minimally invasive laparoscopic surgery.

Modification to the Standard Technique

Only the procedure of specimen extraction of NOSES radical gastrectomy is different compared with TLG. Based on the pre-operative staging of tumour, gastrectomy and D2 lymph node dissection were completed based on Chinese guidelines for diagnosis and treatment of gastric cancer (2018).[3] The different steps may be cited in the following:

All of the patients were parous with no gynaecological problems such as vaginal stenosis or vaginal malformations. Diagnosis of gastric cancer and a depth of invasion of gastric cancer ≤T3 were confirmed by gastroscopy and computed tomography (CT). The cardiopulmonary function was checked before surgery to eliminate contraindications. Informed consent was obtained from all patients and their family members prior to the start of the surgery.

Before removing the specimen, a tension suture line was applied to suspend the vagina. In this way, a better operative view can be obtained without any additional operating holes.

A specimen bag was placed through the 12 mm Trocar at 1 cm below the umbilicus, and the surgical specimens were placed in specimen bags in the original position.

The vagina was sterilise with povidone-iodine cotton balls, then a 2–3 cm incision was made transversely along the posterior fornix under the guidance of sponge forceps inserted into the vaginal. At this point, the vaginal orifice was blocked by an inflated sterile glove to avoid air leakage.

After the specimen, bag was removed by the sponge forceps, the incision at posterior fornix was sutured using a 3/0 self-locking barbed suture (Stratafix™ 3-0; Ethicon). The completed specimen extraction is exhibited in Figure 1. The appearance of abdominal after surgery is revealed in Figure 2. The process of specimen extraction was shown in video 1.

Figure 1

Procedures of specimen extraction. (a) Hung up the uterus; (b) Open the posterior fornix; (c) Take out the specimen by sponge forceps; (d) Suture the incision at posterior fornix by barb thread

Figure 2

The appearance of the abdomen. (a) Appearance of abdominal after surgery; (b) Appearance of abdominal 3 months after surgery

RESULTS

The NOSES technique was used in 4 cases of TLG during the past year in our department. The clinical features are shown in Table 1. All patients successfully went through the radical operation of gastric cancer under total laparoscopy, and the specimens were taken out through the vagina. Classified by tumour staging, there were 1 stage III B and 1 stage IB and 2 stage II A cases, according to the 8th edition of the AJCC. The patients had a median pain score of 2 (out of 10) on the day of the operation, and a score of 1 on the 1st post-operative day. All had no significant pain after the 2nd post-operative day. According to short-term follow-up (1–10 months), no relapse and metastasis was discovered. CT re-examination showed that the posterior fornix of the vagina healed well [Figure 3]. The post-operative data are shown in Table 2.

Table 1

Clinical features of 4 patients

Patient	1	2	3	4
Age (years)/sex	60/female	57/female	61/female	52/female
BMI (kg/m2)	26.5	19.4	25.0	19.0
Symptom	Abdominal pain	Nausea	Midsection discomfort	Abdominal pain
Occupation	Antrum greater curvature side Anterior wall side	Angle of stomach	Fundus of stomach	Antrum lesser curvature side Anterior wall side
Size (cm)	3	4	3	3
Pre-operative staging	cT3N0M0	cT3N1M0	cT2N0M0	cT2N0M0

BMI: Body mass index

Figure 3

The results of posterior wall computed tomography re-examination on the 6 months after surgery

Table 2

Post-operative data of 4 patients

Patient	1	2	3	4
Surgical method	LTG + D2	LSG + D2	LSG + D2	LTG + D2
Reconstruction	Roux-en-Y	Billroth II	Billroth II	Roux-en-Y
Number of lymph nodes	28	43	27	38
Operating time (min)	300.0	120.0	180.0	160.0
Blood loss (ml)	100.0	200.0	50.0	50.0
Post-operative feeding time (day)	3	2	3	3
Pathological stage	pT3N0M0	pT4aN3M0	pT2N1M0	pT2N0M0
Hospital stay after surgery (day)	15	7	7	8

LTG: Laparoscopic total gastrectomy, LSG: Laparoscopic subtotal gastrectomy

BENEFITS

In our study, all the patients achieved R0 resection. Moreover, the mean number of retrieved lymph nodes meets the needs of judging tumour node metastasis stage while in terms of oncology. CT re-examination showed that the posterior fornix of the vagina healed well, and no implantation metastasis occurred in those cases. Combined with the current reports[45] and our experience, TLG with NOSES has similar effect of surgical resection as the LG. It avoids abdominal incision which brings the most direct advantage of aesthetics and alleviate post-operative pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.