Transvaginal Extraction: Feasible

Howard Ross, MD, FACS, FASCRSChief, Colon and Rectal Surgery

Riverview Medical CenterClinical Associate Professor of Surgery UMDNJ

Disclosures• Consultant

and Course Director:– Applied

Medical– Covidien

• Woke at 4 am to watch royal wedding

Natural Orifice Surgery

50% of Population Have a Vagina

Transvaginal Extraction

Transvaginal Extraction

Published Results• Studies Small• Selected patients• As of February 2011:

– 23 articles– 130 patients

• Complications Related to Transvaginal Extraction– Rectovaginal fistula– Pelvic Seroma

Diana M, Perretta S, Wall J, Costantino FA, Leroy J, Demartines N, MarescauxJ. Colorectal Dis. 2011 Jun;13(6):e104-11.

An Innovative Technique for ColorectalSpecimen Retrieval: A New Era

of “Natural Orifice Specimen Extraction”(N.O.S.E)

• Laparoscopic restorative proctocolectomy • 7 patients 2004-2007• Familial adenomatous polyposis with cancer• Posterior vaginal vault was opened with an

ultracision shears, endobag placed in the vagina– All vaginal wounds healed– No vaginal metastasis– 1 DVT, 1 anastamotic leak

Palanivelu C, Rangarajan M, Jategaonkar PA, Anand NV. Dis Colon Rectum. 2008 Jul;51(7):1120-4. Epub 2008 May 15.

Transvaginal Extraction of the Specimen After TotalLaparoscopic Right Hemicolectomy With

Intracorporeal Anastomosis

• First US report• 88 yr old woman, 4 cm cecal cancer• 3-cm transvaginal posterior colpotomy• No complications

Franklin ME Jr, Kelley H, Kelley M, Brestan L, Portillo G, Torres J Surg Laparosc Endosc PercutanTech. 2008 Jun;18(3):294-8.

Case ReportsLead Author

Country Op Type Disease n Complication Year

Dozois USA JPouch Vag hys

FAP 1 None 2008

Garcia Florez

Spain LAR RSO(Alexis ring)

Colon Ca 1 None 2010

McKenzie (Pigazzi)

USA R Colectomy

2 Cancer2 polyp

4 None (sbo unrelated)

2010

Park S Korea R colectomy

Colon Ca 14 2 aborted extractions d/t colpotomy issues

2010

Case Controlled StudyLaparoscopic Right Colectomy

vs. Laparoscopic R Colectomy with natural orifice

specimen extraction (NOSE)

• 34 Patients Each Group• NOSE patients less pain POD 1 and POD 3 (0.01)

– Visual analogue and blinded observer• Improved Cosmesis• No morbidity difference

J. S. Park, G.-S. Choi, H. J. Kim, S. Y. Park and S. H. JunBritish Journal of Surgery 2011; 98: 710–715

Trans-Vaginal Extraction

For Discussion

• Patient Selection• Process to begin

– IRB, Ethics• Who should try?