Contemporary Surgery

Culdoscopy via MANOS
as a prelude to NOTES?

Director, Minimally Invasive Surgery, The Mount Sinai Hospital of Queens, Long Island City, NY

  THE PROBLEM

Natural orifice transluminal endoscopic surgery—more commonly known as NOTES¹—could well become the next advance in minimally invasive surgery for some intraperitoneal general surgical, gynecological, and urological procedures. These operations include cholecystectomy, appendectomy, myomectomy, nephrectomy, splenectomy, sigmoidectomy, and oophorectomy.

Advances in NOTES have been associated with innovations in flexible technology, radio-controlled robotics, and magnetic platforms, among others. However, recommendations and training guidelines are still being developed for NOTES. The technology is expensive and not widely available.

  THE SOLUTION

Until proper technology and guidelines become available and affordable for revolutionary procedures such as NOTES, experienced laparoscopists can do procedures with mini-laparoscopy-assisted natural orifice surgery, or MANOS. One such operation is culdolaparoscopy.

The revival of transvaginal endoscopy happened partly due to the technological advances and the experience with transvaginal hydrolaparoscopy and culdolaparoscopy around 1998.² Culdolaparoscopy combines operative culdoscopy with MANOS.³ We have successfully performed this operation in 100 patients with minimal complications.⁴

Patient selection and preparation

Patient selection for MANOS is the same as laparoscopy. The patient’s anatomy must provide easy access to the posterior vaginal fornix with no obliteration of the posterior cul-de-sac.

The patient receives prophylactic antibiotics and a bowel preparation. The operating room setup includes a table with a large perineal cut and two mobile monitors for the surgeon and the assistant.

The surgeon should move from a lateral position to operate between the patient’s legs. The patient is placed in a modified dorsolitotomy position and in Allen telescopic stirrups. The vagina is cleansed with antiseptic, and a Foley catheter and a uterine manipulator are placed inside the bladder and the uterus.

Operative steps

We use laparoscopy instruments no larger than 5 mm in diameter, preferably 3 mm. We use a 10-mm × 46-cm plastic rod (Port-Saver, ConMed, Utica, NY) mounted in a 12-mm × 15-cm insufflation cannula as the vaginal port (FIGURE 1). We place the vaginal port under laparoscopic or minilaparoscopic surveillance.

We push the uterus with the uterine manipulator anteriorly and cephalad to expose the pouch of Douglas. With the rod placed against the posterior vaginal fornix, its end can be seen protruding in the center of the cul-de-sac (FIGURE 2).

We make our incision at the tip of the protrusion with a minilaparoscopic spatula or hook. With gentle yet steady pressure, we then introduce the rod into the pouch of Douglas, and slide the cannula over the rod. When in place, the vaginal port fits tight and is well sealed.

Multifunctional vaginal port

The vaginal port is used for insufflation, visualization, operation, and extraction. The vaginal port can also be used to place 10-mm laparoscopes or gastroscopes as well as magnets or larger and longer instruments: clip appliers, endoscopic gastrointestinal anastomosis clamps, morcelators, large bipolar clamps, or irrigators.

The port also allows for extraction of large specimens because the elasticity of the vagina stretches in most cases to up to 8 cm. We perform closure of the colpotomy vaginally using chromic sutures.

Our limited laboratory experiences, which combined gastroscopy with laparoscopy and minilaparoscopy, suggest the same concept could be used to assist in flexible transgastric peritoneoscopy.⁵ The advantages of this synergistic effect have been used successfully in humans for other surgical indications.⁶

Disclosure

The author had no affiliations to disclose.

References

1. Kalloo  AN, Singh  VK, Jagannath  SB , et al.  Flexible transgastric peritoneoscopy: A novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastorintest Endosc. 2004;60:114–116.
2. Gordts  S, Campo  R, Rombatous  L, Bronsen  I. Transvaginal salpingoscopy: An office procedure for infertility investigation.  Fetil Steril. 1998;70:523–526.
3. Tsin  DA. Culdolaparoscopy a preliminary report.  JSLS. 2001;5:69–71.
4. Tsin  DA, Colombero  L, Mahmood  D, Padouvas  J, Manolas  P. Operative culdolaparoscopy: A novel approach combining operative culdoscopy and minilaparoscopy.  J Am Assoc Gyn Laparoscopist. 2001;8:438–441.
5. Tsin  DA, Colombero  L, Lambeck  J, Manolas  P. Minilaparoscopy assisted natural orifice surgery.  JSLS. 2007;11:24–29.
6. Franklin  ME, Megchun  A, Madrigal  SA, Trevino  JM, Arellano  PP. Intraluminal approach for resection of a gastric ulcer: a case report.  JSLS. 2006;10:364–367.