Transvaginal Appendectomy

Acute appendicitis is the most common acute surgical condition of the abdomen, with an overall incidence of approximately 7% and an overall mortality of 0.2-0.8%. ^[1]

From the initial technique of open appendectomy pioneered by McBurney in the 19th century ^[2] to the first laparoscopic appendectomy performed by Kurt Semm in 1980 ^[3] to the first natural orifice transluminal endoscopic surgery (NOTES; transgastric) appendectomy performed by Rao and Reddy in 2004 ^[4] to the first transvaginal appendectomy performed by Bernhardt in 2007, ^[5] the treatment of acute appendicitis has come a long way.

The transition from open to laparoscopic surgery has been associated with a marked reduction in the degree of invasiveness, and NOTES surgery represents the next step in the evolution of surgery. ^{[6, 7, 8]}

The treatment of choice for acute appendicitis is appendectomy; however, there are several techniques by which this can be performed, such as the following:

• Open appendectomy
• Laparoscopic appendectomy
• Transgastric or transvaginal appendectomy, which may involve either a pure NOTES or a hybrid NOTES approach (combined laparoscopic and NOTES techniques, which usually results in an extra port placed transabdominally through the umbilicus ^[9] )

Whereas Bernhardt performed the first transvaginal appendectomy utilizing a therapeutic Olympus single-canal standard gastroscope, the approach has evolved into the use of a single-incision laparoscopic surgery (SILS) port, through which a 5-mm endoscope may be placed, as well as additional instruments. This provides exceptional visualization and exposure.

This article describes pure transvaginal appendectomy via NOTES, without any abdominal incisions whatsoever.

Indications for transvaginal appendectomy include the following:

• Acute appendicitis
• Subacute appendicitis
• Chronic appendicitis

Absolute contraindications for transvaginal appendectomy include the following:

• Evidence of perforation
• Pregnancy
• Recent delivery (within the preceding 2 months)
• American Society of Anesthesiologists (ASA) classification 3 or 4
• History of pelvic inflammatory disease
• History of endometriosis
• History of inflammatory bowel disease
• History of retroflexed uterus

In all such cases, conventional laparoscopic appendectomy or open appendectomy should be performed.

These contraindications are likely to evolve as transvaginal appendectomy advances and gains momentum and surgeon expertise increases.

If intraoperative complications arise while NOTES appendectomy is being performed, an understanding of when to convert to a conventional technique is of utmost importance; appropriate conversion shows good surgical judgment.

Anatomy

The vermiform appendix is a vestigial structure that arises from the posteromedial aspect of the cecum about 2.5 cm from the ileocecal valve.

The appendix is embryologically derived from the midgut. It appears first between the 6th and 8th weeks of gestation. As the growth rate of the cecum is faster than the appendix, the appendix tends to be displaced more medially toward the ileocecal valve. The base of the appendix is located at the union of the taeniae coli. This landmark is usually used to identify the appendiceal base. The appendiceal tip, however, is more variable and can be found in several different locations, including the following ^[10] :

• Retrocecal (65%)
• Pelvic (31%)
• Subcecal (2.5%)
• Ascending, paracecal, and preileal (1%)
• Postileal (0.4%)

The mesentery is embryologically derived from the posterior mesentery of the terminal ileum and attaches to the proximal appendix and cecum. It contains the appendicular artery, which arises from the ileocolic artery, an ileal branch, or a cecal artery. Although this is usually singular, duplications have been described.

Best practices

Safe and effective surgical technique involves two major principles: exposure and mobilization. Working within a confined space also interferes with the ability to triangulate the camera and working instruments, leading to decreased three-dimensional perception and a reduced ability to manipulate intra-abdominal organs. ^[11] This hindrance may prove challenging in more complicated cases of acute appendicitis and should not be performed if a perforation is suspected.

Loss of tactile function, as seen to some extent with laparoscopy, is also a concern with NOTES. However, tactile function is not essential to the practice of safe surgery, as is amply demonstrated by the ability to perform laparoscopic surgery safely and effectively.

These factors are likely to improve significantly as surgical experience increases and newer and improved surgical devices are developed specifically for transvaginal procedures.

If intraoperative complications arise while NOTES appendectomy is being performed, an understanding of when to convert to a conventional technique is of utmost importance and shows good surgical judgment.

Pure transvaginal appendectomy via NOTES requires no abdominal incision, eliminating the risk of skin infections and incisional hernias.

Postoperative pain is also reduced with this technique. This benefit has been noted by the authors of this article and by evidence from the gynecologic literature, in which transvaginal hysterectomies compare favorably with abdominal hysterectomies with regard to pain. ^{[12, 13, 14]}

This procedure also tends to hasten the patient’s return to daily activities and to work, resulting in decreased health care costs.

Finally, this approach leaves no visible scars, improving cosmesis.