Transvaginal Appendectomy 

Updated: Nov 30, 2020
Author: Kurt E Roberts, MD; Chief Editor: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed) 

Overview

Background

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

Indications for transvaginal appendectomy include the following:

  • Acute appendicitis
  • Subacute appendicitis
  • Chronic appendicitis

Contraindications

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.

Technical Considerations

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.

Outcomes

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.

 

Periprocedural Care

Equipment

Equipment used for transvaginal appendectomy is as follows:

  • Electrocautery
  • Single-incision laparoscopic surgery (SILS) port (Covidien, North Haven, CT)
  • Endoscope (30°, 5 mm)
  • Flexible endoscopic grasper
  • Maryland dissector
  • Endoscopic stapler

Patient Preparation

Anesthesia

General anesthesia is necessary because of the need to insufflate the abdominal cavity to ensure adequate visualization.

Positioning

The patient is placed in the low lithotomy position with the lower extremities in stirrups. After the patient is prepared and draped and just before vaginal access is attempted, the patient is placed in a steep Trendelenburg position (see the image below).

Transvaginal appendectomy. Position of patient. Transvaginal appendectomy. Position of patient.

Monitoring and Follow-up

Patients are recommended to refrain from sexual intercourse for a period of 2 weeks following surgery, as recommended by the gynecologists in the authors’ institution.

 

Technique

Transvaginal Appendectomy

After a surgical timeout, the patient is positioned, prepared, and draped (see Periprocedural Care). Once the patient is in a steep Trendelenburg position, a weighted speculum is introduced into the vagina, allowing visualization of the cervix and exposure of the posterior vaginal fornix.

The fornix is grasped with a single-toothed tenaculum on the posterior cervical lip; this brings the posterior vaginal fornix into the operative field. Access to the peritoneum may be achieved with electrocautery and then sharp dissection (see the image below).

Transvaginal appendectomy. Culdotomy. Transvaginal appendectomy. Culdotomy.

Once successful access to the peritoneum is established and confirmed, the single-incision laparoscopic surgery (SILS) port with two 5-mm ports and one 12-mm port is introduced. Pneumoperitoneum up to 15 mm Hg is achieved. A feasible and safe modification of transvaginal appendectomy with gasless laparoscopy has also been reported.[15]  

The right lower quadrant of the abdomen is inspected and the appendix identified (see the image below).

Transvaginal appendectomy. Identification of appen Transvaginal appendectomy. Identification of appendix.

The flexible endoscopic grasper may be used to elevate the appendix medially and superiorly, so that the mesoappendix and base can be adequately visualized (see the image below).

Transvaginal appendectomy. Identification of mesoa Transvaginal appendectomy. Identification of mesoappendix.

The Maryland dissector is passed through the port and used to dissect the appendix at its base of the mesoappendix (see the image below).

Transvaginal appendectomy. Dissection of appendix. Transvaginal appendectomy. Dissection of appendix.

The mesoappendix is divided with either a LigaSure (Covidien, North Haven, CT) device or a stapler. The appendix is divided at the cecoappendiceal junction with a stapler (see the image below).

Transvaginal appendectomy. View of cecoappendiceal Transvaginal appendectomy. View of cecoappendiceal junction.
Transvaginal appendectomy. Stapling of appendix. Transvaginal appendectomy. Stapling of appendix.

Good hemostasis and the absence of spillage are confirmed (see the image below).

Transvaginal appendectomy. Inspection of staple li Transvaginal appendectomy. Inspection of staple line.

The appendix is placed in a retrieval bag and removed (see the image below).

Transvaginal appendectomy. Appendix being placed i Transvaginal appendectomy. Appendix being placed into endoscopic retrieval bag.

The culdotomy is closed with a running absorbable suture (see the image below).

Transvaginal appendectomy. Closure of culdotomy. Transvaginal appendectomy. Closure of culdotomy.

Complications

Potential complications of this procedure may be extrapolated from the complications of culdoscopy (accessing the abdominal cavity through the posterior fornix, which is performed as an office procedure for evaluation of infertility, for treatment of polycystic ovarian disease, or for harvest of oocytes) described in the gynecology literature.

One potential complication described in the culdoscopy literature is bowel or rectal injury, which occurs in approximately 0.25% of cases.[16, 17] Other potential adverse effects from a gynecologic perspective include the formation of adhesions and spread of preexisting endometriosis.

Although the potential for infertility or dyspareunia was once a concern, the uterus is only passed by and uninjured on the way to the posterior fornix, so any effect on potential childbearing is unlikely.

Also extrapolated from the gynecologic literature, preservation of sexual function with transvaginal access for hysterectomy is similar to that associated with transabdominal access.[18] However, patients are recommended to refrain from sexual intercourse for a period of 2 weeks, as recommended by the gynecologists in the authors’ institution.

Antibiotic prophylaxis may be employed for reducing the incidence of infectious complications (eg, intra-abdominal abscess) after the procedure.[19]