Pure transgastric NOTES in an adnexal procedure: the first human case report.

Natural orifice transluminal endoscopic surgery (NOTES) is an innovative procedure that represents a further evolution of minimally invasive surgery. To date, there are few cases reported in the literature that have been performed using pure NOTES [1–3]. Recently, Lee et al. [4] described pure transvaginal NOTES in adnexal procedures using modern laparoscopic rigid instruments. To the best of our knowledge, however, transgastric NOTES for adnexal disease has not previously been reported in humans. Herein, we report on a pure transgastric NOTES procedure performed for adnexal disease in a young woman. A 36-year-old woman presented to our hospital with left lower abdominal pain for 3 days. Her serum beta-human chorionic gonadotropin (beta-hCG) was 547.23mIU/mL (normal <5mIU/mL). Transvaginal ultrasonography confirmed the diagnosis of a left tubal ectopic pregnancy and right simple ovarian cyst. A pure transgastric NOTES procedure was performed after approval by the hospital ethics committee. The stages of the operation we performed were as follows: (i) creation of gastric access using a percutaneous endoscopic gastrostomy (PEG)like technique; (ii) establishment of a pneumoperitoneum with a laparoscopic insufflator; (iii) visualization of the uterus (●" Fig.1a) and inspection of the adnexa, which revealed a superficial endometriosis lesion on the right ovarian wall, in addition to the left fallopian tubal ectopic pregnancy mass (●" Fig.1b) and right ovarian cyst; (iv) cystotomy of the ovarian cyst with an injection needle; (v) electrocautery of the endometriosis lesionwith a Coagrasper; (vi) transgastric NOTES salpingostomy (●" Fig.1c) and dissection of the ectopic pregnancy lesion from the tubal wall without laparoscopic assistance; (vii) removal of the lesion and confirmation that no remnant was left; (viii) closure of the gastric incision with endoclips and a nylon loop (●" Fig.1d). The ectopic pregnancy lesion was removed successfully, giving a specimen of 4.0×2.0cm (●" Fig.2). The patient did well postoperatively and had no complications. Her serum beta-hCG returned to normal 3 days after the operation. Histological examination confirmed the presence of chorionic villi in the specimen. Follow-up endoscopy 5 days later showed good healing of the gastric incision (●" Fig.3).