What is Hybrid Transvaginal NOTES Sleeve Gastrectomy?

Hybrid transvaginal NOTES sleeve gastrectomy is an innovative surgical approach to treat morbid obesity.

Obesity is a chronic condition in which there is an excessive accumulation of fat in the body. Obesity is defined as a Body Mass Index (BMI) of 30 to 34.9 and extreme or morbid obesity is a BMI of 40 or more.

Sleeve gastrectomy is a bariatric (weight-loss) surgery performed to reduce the stomach size and restrict the amount of food intake. The procedure is intended for extremely obese patients with a BMI of 40 and above, or patients with a BMI of 35 or more with serious medical conditions such as diabetes or heart disease. It encourages weight loss by restricting the stomach size so that it holds only a limited amount of food. 

The hybrid transvaginal NOTES (Natural Orifice Transluminal Endoscopic Surgery) sleeve gastrectomy involves a hybrid approach of using transvaginal (through or across the vagina) access and one or more additional abdominal wall trocars. An endoscope is inserted transvaginally through a Steerable Flex Trocar (SFT) from Ethicon Endo-Surgery. The device consists of a flexible overtube that can be articulated independently on the endoscope, providing standard flexible endoscopes with improved targeting capabilities. With the exception of visualization and the additional endoscopic stability thus provided, the laparoscopic sleeve gastrectomy procedure is performed per standard practice with standard laparoscopic devices introduced into the peritoneal cavity through abdominal incisions or trocars. The resected portion of the stomach is removed through the vaginal incision at the end of the procedure.

Indications for Hybrid Transvaginal NOTES Sleeve Gastrectomy

Your physician may recommend hybrid transvaginal NOTES sleeve gastrectomy for the treatment of obesity when non-surgical options such as lifestyle and weight-loss modification have proven to be ineffective.

Obesity is one of the leading causes of preventable death and impaired quality of life. It is an important underlying cause for a number of serious and chronic disease conditions such as the following:

  • Cardiac disease
  • Diabetes 
  • High blood pressure
  • Cancer
  • Sleep apnoea and breathing difficulties
  • Joint complaints, such as arthritis
  • Gastrointestinal concerns such as gallstones
  • Mental health challenges, such as depression
  • Fertility and pregnancy issues

Preparation for a Hybrid Transvaginal NOTES Sleeve Gastrectomy

In general, preparation for hybrid transvaginal NOTES sleeve gastrectomy may involve the following steps:

  • A thorough examination by your doctor to check for any medical issues that need to be addressed prior to surgery.
  • Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
  • You will be asked if you have allergies to medications, anesthesia, or latex.
  • You should inform your doctor of any medications or supplements you are taking, or any serious medical conditions such as lung or heart disease.
  • You may need to refrain from certain medications such as blood thinners, anti-inflammatories, or supplements for a week or two prior to the procedure.
  • Refrain from smoking or alcohol for at least a couple of weeks before surgery and several weeks after surgery.
  • You should not consume any solids or liquids at least 8 hours prior to the procedure.
  • You should arrange for someone to drive you home after the surgery.
  • A signed informed consent is required from you after the procedure has been explained in detail.

Procedure for Hybrid Transvaginal NOTES Sleeve Gastrectomy

Hybrid transvaginal NOTES sleeve gastrectomy procedure is performed under general anesthesia. Two to three small keyhole incisions or trocars are made at the umbilicus and side respectively. A laparoscope, a thin instrument with a light and camera attached, is inserted through one incision, allowing your surgeon to clearly view the internal organs on a monitor. Additional surgical instruments such as retractors are inserted through the other incisions and the internal organs are moved aside to provide a clear view of the operative field. A 2 cm incision is made at the posterior wall of the vagina 1 cm inferior to the cervix through which the SFT is placed into the posterior cul-de-sac and advanced into the upper abdomen under laparoscopic visualization at the umbilical site. Additional visualization is maintained through an endoscope passed through the SFT. A vertical sleeve gastrectomy is performed under laparoscopic/endoscopic visualization wherein your surgeon will remove about 80% of the stomach, and a thin sleeve shaped like a banana is created by stapling the remaining part of the stomach. The excised portion of the stomach is removed through the vaginal incision with the assistance of an endoscopic polypectomy snare. At the end of the procedure, the scope and surgical instruments are withdrawn, and the incisions are closed with sutures and bandaged.

Postoperative Care and Recovery

After the surgery, you are required to stay in the hospital for 2 to 3 days. You will be given pain medications to keep you comfortable and antacids to reduce stomach acidity. You will be kept on a liquid diet for the first 2 weeks and slowly transitioned from a soft, pureed to a solid diet. Avoid spicy, fried, and oily foods for a defined period. Eat a highly nutritious diet rich in protein with low-fat content. It is important to drink plenty of fluids throughout the day to avoid dehydration. Refrain from smoking and alcohol for a specific period of time as they can irritate the stomach lining and hinder the healing process. Refrain from strenuous activities and lifting anything heavier than 5 pounds for a defined period. Refrain from driving until you are fully fit and receive your doctor’s consent. Instructions on incision site care and bathing will be provided to keep the wound clean and dry. A follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Hybrid transvaginal NOTES sleeve gastrectomy surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as follows:

  • Internal bleeding 
  • Infection
  • Nausea and vomiting
  • Blood clots
  • Leakage of gastric contents
  • Lung or breathing problems