Feasibility and technique for transvaginal natural orifice transluminal endoscopic surgery liver resection: A porcine model

Toshio Katagiri, Yuichiro Otsuka, Santiago Horgan, Bryan J. Sandler, Garth R. Jacobsen, Alisa M. Coker, Masaru Tsuchiya, Tetsuya Maeda, Hironori Kaneko

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Introduction: Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure. Although laparoscopic techniques for liver resection are gaining acceptance worldwide, few studies have investigated NOTES liver resection. We used a porcine model to assess the feasibility and safety of transvaginal NOTES liver resection (TV NOTES LR). Materials and Methods: Nine female pigs underwent TV NOTES LR. A nonsurvival acute porcine model with general anesthesia was used in all cases. Using hybrid NOTES technique, we placed only 1 umbilical 12-mm umbilical trocar in the abdominal wall, which was used to create pneumoperitoneum. A laparoscope was then advanced to obtain intra-abdominal visualization. A 15-mm vaginal trocar was inserted under direct laparoscopic vision, and a flexible endoscope was introduced through the vaginal trocar. A long, flexible grasper and endocavity retractor were used to stably retract the liver. The liver edge was partially transected using energy devices inserted through the umbilical trocar. To transect the left lateral lobe, a flexible linear stapler was inserted alongside the vaginal trocar. A specimen extraction bag was deployed and extracted transvaginally. Blood loss, bile leakage, operative time, and specimen size were evaluated. Necropsy studies were performed after the procedures. Results: Eighteen transvaginal NOTES partial liver resections and 4 transvaginal NOTES left lateral lobectomies were successfully performed on 9 pigs. Mean operative time was 165.8 minutes, and mean estimated blood loss was 76.6 mL. All TV NOTES LRs were performed without complications or deaths. Necropsy showed no bile leakage from remnant liver. Conclusions: Our porcine model suggests that TV NOTES LR is technically feasible and safe and has the potential for clinical use as a minimally invasive alternative to conventional laparoscopic liver resection.

Original languageEnglish (US)
Pages (from-to)e6-e11
JournalSurgical Laparoscopy, Endoscopy and Percutaneous Techniques
Issue number1
StatePublished - 2017
Externally publishedYes


  • animal model
  • hepatectomy
  • liver
  • porcine
  • transvaginal

ASJC Scopus subject areas

  • Surgery


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