LETTER TO THE EDITOR Pure Transvaginal Appendectomy Versus Traditional Laparoscopic Appendectomy for Acute Appendicitis To the Editor: read with interest the article, titled “Pure Transvaginal Appendectomy Versus Traditional Laparoscopic Appendectomy for Acute Appendicitis,” by Dr Roberts et al.1 This cohort study of pure transvaginal endoscopic appendectomy (TVEA) performed by general surgeons and gynecologists concluded that the approach is a safe, well-tolerated procedure that causes less pain and has a faster recovery time than laparoscopic appendectomy. However, the complication of 1 intraabdominal abscess in 18 cases was not fully analyzed. Culdolaparoscopy appendectomy initially had many detractors and few supporters. Today, several years later, the majority of surgeons are still uncomfortable with the concept.2 Notwithstanding this, there has been renewed interest in transvaginal approaches after recent research in the area of flexible transgastric peritoneoscopy. The introduction of flexible technology prompted multiple publications and clinical trials to confirm the safety and benefits of natural orifice transluminal endoscopic surgery (NOTES), including TVEA, for appendicitis.3
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The cohort study, which involved 18 cases of pure TVEA with preoperative diagnosis of appendicitis, reported 1 case of abdominal abscess (5.5%)—a known complication of appendicitis. The cohort study does not mention the use of preoperative antibiotic. In fact, the word antibiotics appears only once in the text describing the treatment of the postoperative intra-abdominal abscess.1 Minilaparoscopy-assisted natural orifice surgery described 100 cases, none of which resulted in an infection. It used prophylactic antibiotics and encountered only 1 complication, which was an antibiotic-related drug fever.4 Experiences in TVEA for appendicitis using preoperative antibiotics were reported without complications.3 In a multicenter clinical trials that included 362 transgastric and transvaginal NOTES, most of the transvaginal NOTES received prophylactic antibiotics. In these trials, 1 case of peritonitis was reported in a transgastric NOTES.5 The use of prophylactic antibiotics in vaginal surgery is recommended for some procedures because of the contamination of the vaginal flora into the abdominal cavity.6 The recommendation is clear for vaginal hysterectomy.7 The use of preoperative antibiotics for appendicitis is different because prophylactic implies that no infection is present before surgery.8 Whether preoperative antibiotics make a difference in transvaginal NOTES is yet to be established by future studies, and a single case in a small series could ruin the statistics. Caution is advised in this evolving field, as we learn the positives of this cohort study and adding other experiences,
including the potential benefits of preoperative antibiotics while advancing to pure NOTES.9 Daniel A. Tsin, MD Mount Sinai Hospital of Queens Long Island City, NY
REFERENCES 1. Roberts KE, Solomon D, Mirensky T, et al. Pure transvaginal appendectomy versus traditional laparoscopic appendectomy for acute appendicitis. A prospective cohort study. Ann Surg. 2012;255:266– 269. 2. Tsin DA, Colombero LT, Mahmood D, et al. Operative culdolaparoscopy: a new approach combining operative culdoscopy and minilaparoscopy. J Am Assoc Gynecol Laparosc. 2001;8:438–441. 3. P´erez RC, Gonz´alez LR, Reyes ED, et al. [The transvaginal approach in acute appendicitis]. Cir Esp. 2011;89:517–523. 4. Tsin DA, Colombero LT, Lambeck J, et al. Minilaparoscopy-assisted natural orifice surgery. JSLS. 2007;11:24–29. 5. Zorron R, Palanivelu C, Galv˜ao Neto MP, et al. International multicenter trial on clinical natural orifice surgery—NOTES IMTN study: preliminary results of 362 patients. Surg Innov. 2010;17:142–158. 6. Culligan P, Heit M, Blackwell L, et al. Bacterial colony counts during vaginal surgery. Infect Dis Obstet Gynecol. 2003;11:161–165. 7. ACOG Committee on Practice Bulletins– Gynecology. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113:1180–1189. 8. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005:CD001439. 9. Tsin DA. Access in natural orifice transvaginal endoscopic surgery. In: Tinelli A, ed. Laparoscopic Entry: Traditional Methods, New Insights and Novel Approaches. London: Springer-Verlag; 2012:291– 302.
Disclosure: The author declares no conflicts of interest. C 2013 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/13/26101-e0027 DOI: 10.1097/SLA.0000000000000529
Annals of Surgery r Volume 261, Number 1, January 2015
www.annalsofsurgery.com | e27
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
I
The cohort study, which involved 18 cases of pure TVEA with preoperative diagnosis of appendicitis, reported 1 case of abdominal abscess (5.5%)—a known complication of appendicitis. The cohort study does not mention the use of preoperative antibiotic. In fact, the word antibiotics appears only once in the text describing the treatment of the postoperative intra-abdominal abscess.1 Minilaparoscopy-assisted natural orifice surgery described 100 cases, none of which resulted in an infection. It used prophylactic antibiotics and encountered only 1 complication, which was an antibiotic-related drug fever.4 Experiences in TVEA for appendicitis using preoperative antibiotics were reported without complications.3 In a multicenter clinical trials that included 362 transgastric and transvaginal NOTES, most of the transvaginal NOTES received prophylactic antibiotics. In these trials, 1 case of peritonitis was reported in a transgastric NOTES.5 The use of prophylactic antibiotics in vaginal surgery is recommended for some procedures because of the contamination of the vaginal flora into the abdominal cavity.6 The recommendation is clear for vaginal hysterectomy.7 The use of preoperative antibiotics for appendicitis is different because prophylactic implies that no infection is present before surgery.8 Whether preoperative antibiotics make a difference in transvaginal NOTES is yet to be established by future studies, and a single case in a small series could ruin the statistics. Caution is advised in this evolving field, as we learn the positives of this cohort study and adding other experiences,
including the potential benefits of preoperative antibiotics while advancing to pure NOTES.9 Daniel A. Tsin, MD Mount Sinai Hospital of Queens Long Island City, NY
REFERENCES 1. Roberts KE, Solomon D, Mirensky T, et al. Pure transvaginal appendectomy versus traditional laparoscopic appendectomy for acute appendicitis. A prospective cohort study. Ann Surg. 2012;255:266– 269. 2. Tsin DA, Colombero LT, Mahmood D, et al. Operative culdolaparoscopy: a new approach combining operative culdoscopy and minilaparoscopy. J Am Assoc Gynecol Laparosc. 2001;8:438–441. 3. P´erez RC, Gonz´alez LR, Reyes ED, et al. [The transvaginal approach in acute appendicitis]. Cir Esp. 2011;89:517–523. 4. Tsin DA, Colombero LT, Lambeck J, et al. Minilaparoscopy-assisted natural orifice surgery. JSLS. 2007;11:24–29. 5. Zorron R, Palanivelu C, Galv˜ao Neto MP, et al. International multicenter trial on clinical natural orifice surgery—NOTES IMTN study: preliminary results of 362 patients. Surg Innov. 2010;17:142–158. 6. Culligan P, Heit M, Blackwell L, et al. Bacterial colony counts during vaginal surgery. Infect Dis Obstet Gynecol. 2003;11:161–165. 7. ACOG Committee on Practice Bulletins– Gynecology. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009;113:1180–1189. 8. Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev. 2005:CD001439. 9. Tsin DA. Access in natural orifice transvaginal endoscopic surgery. In: Tinelli A, ed. Laparoscopic Entry: Traditional Methods, New Insights and Novel Approaches. London: Springer-Verlag; 2012:291– 302.
Disclosure: The author declares no conflicts of interest. C 2013 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/13/26101-e0027 DOI: 10.1097/SLA.0000000000000529
Annals of Surgery r Volume 261, Number 1, January 2015
www.annalsofsurgery.com | e27
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
