Trans-umbilical NOTES for abdominal adhesion lysis using a flexible endoscope： a case report

Objective To evaluate the feasibility and safety of trans-umbilical NOTES to perform abdominal adhesion lysis using a flexible endoscope. Methods A 42-year-old female was admitted to our hospital with a complain of abdominal pain due to abdominal adhesion after hysterectomy. A gastroscope （ GIF-2TQ260M, Olympus） was inserted into the peritoneal cavity through an incision （ 1.5 cm） of the umbilical opening. Pneumoperitoneum was established by the endoscopic air supply system using CO2 instead of air. Abdominal exploration showed that omentum and bowel were stuck to the scar of the low central peritoneum incision. Separation of the abdominal wall adhesions was performed with an IT knife and a hook knife respectively. After most of the adhesions were separated, bleeding was found from the isolated adhesion wound of the omentum and bowel. Hemorrhaged blood vessel was difficult to be found with the flexible gastroscope. Then a 5 mm Trocar was placed at the left lower abdomen and laparoscopic assistance was adopted to search the bleeding point. However, no bleeding site was found and the hemorrhage was stopped automatically. Residual adhesion lysis was conducted with laparoscopic assist. After the procedure, the umbilical incision was closed with absorbable suture, but lower left abdominal incision was left without suturing. Results The operation time was 40 minutes. The patient suffered from minus pain from the umbilical incision without need of treatment. She had normal diet and got out of bed after reconsious, She was discharged 2 days after the procedure without any complaints. Conclusion Trans-umbilical NOTES using a flexible endoscope for perito- neal adhesion lysis is safe and feasible, but the effectiveness remains to be further confirmed. Key words: Natural orifice transluminal endoscopic surgery;  Endoscopic surgical procedures;  Pneumoperitoneum;  Peritoneal adhesiolysis