, the feasibility of laparoscopic gastrectomy in advanced gastric cancer has been reported as well .
laparoscopic gastrectomy combined with natural orifice specimen extraction ( nose ) may potentiate the advantages of two minimal invasive techniques .
nose is an ever - evolving advanced laparoscopic technique that minimizes surgical injury , involving a low risk of wound complications , fewer incisional hernias , faster recovery and less postoperative pain , , .
we aim to demonstrate the feasibility of laparoscopic subtotal gastrectomy with transvaginal specimen extraction in advanced gastric cancer .
a 72-year - old woman was referred to our department after gastroscopy and biopsy , which showed a 2  cm in diameter ulcerous mass in the gastric antrum ( adenocarcinoma ) .
body mass index was 29  kg / m and asa ( american society of anesthesiology ) score was ii ( because of hypertension ) .
tumor markers ( cea , ca 199 ) and routine laboratory tests were within the normal ranges .
contrast enhanced computed tomography showed no distant metastasis , no significantly enlarged perigastric lymph nodes but only a thickening on the distal gastric wall ( fig .
detailed information about the surgical procedure to the patient was given and informed consent was taken . under general anesthesia , the abdomen , pelvis , and vaginal canal
were disinfected with povidone iodine . in the reverse trendelenburg position with the legs apart , five trocars were inserted .
inspection of abdominal viscera demonstrated no metastasis and there was a tumoral protrusion at the antral serosa .
after placement of a nathanson liver retractor for left liver elevation , the gastrectomy was started with the mobilization of the greater curvature along the transverse colon by harmonic scalpel ( ethicon endo - surgery inc . ,
cincinnati , oh , usa ) . left gastric vessels were identified after opening the bursa omentalis .
the infra - pyloric lymph nodes were dissected toward the duodenum and the distal gastric vessels ( right gastroepiploic and right gastric ) were transected by ligasure ( forcetriad , covidien , boulder , co , usa ) . after cutting the duodenum by endoscopic 60  mm stapler ( endogia , covidien ,
mans - field , ma , usa ) , the roots of left gastric vessels were exposed and left gastric vein was divided with ligasure .
intact left gastric artery was used to expose the other branches of the celiac truncus .
the left gastric artery was divided near to its root after double clips and ligasure sealing .
the dissection was moved to esophagocardiac junction at lesser curvature and these lymph nodes were included to the resection specimen .
the stomach was divided with 60  mm endoscopic staplers in a tranverse plane 5  cm below to esophagogastric junction . a retrocolic roux - en - y reconstruction ( 2060  cm )
was performed by laparoscopic 60  mm linear stapler and common hole of the stapling legs were closed with 3/0 polyprolene suture intracorporeally .
side - to - side jejuno - jejunostomy was fashioned by endoscopic stapler again and the common hole was closed intracorporeally as well .
briefly , a 3  cm length transverse transvaginal posterior colpotomy was performed under laparoscopic control and the colpotomy incision was enlarged bluntly with fingers .
the specimen was grasped with an ovary clamp through the vaginal incision and it was pulled into the vagina .
the patient was allowed to drink fluids and a soft oral diet on the first postoperative day .
the histological analysis showed tumor free margins , 56 pieces of tumor negative lymph nodes which indicate a pt3pn0 lesion and the patient was referred to medical oncology department .
after ten months follow - up , the patient had no vaginal discharge or pain , tolerated normal diet , and had normal bowel movements .
patients with advanced cancers usually require postoperative adjuvant chemo - radiotherapy and the prolonged postoperative period due to morbidities can cause a delay on the postoperative adjuvant therapies .
when compared to open surgery , laparoscopic surgery has a clear advantage with less postoperative morbidities and particularly on wound related complications , .
laparoscopic - assisted , hand - assisted and total laparoscopic gastrectomies have all been described in the surgical management of gastric cancer , . despite the good results obtained by these procedures , an abdominal wall incision ( a mini - laparotomy ) is always required to retrieve the specimen .
natural orifice surgery allows laparoscopic resections only through 512  mm trocar orifices on the abdominal wall without any abdominal incisions or extensions . here , we have presented a totally laparoscopic subtotal gastrectomy with lymph node dissection and transvaginal specimen extraction for an advanced gastric cancer .
there are four potential natural orifice extraction routes for an abdominal specimen ; transanal , transurethral , transoral and transvaginal .
transanal extraction of a specimen except colorectal origin has not been reported yet because of the risk of infection and intestinal leak , .
we have experienced in our clinic that a sleeve gastrectomy material could be removed without any difficulty through the esophagus by the help of an endoscope .
however , the transoral route is limited to small specimens because of risk of esophageal damage . in our country
most of the patients with gastric cancers are stage iii or more when they are diagnosed .
so , most of our patients with gastric cancer can not be a candidate for transoral specimen extraction , .
previously , an italian study   described a transoral specimen extraction in a patient with a large gastric stromal tumor by using the morcellation , however it is unsuitable for a gastric cancer specimen . consequently , transvaginal route seems to be more suitable for specimen extraction in advanced gastric cancer .
although transvaginal extraction following partial gastrectomy has been reported in patients with gastric submucosal tumors and early gastric cancers , this is the first case in an advanced gastric cancer .
the technical difficulties in this type of laparoscopic surgery are the establishment of intracorporeal anastomosis , dissection of adequate lymph nodes and incompatibility between the size of specimen and posterior fornix of vagina .
patient selection is important and limitations of the procedure can be adverted as male gender , unacceptance of patient , unsuitable vaginal access and large masses .
the maximum size of a specimen that can pass through the vagina is not well studied .
recently , we systematically reviewed the transvaginal extraction of right hemicolectomy materials in the literature and observed that up to 8  cm tumors could be removed through the posterior fornix of the vagina . in our own experience
, a 12  cm diameter right hemicolectomy specimen was removed through the vagina after an intracorporeal size reduction to 9  cm . to make a more clear comment about the oncological outcomes of this new technique for advanced gastric cancer , the necessity of a longer follow - up is inevitable .
however , it is expected that the tranvaginal route may not carry any additional risks for the oncological results over conventional laparoscopic gastric cancer surgery , in which the specimen is removed trans - abdominally .
when the same preventive procedures for the oncological principles are carried out during the specimen extraction , the oncological outcomes of the transvaginal and transabdominal extraction methods can be expected to be identical .
transvaginal specimen extraction after laparoscopic gastric resection can be a feasible procedure in some patients with advanced gastric carcinoma .
we have presented , as far as we know , the first human case of a transvaginal extraction of an advanced gastric cancer after laparoscopic gastrectomy .
 highlightslaparoscopic gastrectomy had satisfactory results in patients with gastric cancer.natural orifice surgery ( nos ) is an ever - evolving advanced laparoscopic technique.nos promises minimizing surgical injury , less wound complications and faster recovery.laparoscopy plus nos can potentiate the advantages of both minimal invasive techniques.we presented a transvaginal extraction of an advanced gastric cancer after laparoscopic gastrectomy . 
Introduction
Case and technique
Discussion
Conclusion
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