Comparing with conventional laparoscopic abdominal surgeries, one of most obvious advantage of NOSE procedure is absence of an abdominal auxiliary incision, along with minimizing access trauma. Considering incision pain and some incision healing associated issues, NOSE procedure theoretically could reduce use of anesthetic drug for releasing incisional pain and morbidity of incision complications, such as incision hernia and wound dehiscence.  For abdominal specimen extraction, transvaginal approach, as one of two mainstream approaches, of which another is transanal approach, has been regarded as a common, uncomplicated and widely used method, due to the reason that vaginal wall is elastic, a larger specimen can be acquired through it.[7–9] Besides this present case colon specimen from right hemicolectomy, gastric specimen from subtotal gastrectomy, liver specimen from liver resection and partial pancreas specimen from distal pancreatectomy are reported to be obtained from vaginal wall incision during NOSE.[10–13] Luyao Zhang et al. have successfully performed laparoscopic pancreaticoduodenectomy through transvaginal NOSE method.
Although advantages of laparoscopic transvaginal NOSE are well recognize, some risks and complications have been observed and drawn attention by surgeons recently. Even though both the amount and length of abdominal incision are reduced maximally, wound infections are still reported occasionally.[8 15] Anastomotic leakage, as one of post-operative complications of conventional laparoscopic surgery, is also observed post laparoscopic transvaginal NOSE.[16 17] Other complications, such as bleeding, internal hernia and abdominal abscess, still exist. Moreover some complications are unique for such NOSE procedure. Abdominal contamination, one of such complications, has already been observed.[4 18]
This present case has experienced an overwhelming infection after laparoscopic transvaginal NOSE procedure for right hemi-colonic radical resection. According to her post-operational clinical examinations files and physical examination findings, abdominal contamination is highly suspected. The reasons for such a rapid infection aggravation, even a septic shock appearance, acute cardiac functional failure and a sudden cardiac arrest are still uncertain, however, immune system dysfunction is supposed to be responsible. As shown in Fig. 5, the count of T and B lymphocytes and the count of Natural Killer cells (NK cells) have fallen down to the lowest level at the 3rd day post-operation, which led to cell and humoral immune response largely weaken. There could be an interactive relationship and reciprocal causation between a septic shock and immune dysfunction. Furthermore, the amount of immunocytes has not risen up to a normal level when she was transferred to cardiovascular internal medicine department with a normal level of WBC and NG, which might be a reminder that some immune-related malfunction can exist even pre-operationally.
In order to reduce transvaginal NOSE related complications, procedures pre-operation and intra-operation in our department follow these protocols: a) bowel preparations pre-operation are mandatory and indispensable, including intestinal antibiotics application and cathartics for thorough evacuation of lumen; b) preventive disinfected vagina preparation with iodine solution is performed; c) assessment about immune system function, if necessary, can be done; d) carefully and skillfully cope with suturing incision on posterior vaginal wall; e) properly handle the process of packaging surgical specimen by using retrieval bag. The last protocol should be top crucial among all these protocols depending on our experience. Preventing surgical specimen leakage, especially lumen contents, is not only a consideration on avoiding malignant tumor cells spreading, but also escaping from bacterium invading into peritoneal cavity.
For a novel surgical procedure, it is always top concerned and frequently discussed that short-term and long-term complications, overall survival (OS), disease-free survival (DFS) and intro-surgery safety, including abdominal contamination, distal resection margin results and number of retrieved lymph nodes. Most studies argued that this procedure of NOSE could receive an equal or even a lower incidence of abdominal contamination and intro- and post-surgery infection, compared with laparoscopic surgery.[4 18–20] In terms of short-term complication, abdominal contamination and consequent intra-abdominal infection are crucial issues. To evaluate and prevent infection, Linke GR et al performed bacterium growth routine culture examination through gathering swaps from vaginal posterior fornix and peritoneal cavity at different intervals post-surgically. Some interventions, such as preoperative administration of prophylactic antibiotics, preoperative intestinal lumen preparation, intraoperative peritoneal irrigation, and intraoperative transanal lavage with iodophor water, are recommended by different clinical centers, coming out with promising outcomes.[19 20] However, due to a consideration of possibility of carcinoma cells spreading, our group does not apply intraoperative transanal lavage.
We have performed an analysis on intra-abdominal complications associated with colorectal NOSE surgery for recent years. (Table 1) As shown in Table 1, intra-abdominal infection is one of short-term complications with a low incidence. There has been no reports about an over-whelming infection post-surgery yet. However, infection after laparoscopic transvaginal NOSE procedure is still a short-term complication which should be paid attention to by each surgeon.
Totally speaking, laparoscopic NOSE procedure is one kind of minimal invasive procedures, characterized as a safe, cosmetics surgical method with less short- or long-term complications and fast recovery when compared with conventional laparoscopy. However, some complications, such as anastomotic leakage and wound infection, still happen occasionally. This case report presented an extreme rare case experiencing an overwhelming intra-abdominal infection post-surgically, which even caused a sudden cardiac arrest. It should be an alert for each surgeon towards NOSE preparations, surgical procedures and complications.