LAUSR

A33‐YEAR‐OLDWOMANwas admitted to our hospital for prolonged abdominal discomfort. The physical examination was normal. A computed tomography scan showed a large cyst measuring 66 9 67 mm, occupying the left abdominal cavity and displacing the surrounding descending colon and small bowel (Fig. 1). Because the patient wanted to avoid a cutaneous scar, after multidisciplinary team discussion transgastric natural orifice transluminal endoscopic surgery (NOTES) was performed. In order to ensure the patient’s safety, the surgery was planned as a backup and a surgeon was on standby. The NOTES procedure was performed as follows (Fig. 2). Endoscopic ultrasound was used to confirm the cyst site where a 20-mm linear full-thickness gastric incision was made. After entering the peritoneal cavity, the cyst margin was observed with an endoscope. A snare as a traction method was attached alongside the endoscope and introduced into the peritoneal cavity to grasp the cyst and pull it into the stomach to expose the cyst margin clearly. A hook knife and an IT knife (Olympus, Tokyo, Japan) were used to dissect the cyst along its margin. Coagulation forceps and endoclips were used for hemostasis. The cyst was then resected completely. Purse-string suture, using a single endoloop and multiple endoclips, was used to close the gastric incision (Video S1). The histological diagnosis was lymphangioma. The patient started a liquid diet 24 h after the procedure. She recovered uneventfully and was discharged on day 5 after the operation. No recurrence or other complications were observed during 2 years of follow-up. As shown, NOTES is a safe and effective minimally invasive technique for peritoneal cyst resection. Since this was our first NOTES experience of peritoneal cyst excision, it was difficult to identify the cyst margins and hemostasis was challenging as well. Hence, it should be performed by highly skilled and experienced interventional endoscopist. Authors declare no conflict of interest for this article.