Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: A Pilot Study of 26 Cases

Study Objective

To describe the surgical technique and short-term outcomes for 26 cases of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy for the treatment of pelvic organ prolapse (POP).

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Myomectomy: A Novel Route for Uterine Myoma Removal

Study Objective

Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure, but it has the limitation of lack of exposure and limited surgical space when using traditional vaginal surgical instrumentation, such as in a hysterectomy for a uterus without descent or for a myomectomy. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) offers similar benefits of traditional vaginal surgery but also expands the horizon of transvaginal surgery by allowing the surgeon to perform procedures that are typically limited to an abdominal approach. The advantages of NOTES may include no incisional pain as well as a better cosmetic outcome. These benefits help outweigh the obstacle of learning this novel approach. Our objective is to demonstrate the transvaginal NOTES technique as a combination of traditional vaginal surgical skill with single-site surgical skill.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery as a Rescue for Total Vaginal Hysterectomy

Background

Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure but can be challenging for many to perform as evidenced by its declining rate. Vaginal removal of the adnexal structures can be difficult because of poor visualization. Factors such as abnormal pathology, incidental finding of early-stage endometriosis or adhesions from previous cesarean section or surgery, and obesity may further complicate the procedure. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) may be performed during vaginal surgery using basic laparoscopic single-site skills as a “rescue” procedure for the complete removal of the adnexae. This allows the surgeon to complete the procedure vaginally without requiring conversion or addition of abdominal incisions. The combination of total vaginal hysterectomy (TVH) with NOTES as a “rescue” procedure may be a useful tool for gynecologic surgeons for removal of the adnexae and performance of other pelvic procedures.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Female-to-Male Transgender Men

Study Objective

Previous studies suggest female-to-male transgender men tend to choose less invasive procedures, but the superior route of hysterectomy for them remains undetermined.

经阴道自然腔道内镜手术在妇科恶性肿瘤中的应用

经阴道自然腔道内镜手术（transvaginal natural orifice transluminal endoscopic surgery,vNOTES）近年来得到快速发展,与传统膜腔镜手术或经脐单孔腹腔镜手术相比,vNOTES具有体表无瘢痕、疼痛轻和术后康复快等优势,目前多用于妇科良性疾病,在妇科恶性肿瘤方面的运用尚有争议,因此,国内外学者针对vNOTES用于妇科恶性肿瘤治疗进行了许多有益的尝试,初步证实了该术式在一定范围内的可行性。综述了vNOTES在妇科恶性肿瘤方向应用的现状、优势、困难与操作要点。     

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Pregnancy and a Device Innovation from Our Institution

Natural orifice transluminal endoscopic surgery (NOTES) is a relatively new technique currently being studied around the world. Between June 2015 and June 2017, 12 patients diagnosed with ectopic pregnancy underwent transvaginal NOTES to remove their fallopian tubes. All 12 surgeries were completed successfully. The median age of patients was 33years (range, 28–42), and the median body mass index was 23.47 (range, 20.55–27.68). The median duration of amenorrhea was 53days (range, 41–60). The median serum β-human chorionic gonadotropin was 8887 U/mL (range, 392–25 695). The median ectopic mass longest diameter was 2.95 cm (range, 2.1–5.0). The median surgical time was 47.5 minutes (range, 40–70). The median hemoperitoneum was 52.5 mL (range, 20–300), and the median blood loss was 7.5 mL (range, 2–20). Our study has proven the feasibility and repeatability of transvaginal NOTES for less difficult ectopic pregnancies. The success of transvaginal NOTES lies in the choice of patients and the establishment of the transvaginal operating platform. We added a plastic ring between the inner and outer rings outside the wound retractor. The modified platform can lessen the technical difficulties of performing transvaginal NOTES and broaden its applicability to other procedures.     

Hysterectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES): A Series of 137 Patients

Study ObjectiveTo evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES).DesignProspective observational study (Canadian Task Force classification II-3).SettingTertiary referral medical center.PatientsFrom May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included.InterventionTotal hysterectomy via transvaginal NOTES.Measurements and Main ResultsThe study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment.ConclusionTransvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.     

Natural Orifice Transluminal Endoscopic Surgery-assisted Versus Single-port Laparoscopic-assisted Vaginal Hysterectomy: A Case-matched Study

ObjectiveNatural orifice transluminal endoscopic surgery (NOTES) is currently a very important procedure for surgeons. This study aimed to describe the initial clinical experience of NOTES-assisted vaginal hysterectomy (NAVH) and to investigate its feasibility and surgical outcomes compared with single-port laparoscopic-assisted vaginal hysterectomy (SP-LAVH).DesignRetrospective chart analysis (Canadian Task Force classification II-1).SettingOne university-affiliated hospital.PatientsWomen undergoing NAVH or SP-LAVH for benign uterine diseases.InterventionNAVH using a novel homemade NOTES system comprised a glove-wound retractor NOTES port or SP-LAVH using conventional laparoscopic instruments and an umbilical glove port.Measurements and Main ResultsSince July 2012, 16 patients with benign uterine disease have undergone NAVH. Another 32 paired, SP-LAVH patients from the registered database were used to compare these 2 modalities of laparoscopic-assisted techniques for vaginal hysterectomy. All NAVHs were completed successfully without the need of an additional port or conversion to the standard laparoscopic approach. Intraoperative and postoperative surgical outcomes were assessed in both groups of patients. There was also no significant difference between both groups in perioperative outcomes such as estimated blood loss, decrease in hemoglobin on postoperative day 1, amount of analgesic drugs used, postoperative visual analog scale pain score, and febrile complications, except for operative time and length of postoperative hospital stay. The mean operative time was 70.6 ± 12.8 minutes for NAVH and 93.2 ± 21.4 minutes for SP-LAVH (p < .001). The median postoperative hospital stay was 3.5 days (range, 3–5) for NAVH and 4 days (range, 3–6) for SP-LAVH (p < .001).ConclusionThe findings show that NAVH is a feasible and safe surgical technique and has a short operative time and postoperative hospital stay compared with SP-LAVH. This new technique at least offers similar surgical outcomes and superior cosmesis in our opinion compared with SP-LAVH. However, prospective studies are needed to determine its full clinical application.     

New Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery Approach to Sentinel Node for Endometrial Cancer: A Demonstration Video

Study ObjectiveTo assess whether sentinel node resection for endometrial cancer is feasible via retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and gives better exposure than transperitoneal vNOTES.DesignThis is a first small IDEAL (Idea Development Exploration Assessment Long-term follow up) stage 1 study to assess the feasibility of a new approach; the technique is explained step-by-step using videos (Video 1) and pictures.SettingThe gynecologic oncology department of a nonuniversity teaching hospital in Belgium.PatientsSince 2015, 15 patients were operated on via vNOTES for endometrial cancer [1].InterventionsOur initial experience showed that a transperitoneal approach via vNOTES [2] provided good access to the cranial pelvic retroperitoneum but not to the caudal pelvic retroperitoneum. Therefore, a new retroperitoneal vNOTES approach via a paracervical incision in the lateral vaginal fornix was developed. Via this incision, the obturator fossa is accessed, and a vNOTES port is placed for endoscopic dissection of the retroperitoneal space. This video article shows this new access route to the pelvic retroperitoneal space.Measurements and Main ResultsOur initial experience with vNOTES for endometrial cancer showed that transperitoneal access to the retroperitoneal space did not give optimal exposure to the caudal parts of the obturator space. The new retroperitoneal vNOTES approach shown in this video article gives better exposure to the entire retroperitoneal space including the caudal part of the obturator space; the sacral plexus; the external, internal, and common iliac arteries; and even the lower para-aortic region.ConclusionIt has been previously shown that vNOTES hysterectomy offers patient benefits over total laparoscopic hysterectomy [3]. The retroperitoneal vNOTES approach now also offers good transvaginal access to the entire retroperitoneal space for sentinel node resection. This is a new approach that requires further validation before vNOTES hysterectomy with retroperitoneal sentinel node resection can be used outside study settings for the treatment of endometrial cancer.     

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Uterosacral Ligament

Study ObjectiveTransvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension.DesignStepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage.SettingAn academic tertiary referral center. The ethics committee ruled that approval was not required for this study.PatientsA 53-year-old woman.InterventionsvNOTES hysterectomy and apical suspension to the uterosacral ligament.Measurements and Main ResultsA 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA).ConclusionvNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.     

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Stump Pregnancy

ObjectiveTo demonstrate a case of left tubal stump pregnancy successfully treated using our 2-step technique for transvaginal natural orifice transluminal endoscopic surgery (vNOTES).DesignDemonstration of the technique using surgical video footage.SettingTertiary university hospital.InterventionsA 27-year-old gravida 3 para 0 patient with a history of laparotomy, left salpingectomy owing to a ruptured tubal pregnancy, was referred to our hospital because of a pregnancy of unknown location. Her serum β human chorionic gonadotropin level was 8400 U/L, and a transvaginal ultrasound revealed an ectopic pregnancy in the left tubal stump. After discussing medical and surgical treatment options, the patient underwent a 2-step vNOTES approach. First, a diagnostic vNOTES was performed using a 5-mm trocar with autoretracting blade. After confirmation of the diagnosis, the trocar was removed, and the incision was enlarged with blunt dissection. A self-constructed pessary port was then placed through the enlarged colpotomy, and the ectopic pregnancy in the left tubal stump was excised using an advanced bipolar device. The colpotomy was closed with running resorbable sutures. The duration of the surgery was 36 minutes, and the patient was discharged on postoperative day 1 without any complications.ConclusionTubal stump pregnancy is a rare form of ectopic pregnancy with an incidence of approximately 0.4% of all ectopic pregnancies [1]. Treatment options include conservative medical management using methotrexate and surgery. Successful surgical treatment using laparoscopy has been previously reported [1,2]. This case demonstrates that vNOTES may be a minimally invasive option for the surgical treatment of tubal stump pregnancy in selected cases.     

Uterosacral Ligament Suspension Sec Shull by Vaginal Natural Transluminal Endoscopic Surgery (vNOTES)

This step-by-step video demonstrates the feasibility of the Shull technique via vaginal natural transluminal endoscopic surgery (vNOTES) in a patient experiencing pelvic organ prolapse (POP) with apical support loss.A 51-year-old woman with apical pelvic organ prolapse quantification (POP-Q) stage III and a right benign ovarian cyst underwent a total hysterectomy and bilateral adnexectomy with vaginal dome uterosacral ligament suspension performed via vNOTES. Total operating time was 82 minutes, with negligible blood loss. The patient remained in hospital for 2 days. There were no intra- or postoperative complications at 30 days post-surgery, and there was complete repair of the apical defect at 6-month follow-up.The advantages of NOTES include avoiding abdominal incisions, eliminating complications associated with the trocar sound, and reducing postoperative pain and length of hospital stay.vNOTES provides safe entry, easy access, and direct visualization of the peritoneal cavity and pelvic anatomy. The Shull technique by vNOTES is technically feasible and permits clear and safe identification of uterosacral ligaments.     

Mesh Exposure and Prolapse Recurrence Following Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: Over 24 Months of Follow-up Data

Study ObjectiveTo describe the results of mesh exposure and prolapse recurrence of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for sacrocolpopexy after more than 24 months of postoperative follow-up.DesignA retrospective cohort study.SettingA university hospital.PatientsWomen with uterine prolapse who underwent vNOTES sacrocolpopexy with an ultralightweight polypropylene mesh between May 2018 and March 2020.InterventionsvNOTES sacrocolpopexy.Measurements and Main ResultsOf 57 women, 55 women (96.5%) were included in the final analysis. The mean follow-up duration was 35.5 ± 7.6 (24–46) months. The total incidence of mesh exposure was 3 of 55 (5.5%). The total incidence of prolapse recurrence was 3 of 55 (5.5%). The changes in the Pelvic Organ Prolapse Quantification System scores, including Aa, Ba, C, Ap, Bp, and total vaginal length values, showed significant improvement after surgery (p <.05 for all).ConclusionThe study demonstrates that vNOTES sacrocolpopexy appears to be an effective option with low risks of mesh exposure and prolapse recurrence. Studies including more patients and longer follow-up periods should be performed before a clear conclusion can be reached.     

Exploration of the Retroperitoneum Using the Transvaginal Natural Orifice Transluminal Endoscopic Surgery Technique

We sought to evaluate the feasibility of the retroperitoneum's exploration via natural orifice transluminal endoscopic surgery (NOTES) using transvaginal access in a porcine model, and its possible application in human beings. Six female pigs (25–30 kg) were used to establish anatomic landmarks and technical steps. Six additional pigs were used for the survival study. Under general anesthesia and with the pig supine, a 1-cm posterolateral colpotomy was performed with the double-channel gastroscope's needle knife. The incision was enlarged laterally using blunt dissection while keeping in contact with the psoas muscle. A retroperitoneal tunnel was created using carbon-dioxide dissection and the movements of the gastroscope up to the level of the kidney. The colpotomy site was closed using interrupted sutures (polyglactin 2/0). A follow-up laparoscopy and necropsy were performed 3 weeks postoperatively. Successful access to the retroperitoneum was achieved in all pigs with a mean operative time of 30 minutes. However, in the first 3 pigs used for the acute study, the peritoneum was perforated during the six-pig dissection and the procedure was abandoned because of the space's collapse. No perforation occurred during the survival study. An excellent view of the retroperitoneal space and structures, such as the vascular and lymphatic tissues, the kidney, the adrenal gland, and the ureter, was obtained. No intraoperative complications or bleeding or injury to any of the retroperitoneal structures occurred. The 3-week follow-up laparoscopy showed no adhesions or abscesses. These findings were confirmed at necropsy. The retroperitoneal space can be successfully accessed via NOTES. Transvaginal NOTES access to the retroperitoneum avoids any transparietal trocars, so it could decrease surgical trauma, be better tolerated, and offer better visualization, with the obvious gender limitation. Future clinical application in human beings may include procedures such as lymphadenectomy, nephrectomy, and adrenalectomy.     

Surgical Outcomes of Hysterectomy via Robot-assisted versus Traditional Transvaginal Natural Orifice Transluminal Endoscopic Surgery

Study ObjectiveTo evaluate the safety and feasibility of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) hysterectomy when compared with traditional vNOTES (T-vNOTES) hysterectomy.DesignRetrospective chart review.SettingAcademic tertiary setting.PatientsTotal of 114 patients with benign gynecologic indication for hysterectomy.InterventionsT-vNOTES or R-vNOTES hysterectomy performed by a single minimally invasive gynecologic surgeon in the study period.Measurements and Main ResultsThe primary outcome of this study was surgical equivalence, measured principally by total operative time between T-vNOTES and R-vNOTES hysterectomy. Secondary operative outcomes that were measured included estimated blood loss, length of hospital stay, reported postoperative pain levels, and number of conversions. A total of 79 women underwent T-vNOTES hysterectomy, and 35 women underwent R-vNOTES hysterectomy without differences in operative time (p = .37), estimated blood loss (p = .27), length of hospital stay (p = .06), or reported postoperative pain levels at weeks 1, 2, and 3 after surgery (p = .78, p = .36, p = .38, respectively). A total of 6 patients underwent conversion in the T-vNOTES hysterectomy group compared with 0 in the R-vNOTES hysterectomy group; however, this was not statistically significantly different, and there were no conversions to laparotomy.ConclusionR-vNOTES hysterectomy is a feasible approach to surgery when compared with T-vNOTES hysterectomy and warrants further consideration as a skill set in a gynecologic surgeon's toolbox. Wristed instruments may allow surgeons who are inexperienced in single-site laparoscopy to adopt vNOTES more quickly as a new technique when performing hysterectomy through a comparable minimally invasive approach.     

Transvaginal endoscopic surgery-assisted versus conventional laparoscopic adnexectomy (TVEA vs. CLA): A propensity-matched study and literature review

Objective

Natural orifice transluminal endoscopic surgery (NOTES) may be useful in gynecologic endoscopic surgery. This study evaluated the efficacy, safety, and perioperative outcomes of combined NOTES and vaginal approach, transvaginal endoscopic surgery-assisted adnexectomy (TVEA), for the surgical treatment of presumed benign ovarian tumors.

Robotic Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Resection of Parametrial and Bowel Deeply Infiltrated Endometriosis

Study ObjectiveTo demonstrate stepwise techniques for the successful utilization of the Robotic-assisted transvaginal Natural Orifice Transluminal Endoscopy Surgery (NOTES) technique for safely surgically managing deeply infiltrated endometriosis (DIE).DesignStepwise demonstration with narrated video footage.SettingAn academic tertiary care hospital.InterventionsA 38-year-old woman—G3P3, who had 1 normal spontaneous vaginal delivery and 1 cesarean delivery for twin pregnancy—with worsening chronic pelvic pain. History of laparoscopic ablation of endometriosis 10 years ago. Magnetic resonance imaging demonstrated adenomyosis, deeply infiltrated endometriosis, and intrapelvic adhesions. Robotic transvaginal NOTES hysterectomy has been demonstrated to be feasible and safe in the surgical management of benign gynecology disease compared with traditional NOTES hysterectomy; however, it can be technically challenging to perform, particularly in managing of additional deep infiltrated endometriosis removal surgery after hysterectomy. The researchers demonstrated that robotic vaginal NOTES surgeries are feasible in complex benign gynecologic procedures such as endometriosis and sacrocolpopexy 1, 2, 3. The robotic wristed instruments with 3D visualization, resulting in delicate tissue dissection and easier suturing and knot tying, are beneficial to surgeons for overcoming the cumbersome surgical techniques in transvaginal NOTES complete endometriosis removal [4,5]. Integration of robotic transvaginal single site surgery and resection of DIE is a novel alternative minimally invasive route that is more cosmetic and less painful.The procedure was successfully performed in approximately 200 minutes, with unevenly postoperative recovery. The patient was discharged home the same day. Her pain level was 7 out of 10 in the first week, 5 out of 10 in the second week, and 2 out of 10 in the third week. Pathology confirmed uterine adenomyosis, endometriosis in the right ureteral, right uterine artery pedicle, and rectum with muscular propria involvement.ConclusionRobotic transvaginal NOTES for deeply invasive endometriosis is challenging but feasible in patients with parametrial and rectal involvement. The advantages of articulating instrumentation and 3D visualization are especially pivotal in complex transvaginal NOTES surgery.