vNOTES Lateral Window Approach to Hysterectomy in a Case with Previous History of Multiple Surgeries Resulting in Keloid Scars and Enlarged Uterus with Dense Bladder Adhesions

ObjectiveTo demonstrate transvaginal natural orifice transluminal endoscopic surgery (vNOTES) lateral window approach to hysterectomy in a case with a history of multiple surgeries resulting in keloid scars and enlarged uterus with dense bladder adhesions.DesignStepwise demonstration of the technique with narrated video.SettingA minimally invasive gynecologic surgery department of tertiary care private hospital. A 43-year-old female presented with menorrhagia and dysmenorrhea in the last 8 months. She had a history of undergoing cesarean section twice and an open appendectomy. These surgeries had resulted in keloid scar formation. She was very anxious about keloid formation and desired to avoid abdominal scars. Examination and transvaginal ultrasound revealed enlarged uterus with multiple fibroids. The largest intramural fibroid measured 11 × 9.4 cm.InterventionsvNOTES hysterectomy with the following key strategies was performed: (1) anterior colpotomy with bilateral lateral window dissection, (2) posterior colpotomy with opening of posterior peritoneal pouch, (3) application of wound retractor and vNOTES glove port, (4) continued dissection of lateral window aiding to the completion of hysterectomy, (5) uterine rotation maneuver aiding to bladder adhesiolysis, and (6) transvaginal retrieval of specimen and closure of colpotomy.ConclusionvNOTES is a feasible method of approaching lateral window dissection in scarred uteri. It allows safe dissection and bladder adhesiolysis. It allows excellent visualization of all pedicles and safe hysterectomy for large uteri. Hysterectomy for adherent uteri can be performed by vNOTES.     

vNOTES for Ovarian Drilling: A New Minimal Invasive Technique

Study ObjectiveTo show a new mini-invasive surgical technique of ovarian drilling and fertility workup using transvaginal natural orifice transluminal endoscopic surgery (vNOTES).DesignStepwise demonstration of the technique with narrated video footage.SettingOvarian drilling is a surgical technique for patients with dysovulatory polycystic ovary syndrome. The aim of this technique is to destroy 5% to 10% of the ovarian cortex to restore spontaneous ovulation. Drilling is proposed as a second-line treatment in case of failure of treatments with clomid, metformin, or letrozole. The Cochrane 2020 review shows that drilling has the same pregnancy rate as the other second-line treatment: stimulation with gonadotropins [1]. After ovarian drilling, the results show 80% of spontaneous ovulation within 3 months and 50% of spontaneous pregnancy within a year; these results are effective in the long term [2]. The techniques used until now were either classic laparoscopy or transvaginal hydrolaparoscopy, which is currently not feasible owing to the cessation of the kit [3,4]. We present to you a new surgical technique: ovarian drilling by vNOTES. This new technique is minimally invasive, without scarring on the abdomen, and very well tolerated. It allows simultaneous ovarian drilling and fertility workup with assessment of tubal patency and uterine cavity by hysteroscopy. It is recommended to use bipolar energy to reduce ovarian lesions and limit the risk of adhesion [5].InterventionsTransvaginal laparoscopic ovarian drilling is a minimally invasive surgical technique using a vNOTES kit from Applied Medical (Rancho Santa Margarita, CA), a hysteroscope of 5 mm with an operating channel from Delmont Imaging (La Ciotat, France), and a bipolar spring electrode, Versapoint from Olympus (Hamburg, Germany).The key steps to perform this surgery are as follows:1. Perform a diagnostic hysteroscopy with vaginoscopy2. Perform a posterior colpotomy3. Introduce the Alexis retractor into the Douglas and place the GelPOINT with 2 sleeves4. Introduce the hysteroscope into the pelvic cavity with serum saline, using a pressure of approximately 150 mm Hg5. Drill approximately 10 holes on each ovary using the bipolar electrode6. Explore the pelvic cavity with the possibility of performing a blue test for tubal patency7. Suture the posterior vaginaConclusionOvarian drilling is a surgical treatment proposed after the failure of first-line treatments in polycystic ovary syndrome to obtain long-term spontaneous ovulations. The development of minimally invasive techniques such as vNOTES will highlight this treatment and allow it to be performed easily and with minimal adverse effects on patients, especially in bariatric women for whom the vNOTES technique provides easier access to their pelvic cavity than abdominal laparoscopy.     

Laparoscopic Management of a Heterotopic Pregnancy in the Tubal Stump

Study ObjectiveTo demonstrate how a heterotopic tubal stump pregnancy can be safely managed with laparoscopy, preserving the intrauterine pregnancy.DesignStepwise demonstration of the technique by means of a video tutorial.SettingThe management of pregnancies in the tubal stump after salpingectomy involves either a surgical intervention or systemic therapy. In case of a simultaneous intrauterine pregnancy, although the prognosis for the fetus remains good with live births in approximately 70% of the cases, the surgical management of the tubal stump pregnancy is challenging owing to the risk of bleeding from the uterine horn 1, 2, 3, 4, 5. We present an effective and reproducible laparoscopic technique on the basis of a 31-year-old patient with 2 prior right fallopian tube pregnancies, which were later treated with salpingectomy. The patient is now presenting in the sixth week of gestation after transfer from 2 oocytes with a pregnancy in the tubal stump and a concomitant vital intrauterine pregnancy.InterventionsThe key steps of laparoscopic surgery include (1) continuous absorbable monofilament suture on the uterine horn around the tubal stump to achieve hemostasis and exposure of the proximal part of the tube, (2) removal of ectopic pregnancy, and (3) closure of the excision site with continuous absorbable polyfilament suture. The instillation of vasoconstrictive substances and the use of electrical coagulation should be avoided.ConclusionThe demonstrated laparoscopic technique is a feasible method of removal of a tubal stump pregnancy without interfering with the vital intrauterine pregnancy. The blood loss can be minimized, and laparotomy can be avoided.     

Laparoscopic Management of 42 Cases of Tubal Stump Pregnancy and Postoperative Reproductive Outcomes

Study ObjectiveTubal stump pregnancy is a rare variant of ectopic pregnancy. The aim of this study was to evaluate laparoscopic surgery for tubal stump pregnancy and to investigate postoperative pregnancy outcomes.DesignRetrospective study.SettingUniversity-affiliated hospital.PatientsPatients (n = 42) diagnosed with tubal stump pregnancy.InterventionsData were extracted from the electronic medical records system of the hospital.Measurements and Main ResultsPatients diagnosed with tubal stump pregnancy between June 2010 and July 2018 were included. Data included demographic characteristics, gravidity and parity, history of pelvic surgery, clinical features, and treatment. All procedures were laparoscopic. Postoperative pregnancy outcomes were identified from electronic medical records or by telephone. Patients’ mean age was 30 (range, 21–39) years. Twelve of 42 tubal stump pregnancies (28.6%) had ruptured ectopic pregnancy at the time of operation. The remaining 30 cases had intact stump pregnancy during surgery. Patients were followed for a mean of 31 (range, 10–60) months. Follow-up data were available for 33 of 39 patients (3 with heterotopic tubal stump pregnancy were not included in follow-up data because all resulted in a live births and had no desire for future pregnancy). Eighteen of 28 patients (64.3%) who attempted conception had intrauterine pregnancies (IUPs) during the follow-up period; of these 18 IUPs, 14 (77.8%) resulted in live births. There was 1 case of uterine rupture in a singleton pregnancy at 20⁺⁵ weeks that resulted in fetal death. Three of 18 IUPs (16.7%) ended in the first trimester with spontaneous abortions.ConclusionLaparoscopic surgery is a feasible option for tubal stump pregnancy and is associated with favorable pregnancy outcomes.     

Utility of Vaginal Natural Orifice Transluminal Endoscopic Surgery for Permanent Sterilization after Failed Attempt at Bilateral Tubal Ligation at the Time of Previous Cesarean Section

Study ObjectiveTo demonstrate the utility of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for opportunistic bilateral salpingectomy for permanent sterilization after a failed attempt at bilateral tubal ligation at the time of previous cesarean section.DesignStepwise demonstration with narrated video footage.SettingThere is evidence to support the statistically significant superiority of vNOTES compared with conventional laparoscopy (CL) in terms of patient satisfaction, postoperative pain, time to recovery, and cosmetic results in bilateral salpingectomies for permanent sterilization [1]. Limited studies demonstrate the ease and safety of access to the abdominal cavity in vNOTES while avoiding passage through the abdominal wall, port site complications (infection, hernia, etc.), and those associated with peritoneal adhesions during abdominal laparoscopy or laparotomy [2]. To the best of our knowledge, this would be the first published video of a vNOTES bilateral salpingectomy performed specifically in a patient whose previously attempted bilateral tubal ligation was unsuccessful owing to adhesive disease from 4 previous cesarean sections.InterventionsInstitutional review board approval was not required. We describe a case of a 31-year-old female, with a history of 4 previous cesarean deliveries and a cholecystectomy, who desired permanent sterilization 3 months after the previous cesarean section. During previous cesarean section, bilateral adnexa were unable to be accessed owing to dense adhesions from previous surgeries. The patient was counseled on various forms of reversible contraceptive methods; however, she desired permanent sterilization with a surgical procedure. She was counseled on the various routes for opportunistic salpingectomy. Risks, benefits, and alternatives of each surgical approach were discussed. The patient consented for vNOTES opportunistic salpingectomy and possible CL. She was aware that she had significant adhesive disease at the time of previous cesarean section, so may potentially require a laparotomy for the procedure. However, she refused a laparotomy if the surgery was unable to be performed minimally invasively.(1) Demonstrate setup of transvaginal access platform for vNOTES bilateral salpingectomy.(2) Abdominal survey and appreciation of severe adhesive disease through posterior cul-de-sac.(3) Bilateral salpingectomy through single-site vaginal natural orifice surgery.ConclusionvNOTES bilateral salpingectomy can be considered as a reasonable alternative to CL in patients with severe abdominal adhesive disease from previous surgeries.     

Management of Ectopic Pregnancy Through a Posterior Colpotomy: Two Cases

BackgroundPrior to the availability of modern laparoscopic surgical techniques and equipment, ectopic pregnancy was managed predominately by laparotomy. An alternative surgical approach, by posterior colpotomy, was advocated as a diagnostic and a therapeutic approach that often avoided laparotomy.CasesWe report two recent cases in which ectopic pregnancies were managed by posterior colpotomy to avoid any scars on the abdomen. One case involved a salpingectomy and the other a salpingostomy.ConclusionPosterior colpotomy is a safe, cost-effective, and time efficient method of managing ectopic pregnancy.     

Ectopic pregnancy following emergency contraception with ethinyloestradiol-levonorgestrel: A case report

Background?Emergency contraception with ethinyloestradiol-levonorgestrel is effective, and ectopic pregnancy following its failure is rare.

Case?A 21-year-old nulligravid Japanese woman with regular menstrual periods took ethinyloestradiol-levonorgestrel pills for emergency contraception (EC) 36 and 48 hours after a coitus complicated by retention of the condom in the vagina. She started bleeding vaginally 24 days after that intercourse. As the bleeding continued for three weeks she consulted a gynaecologist. The pregnancy test was positive. Two weeks later she complained of lower abdominal pain, and transvaginal ultrasonography suggested a pelvic blood collection. At emergency surgery, she was found to have a left tubal pregnancy.

Conclusion?Although ectopic pregnancy after failure of EC is rare, one should be alert to its possible occurrence.     

Factors determining fertility after conservative or radical surgical treatment for ectopic pregnancy

Objective: To examine factors determining choice of radical or conservative surgical procedure for tubal ectopic pregnancy and subsequent pregnancy rates.Design: A retrospective study collating information from the operative notes and previous gynecologic history associated with the choice of procedure and pregnancy rates and outcome over 3 years after a primary tubal ectopic pregnancy.Patient(s): Thirty-four women who had undergone conservative (tube sparing) and 56 who had undergone radical (salpingectomy) surgical treatment for tubal ectopic pregnancy at least 3 years before the study.Main Outcome Measure(s): The main outcome measure was the occurrence of a pregnancy (live birth, miscarriage, or ectopic pregnancy) over 3 years after the ectopic pregnancy.Result(s): The type of surgery performed was not affected by a previous history of infertility, known pelvic inflammatory disease, the presence of tubal adhesions, or abnormalities on the contralateral tube. Intrauterine pregnancy was not more likely after conservative treatment of ectopic pregnancy but, equally important, the risk of a further ectopic pregnancy was not increased. The single factor that was clearly associated with future fertility problems was a past history of infertility.Conclusion(s): Better results may be obtained by careful selection of operative procedure based on history and findings at the time of surgery.     

Adnexectomy by poor man’s transvaginal NOTES

The purpose of this study was to demonstrate the feasibility and safety of adnexectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign adnexal masses. Conventional, reusable laparoscopic instruments were used, inserted through aninexpensive, self-constructed single port device. Between November 2013 and November 2014, 20 adnexectomies by vNOTES were performed by a single surgeon (BJ). Only conventional, reusable laparoscopic instruments were used. The self-constructed single port device was made by assembling a surgical glove, a wound protector, one reusable 10-mm trocar, and four reusable 5-mm trocars. The adnexectomy was performed according to the technique for standard laparoscopic surgery, and the specimen was removed through the colpotomy incision. Patient and perioperative data were analysed. Twenty patients underwent adnexectomy by vNOTES, and no conversion to standard laparoscopy or laparotomy was necessary. Mean operation time was 32 min (20–50 min); mean drop in hemoglobin level was 0.9 g/dl (0–2.1 g/dl). There were no operative complications. Post-operative pain scores were very low. The mean size of the removed adnexal mass was 51.8 mm (35–110 mm). Adnexectomy by vNOTES is feasible even for masses up to 110 mm and even when performed with reusable, conventional laparoscopic instruments. The main advantages of vNOTES are better cosmetics, low postoperative pain scores and easy removal of the specimen without spillage. This frugally innovative technique also enables surgeons to perform adnexectomies by vNOTES in low resource settings.     

Transvaginal Natural Orifice Transluminal Endoscopic Uterosacral Ligament Hysteropexy: An Innovative Approach for Treatment of Uterine Prolapse

Study ObjectiveTransvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH).DesignStepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board–approved study.SettingAcademic tertiary referral center.InterventionsThis video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture.ConclusionvNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.     

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Meshless Anterior Repair for the Treatment of Pelvic Organ Prolapse

Study ObjectiveTo demonstrate the feasibility of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) meshless anterior repair for the treatment of pelvic organ prolapse (POP).DesignStepwise demonstration of the technique with narrated video footage.SettingThe vNOTES approach is a recent and rapidly developing technique that allows safe endoscopic transvaginal treatment of benign uterine pathologies [1]. Its use in the treatment of POP is still in its early stages; however, the first results are encouraging in terms of anatomy, functionality, and safety [2].InterventionsWe describe the vNOTES technique of meshless anterior POP repair using a vaginal plastron [3]. The “vaginal plastron” technique uses an autologous vaginal strip that is left attached to the bladder and suspended from the arcus tendineus.After the delimitation of a 6 cm square vaginal strip, a lateral dissection is performed on each side between the bladder and the vaginal fascia to enter the paravesical space. The vaginal strip is left attached to the bladder wall and will later be fixed laterally to the arcus tendineus with 6 nonabsorbable monofilament sutures, caliber 0 (3 on each side of the plastron). The fixation points on the arcus tendineus concern the internal obturator fascia ventrally and the iliococcygeus fascia dorsally. The sutures are placed under endoscopic view using a transvaginal access platform (GelPOINT V-Path, Applied Medical, Rancho Santa Margarita, CA). After deflation and removal of the platform, the sutures are attached to the vaginal strip. Once the vaginal plastron is secured, the anterior vaginal wall is closed.ConclusionThe vNOTES approach offers an endoscopic anatomic view of the paravesical space, thus reducing any blind surgical procedure. It provides an alternative route in the performance of meshless anterior POP repair.     

vNOTES Hysterectomy,Adnexectomy, and Uterosacral Ligament Suspension: A Walk-Through Guide

ObjectiveTo provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy, and vault suspension, using 2 access platform methods.DesignNarrated surgical video based on 2 cases of vNOTES for abnormal uterine bleeding and endometrial intraepithelial neoplasia.SettingA single tertiary-care academic center.InterventionsStep-by-step walk-through is shown to demonstrate the successful completion of a hysterectomy, adnexectomy, and vault suspension. Use of a traditional glove platform and that of an advanced access system, the GelPOINT Access System (Applied Medical), are illustrated. The surgical steps are summarized as follows: (1) colpotomy and abdominal entry, (2) transection of the uterosacral ligaments, (3) placement of an access platform, (4) upper abdominal survey, (5) transection of the uterine and cornual pedicles, (6) identification of the ureters, (7) bilateral salpingo-oophorectomy, (8) uterosacral ligament suspension, (9) cystoscopy, and (10) vaginal vault closure and tying of the suspension sutures.ConclusionThis video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy, and uterosacral ligament suspension with 2 access techniques. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favorable recovery profile, making it an attractive surgical route in appropriate candidates.     

Maternal serum creatine kinase does not predict tubal pregnancy

Purpose: Our purpose was to validate prospectively the predictive value of maternal serum creatine kinase in the evaluation of ectopic pregnancy. Methods: Fifty-one consecutive pregnant first-trimester patients who presented for suspected abnormal pregnancy were enrolled. Maternal serum samples were obtained and assayed for creatine kinase. Patients were subsequently evaluated for abnormal pregnancy by serial quantitative hCG levels, transvaginal ultrasonography, and surgery when appropriate. A receiver operating characteristic (ROC) curve was generated comparing intrauterine to extrauterine (ectopic) pregnancy. Results: Of 51 patients, 18 had an ectopic pregnancy, 16 had a spontaneous abortion, and 17 had an ongoing intrauterine pregnancy. The ROC curve revealed that maternal serum creatine kinase had no ability to predict ectopic pregnancy. Conclusions: Maternal serum creatine kinase is not a reliable predictor of tubal pregnancy.Presented at the Forty-Second Annual Meeting of the Society for Gynecological Investigation, March 15–18, 1995, Chicago, Illinois.     

Ectopic pregnancy: its relationship to tubal reconstructive surgery

Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. The incidence of ectopic pregnancy after tubal surgery is extremely variable and is closely linked to the degree of restoration of normal functional and anatomic integrity after the surgical procedure. This depends, to a large extent, on the amount of previous damage to the tube and its potential reversibility. Major improvements in surgical technique can, therefore, have reduced, but not eliminated, the occurrence of tubal pregnancy. The incidence of ectopic pregnancy associated with any given tubal surgical procedure should be taken into consideration when surgery is contemplated. When the risk of ectopic pregnancy is unacceptably high, or when the patient is reluctant to be exposed to a high risk of ectopic pregnancy, IVF-ET could be offered as an alternative. Table 11 represents the incidence of ectopic pregnancy associated with the various surgical procedures. The figures demonstrate the wide variation in outcome for the same procedure.     

Omental trophoblastic implants and hemoperitoneum after laparoscopic salpingostomy for ectopic pregnancy. A case report

BACKGROUND: In this era of cost containment, laparoscopic management of ectopic pregnancy has become the mainstay of dealing with this common gynecologic emergency. The aim of surgical intervention remains conservation of the fallopian tube, if possible; salpingectomy is reserved for cases of tubal rupture and/or recurrent ectopic pregnancy, where little hope exists of salvaging tubal function. CASE: A 28-year-old woman, para 2, underwent laparoscopic salpingostomy for ectopic pregnancy. She experienced intraabdominal bleeding within the initial 12 hours of the postoperative period. On exploratory laparotomy, there was active bleeding from the site of the salpingostomy, and a salpingectomy was performed. The patient was lost to follow-up and on postoperative day 21 presented with signs of intraabdominal bleeding; repeat laparotomy revealed active bleeding from trophoblastic implants within the greater omentum. The omentum was adherent to the anterior abdominal wall at the site of umbilical trocar placement. An infracolic omentectomy was performed, with a subsequent uneventful postoperative course; the patient was followed until resolution of the serum beta-hCG. CONCLUSION: Postoperative surveillance is important. Positive intraabdominal pressure during laparoscopic surgery and the Trendelenburg position may be contributory to cephalad migration of trophoblast remnants, with the scavenging action of the omentum and adherence to the site of umbilical trocar placement theoretically providing a mechanism for neovascularization and sustenance of the parasitic trophoblast.     

Long-term Outcome After Laparoscopic Treatment of Heterotopic Pregnancy: 19 Cases

Study ObjectiveTo determine the long-term outcome of intrauterine pregnancies after treatment of heterotopic pregnancies.DesignRetrospective cohort study (Canadian Task Force classification II-3).SettingTertiary center university hospital.PatientsAll women who underwent surgery because of heterotopic pregnancy over 12 years.InterventionLaparoscopic surgery.Measurements and Main ResultsInfant development and future pregnancy. Extrauterine pregnancies were located in the tube (n = 13), uterine cornua (n = 3), ovary (n = 1), and tubal stump (n = 2). During laparoscopy, a ruptured tube was found in 6 tubal pregnancies (46%), blood transfusion was needed in 7 heterotopic pregnancies (37%), and salpingectomy was performed in 12 women with tubal pregnancies (91.7%). The pregnancy outcome consisted of 13 babies (term and preterm) taken home and 5 miscarriages. Long-term follow up demonstrated that 10 of 13 infants (76.9%) exhibited normal development. Three infants, all from 1 triplet pregnancy, exhibited borderline to normal development. Ten of 15 women achieved additional pregnancies, with 10 deliveries and only 1 extrauterine pregnancy in the tubal stump.ConclusionsWomen with a heterotopic pregnancy are at high risk for late diagnosis and at risk for hypovolemic shock at diagnosis, and may require blood transfusion. The outcome of intrauterine pregnancy in association with heterotopic pregnancy requiring surgical intervention is good, and most complications were associated with multifetal pregnancy and preterm delivery.     

Learning Curve Analysis of Transvaginal Natural Orifice Adnexal Surgery

Study ObjectiveThis study was designed to evaluate the learning curve of transvaginal natural orifice surgery (NOS) for adnexal tumors based on the type of procedure (adnexectomy or cystectomy).DesignRetrospective cohort study.SettingTertiary-care university hospital.PatientsOne hundred thirty-six women with adnexal tumors.InterventionsA series of 136 consecutive transvaginal NOS for adnexal tumor were performed between April 2011 and June 2016. Eighty-five patients (62.5%) had undergone cystectomy, and 51 patients (37.5%) had undergone adnexectomy.Measurements and Main ResultsThe transvaginal NOS procedures included vaginal, endoscopic, single-port access techniques and were divided into 2 categories: adnexectomy and cystectomy. Operating time was electronically recorded and was defined as the time from the creation of a posterior colpotomy incision until the complete closure of the posterior colpotomy opening. The average operating time for the cystectomy and adnexectomy groups was 42.7 and 37.7 minutes, respectively (p = .015). The learning curve was analyzed using the cumulative summation method and showed that 36 cases were needed to achieve proficiency in transvaginal NOS for ovarian cystectomy. However, there was no significant cut-off point to determine the number of patients who had undergone adnexectomy.ConclusionA well-trained gynecologic endoscopist can achieve surgical proficiency in transvaginal NOS cystectomy after 36 cases. It is suggested that the surgical transvaginal NOS procedure should begin with adnexectomy rather than with cystectomy to avoid initial technical challenges.     

Shoulder pain after natural orifice transluminal endoscopic surgery decreased with abdominal compression and pulmonary recruitment maneuver: A retrospective study

ObjectiveThe study aimed to assess the efficacy of abdominal compression and pulmonary recruitment maneuver (CPRM) after transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to alleviate post-laparoscopic shoulder pain (PLSP).Materials and methodsIn this retrospective cross-sectional study conducted in a tertiary referral medical center, women who underwent vNOTES between January 2018 and May 2019 were classified into control group and CPRM group with CO₂ force expelled. Data on the demographic characteristics, indications for surgery, and surgical history were collected. Postoperative pain was assessed 24 and 48 h postoperatively using the visual analog scale (VAS, 0–10). Chest radiography was used to determine the residual air volume 24 h after surgery.ResultsOf 10 patients, 6 and 4 underwent vNOTES adnexal surgeries and vNOTES hysterectomy, respectively. The median volumes of residual pneumoperitoneum were 9.02 mL and 28.11 mL in the CPRM and control groups, respectively (p = 0.001). The intensity of PLSP in the CPRM and control groups were 0 ± 0 vs. 3.4 ± 3.4 and 0.4 ± 0.8 vs. 2.2 ± 2.2 24 and 48 h after surgery, respectively (p = 0.005 for 24 h and p = 0.04 for 48 h).ConclusionCPRM might facilitate decrease in residual gas volume and PLSP after vNOTES. CPRM might be considered using in vNOTES to decrease PLSP.     

Ectopic tubal pregnancy after hysterectomy and tubal ligation

Posthysterectomy ectopic pregnancy is an unusual condition that may present soon after hysterectomy or several years later. Similarly, although tubal ligation is a widespread method of contraception, tubal pregnancy after tubal ligation is not common either. If any of these conditions are rare, having an ectopic pregnancy after hysterectomy and tubal ligation is even more infrequent and only one of such cases was found in our review of the literature. We describe the case of a 35-year-old patient, with history of bilateral tubal ligation and vaginal hysterectomy that looked for medical attention due to abdominal pain. A pregnancy test was positive and a transvaginal ultrasound demonstrated the presence of a gestational sac at the vaginal cuff, adjacent to the ovary. An exploratory laparotomy showed a ruptured ectopic pregnancy located in the distal portion of the left fallopian tube. The occurrence of an ectopic pregnancy several years following tubal ligation and vaginal hysterectomy is a rare phenomenon that appears to be secondary to a fistulous connection into the peritoneal cavity.