经阴道自然腔道内镜手术在妇科良性疾病中的应用

经阴道自然腔道内镜手术（vNOTES）是指通过女性阴道这一自然腔道,置入内镜及手术器械进行手术。目前主要应用于妇科良性疾病中,因其手术无瘢痕、术后康复迅速、伤口疼痛极轻而备受关注。文章探讨了vNOTES治疗妇科良性疾病的手术指征、方法、优势、操作难点及手术技巧,分析了vNOTES的临床应用价值及可行性。     

妇科经自然腔道内镜手术

        20世纪随着微创外科的迅猛发展及快速康复理念（ERAS）的提出,如何在保障疗效的前提下探寻更加微创甚至无创的手术方式成为外科医生追求的目标,同时从提升医疗技术的角度充分体现对患者的人文关怀。微创外科领域正经历从多孔腹腔镜向单孔腹腔镜（LESS）及经自然腔道内镜手术（NOTES）的演变。 浏览更多请关注本刊微信公众号及当期杂志。     

妇科经自然腔道内镜手术

20世纪随着微创外科的迅猛发展及快速康复理念（ERAS）的提出,如何在保障疗效的前提下探寻更加微创甚至无创的手术方式成为外科医生追求的目标,同时从提升医疗技术的角度充分体现对患者的人文关怀。微创外科领域正经历从多孔腹腔镜向单孔腹腔镜（LESS）及经自然腔道内镜手术（NOTES）的演变。 浏览更多请关注本刊微信公众号及当期杂志。     

经阴道自然腔道内镜手术在不孕症治疗中的临床应用

目的:探讨经阴道自然腔道内镜手术(vNOTES)在不孕症患者治疗中的可行性及优势。 方 法:纳入 2019 年 1 ~ 7 月成都市妇女儿童中心医院诊治的 34 例因输卵管病变行 vNOTES 双侧输卵 管切除术的不孕症患者作为研究对象,记录患者一般资料、围术期资料、术后性生活及妊娠分娩等指 标。 结果:1 例因由阴道后穹隆进入腹腔失败中转传统腹腔镜,手术顺利完成 33 例。 术后第 1 日视 觉模拟疼痛评分,有镇痛泵(14 例)为 1(0,2)分,无镇痛泵(19 例)为 1(0,2)分,差异无统计学意义 (P > 0. 05)。 术后无切口愈合不良,性生活恢复时间 43. 15 ± 18. 86 天,术前及术后女性性功能指数 评分各维度的数据比较,差异无统计学意义(P > 0. 05)。 术后 23 例患者通过体外受精 - 胚胎移植 (IVF-ET)妊娠,妊娠与手术间隔时间 5. 00 ± 3. 60 个月,现已分娩 17 例,其中阴道分娩 6 例,产时顺 利。 结论:vNOTES 可以安全有效地完成因输卵管病变而致不孕症的双侧输卵管切除,术后疼痛轻, 对患者的性功能无不良影响,且在切口愈合良好的情况下进行阴道分娩是可行的。     

无气腹经阴道自然腔道内镜手术在妇科良性疾病中的应用

目的 探讨无气腹经阴道自然腔道内镜手术（V-NOTES）在妇科良性疾病中治疗的可行性。方法 收集2019年1月至2021年4月在沈阳市第四人民医院行无气腹V-NOTES治疗的妇科良性疾病31例,其中输卵管切除术3例,卵巢囊肿切除术11例,子宫肌瘤切除术5例,全子宫+双附件切除术12例。结果31例患者平均手术时间（60.91±22.97）min,平均术中出血量（80.87±57.79）ml,术后平均峰值体温（37.20±0.30）℃,术后平均肛门排气时间（19.07±1.92）h,术后平均住院时间（3.65±0.42）d,术后平均疼痛视觉模拟评分（2.71±0.72）分。31例患者均未发生并发症。结论 无气腹V-NOTES治疗妇科良性疾病安全有效,具有一定的临床推广价值。     

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。     

经阴道自然腔道内镜手术治疗卵巢良性疾病的应用

目的:评估经阴道自然腔道内镜手术(V-NOTES)治疗卵巢良性疾病的安全性及有效性。方法:回顾性分析比较2019年6月至2021年1月在乌鲁木齐市妇幼保健院开展V-NOTES(V-NOTES组,15例)、经脐单孔腹腔镜手术(LESS组,40例)、传统多孔腹腔镜手术(传统腹腔镜组,20例)行卵巢良性肿物剥除术的相关数据及术后情况。结果:V-NOTES组的手术时长(105.10±32.11分钟)与LESS组(92.87±36.54分钟)和传统腹腔镜组(85.06±17.32分钟)比较,差异有统计学意义(P0.05);V-NOTES组的术后24小时疼痛评分(1.93±0.71分)与LESS组(2.83±0.39分)和传统腹腔镜组(2.62±0.93分)比较,差异有统计学意义(P0.05);V-NOTES组的术后24小时肛门排气情况80.00%(12/15)与LESS组57.50%(23/40)比较,差异有统计学意义(P0.05)。3组患者的术中出血量、术后48小时内白细胞计数(WBC)、血红蛋白浓度(Hb)及血细胞比容(Hct)、术后发热、术后病率及术后住院天数比较,差异均无统计学意义(P0.05)。结论:经阴道自然腔道内镜手术治疗卵巢良性疾病安全可靠,在减轻患者术后疼痛、缩短术后肛门排气时间方面更有优势。【     

经阴道自然腔道内镜手术在妇科领域的应用发展现状与展望

随着医学的迅速发展以及微创手术设备和器械的不断开发,手术入路正从传统多孔腹腔镜手术向经脐单孔腹腔镜手术乃至经自然腔道内镜手术（NOTES）演变。NOTES是一种通过人体自然腔道如口腔、肛门、尿道、阴道等,将内镜送入人体自然腔道,并穿透管壁到达胸、腹、盆腔内,建立操作通道和气腹,对器官进行诊治的内镜外科学［1］,其理念来自于外科领域对于有创向微创再向“无创”手术方向发展追求的结果。在保证手术安全性、彻底切除肿瘤与病变组织、保留器官功能的前提下,是一种减轻患者疼痛和不适感、体表无瘢痕、机体反应小、不增加医疗费用的手术方式与途径,这是每一位外科医生所追求的。 浏览更多请关注本刊微信公众号及当期杂志。     

经阴道自然腔道内镜手术在妇科领域的应用发展现状与展望

        随着医学的迅速发展以及微创手术设备和器械的不断开发,手术入路正从传统多孔腹腔镜手术向经脐单孔腹腔镜手术乃至经自然腔道内镜手术（NOTES）演变。NOTES是一种通过人体自然腔道如口腔、肛门、尿道、阴道等,将内镜送入人体自然腔道,并穿透管壁到达胸、腹、盆腔内,建立操作通道和气腹,对器官进行诊治的内镜外科学［1］,其理念来自于外科领域对于有创向微创再向“无创”手术方向发展追求的结果。在保证手术安全性、彻底切除肿瘤与病变组织、保留器官功能的前提下,是一种减轻患者疼痛和不适感、体表无瘢痕、机体反应小、不增加医疗费用的手术方式与途径,这是每一位外科医生所追求的。 浏览更多请关注本刊微信公众号及当期杂志。     

经自然腔道内镜手术在妇科恶性肿瘤中的应用

微创治疗对妇科肿瘤有重要意义。单孔腹腔镜手术（LESS）与经自然腔道内镜手术（NOTES）是微创治疗领域最新发展起来的技术。目前多种妇科良性手术均可以经LESS或NOTES完成,并取得了良好的临床疗效。妇科恶性肿瘤手术较为复杂,LESS与NOTES用于妇科恶性肿瘤的治疗尚有争议,目前国内外学者对NOTES用于恶性肿瘤的治疗已经进行了一些有益的尝试,初步数据证实了该术式的可行性,但是由于操作空间小,造成操作难度较大,手术操作技巧仍有待开发。文章结合笔者单位初步探索的经验,对NOTES在妇科恶性肿瘤中应用的现状、优势、困难与技术经验进行阐述。     

经自然腔道内镜手术在盆底功能障碍性疾病中的应用

随着老龄化社会的到来,盆底功能障碍（PFD）性疾病的诊治近年成为国内外妇产科领域的研究热点之一。而手术是中重度PFD患者的首选治疗方案。随着微创外科技术的发展以及微创理念的更新,PFD术式不断改进,经自然腔道内镜手术（NOTES）因其术后恢复快、疼痛轻、无明显伤口,陆续应用于各类妇科疾病的治疗,PFD也是其适应证之一。虽然微创技术的发展为临床提供了更多的选择方式,但不同术式各有利弊,应严格把握经自然腔道手术的适应证,根据患者的年龄、症状、体征、病史、全身状况等情况综合评估,以达到最好的治疗效果。     

Surgical outcomes of hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) compared with laparoscopic total hysterectomy (LTH) in women with non-prolapsed and benign uterine diseases

ObjectiveWe aimed to compare the surgical outcomes between hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and laparoscopic total hysterectomy (LTH).Materials and methodsThis study is a retrospective chart analysis. From January 1, 2015, to December 31, 2017, a total of 183 patients of reproductive age with an indication for hysterectomy due to non-prolapsed and benign uterine diseases were enrolled. After exclusion, 20 patients were included in the vNOTES group, and 66 patients were included in the LTH group. Various post-operative surgical outcomes such as operative time, blood loss, uterus weight, a decrease in hemoglobin level on post-operative day one, post-operative pain scale, complications, length of hospitalization, and re-admission rate were measured.ResultsNo difference was observed between both groups regarding operative time, blood loss, uterine weight, a decrease in hemoglobin level on post-operative day one, complications, hospital stay, and re-admission rate. Patients in the vNOTES group had significantly less post-operative pain compared with those in the LTH group (p = 0.03).ConclusionsThe surgical outcomes of hysterectomy by vNOTES could be similar to those of LTH. Patients undergoing hysterectomy by vNOTES may have less post-operative pain compared with those undergoing LTH. However, the sample size was small, and the results need more evidence to confirm these findings.     

Natural orifice transluminal endoscopic surgery (NOTES) subtotal hysterectomy: A feasibility study

Objective

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES) has been carried out for benign uterine diseases and nonprolapsed uteri in recent years. Subtotal hysterectomy was performed to remove the uterus with preservation of the cervix by abdominal, laparoscopic, or vaginal routes. The aim of this retrospective study is to gain insight into the feasibility and safety of subtotal hysterectomy through transvaginal NOTES.

Pure natural orifice transluminal endoscopic surgery (NOTES) involving peroral endoscopic salpingo-oophorectomy (POESY)

Objective

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical approach that uses natural orifices to gain access to areas of the body. In the present article, we describe the first transgastric pure NOTES salpingo-oophorectomy, which we call peroral endoscopic salpingo-oophorectomy (POESY).

Methods

A woman with BRCA1 mutation presented for prophylactic bilateral salpingo-oophorectomy. We offered her the transgastric approach, having performed more than 25 transgastric appendectomies. After gastroscopic incision in the corpus wall, we advanced the gastroscope into the abdominal cavity. Salpingo-oophorectomy was performed with the help of an intrauterine manipulator and a transvaginally introduced 5-mm trocar. The posterior colpotomy was dilated and the specimens were extracted. The gastrotomy was closed with an over-the-scope clip, and the colpotomy with a running suture.

Results

The gastroscope provided excellent optical control and good tissue preparation. Prophylactic bilateral salpingo-oophorectomy was performed successfully via POESY. The patient recovered quickly and was discharged on the third day, with an uneventful follow-up.

Conclusion

The present case demonstrates the feasibility of transgastric access. The gastroscope provided excellent optical control and good tissue preparation. Therefore, we expect an increasing role of transgastric procedures for diseases in the pelvic region, particularly if new endoscopic platforms with better means of instrumentation and tissue management become available.     

机器人辅助腹腔镜在妇科经自然腔道内镜手术中的应用

经自然腔道内镜手术（NOTES）是从微创外科发展起来的一种新的革命性外科技术,它利用内镜经人体的自然腔道（如口腔、胃、阴道、膀胱、结直肠等）进入胸、腹腔等进行各种内镜下的操作。传统的NOTES为二维成像,将机器人系统应用于NOTES可实现三维成像。目前开展的机器人NOTES妇科手术主要包括机器人辅助经脐单孔腹腔镜手术及机器人辅助经阴道自然腔道内镜手术。文章就目前机器人辅助腹腔镜在妇科NOTES中的应用进行阐述及讨论。     

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.