Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery for nonprolapsed uteri

Health-related quality of life following hysterectomy by vNOTES versus conventional laparoscopy

OBJECTIVE

To evaluate safety, efficacy, pre- and postoperative outcomes of vNOTES hysterectomy compared to conventional laparoscopic (CL) hysterectomy.

MATERIAL AND METHODS

This prospective study was conducted on patients who underwent CL or vNOTES hysterectomy for benign gynecological indications between January and July 2021. Sociodemographic, clinical, and surgical data were collected. Health-related quality of life (HRQoL) outcomes were evaluated using the EQ-5D-5L questionnaire.

RESULTS

A total of 228 patients (CL vs. vNOTES: 147 vs. 81) were included. No significant differences were observed between the two groups in terms of blood loss, uterine weight, complications, length of hospital stay, and readmission rate. Patients in the vNOTES group experienced significantly less postoperative pain and required less analgesia compared to those who underwent CL hysterectomy (p < 0.001). The CL group had a shorter operative time (p < 0.001). There was a significant difference between the two groups in the EQ-5D-5L pain/discomfort dimension (p = 0.047).

CONCLUSION

This research showed that vNOTES has various advantages, such as less postoperative pain, reduced analgesic usage, and better HRQoL outcomes three months after surgery.

Perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery and transumbilical laparoendoscopic single-site surgery in hysterectomy: A comparative study

OBJECTIVE

This study aimed to compare the perioperative outcomes of patients who underwent hysterectomy for benign gynecologic diseases using transvaginal natural orifice transluminal endoscopic surgery (vNOTES) or transumbilical laparoendoscopic single-site surgery (TU-LESS).

METHODS

A total of 314 patients who underwent hysterectomy for benign uterine disease at West China Second University Hospital between October 2018 and December 2021 were enrolled in this retrospective study. vNOTES (n = 157) and TU-LESS (n = 157) recipients were matched 1:1 in terms of uterine volume. The operation time, blood loss, postoperative decrease in hemoglobin, uterus weight, postoperative hospital stay, postoperative pain score at 12 h, postoperative indwelling catheter time, and other clinical indicators were compared between the two groups.

RESULTS

All 314 patients successfully completed the surgery, and the two groups had similar baseline characteristics, with no statistical difference. Regarding intraoperative outcomes, the operation time was shorter in the vNOTES group than in the TU-LESS group (80 vs 100 min, P = 0.04), and there were no significant differences in intraoperative blood loss, intraoperative blood transfusion rate, postoperative decrease in hemoglobin, or uterine weight. Concerning postoperative outcomes, vNOTES hysterectomy was significantly superior to TU-LESS hysterectomy in terms of the length of hospital stay (3 vs 4 days, P < 0.001), visual analog scale score for pain at 12 h after surgery (P = 0.04), postoperative indwelling catheter time (39.5 vs 64.0 h, P < 0.001), and postoperative exhaust time (24.0 vs 42.0 h, P < 0.001). There were no significant differences in postoperative complications between the two groups.

CONCLUSION

vNOTES and TU-LESS seem safe and feasible for hysterectomy, but vNOTES hysterectomy was more conducive to the postoperative rehabilitation of patients, with less trauma, less pain, and better cosmetic effects than TU-LESS hysterectomy. As an emerging surgical approach, more studies, including large-sample, multicenter, randomized controlled trials, are needed to validate our findings.

Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men

BACKGROUND AND AIM

Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62).

RESULTS

TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001).

CONCLUSIONS

For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

Comparison of hysterectomy cases performed by transvaginal natural orifice transluminal endoscopic surgery: A paired sample cross-sectional study

This study aimed to investigate the feasibility, indications, and benefits of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) hysterectomy for nonmalignant gynecological diseases. The clinical data, including the baseline information and surgical conditions of 81 patients who underwent v-NOTES hysterectomy for nonmalignant gynecological diseases in a tertiary university hospital from October 2018 to August 2022, were retrospectively analyzed and compared with the total laparoscopic hysterectomy group (200 cases) and the transumbilical laparoendoscopic Single Site Surgery group (150 cases). In comparison with the other 2 groups, the highest proportion of patients in the v-NOTES group had cervical intraepithelial neoplasia. Accordingly, mean preoperative uterine volume measured by sonography was significantly smaller in the v-notes group. In the v-NOTES group, the mean number of vaginal deliveries and age were significantly higher, while the mean number of previous abdominal surgeries was lower compared to the other 2 groups. The V-NOTES group had a shorter operation time, shorter postoperative urinary catheter insertion time, earlier intestinal recovery days, shorter hospital stay, and lower visual analogue scale scores after surgery, and the differences were statistically significant. When indicated appropriately, v-NOTES hysterectomy can be a feasible and advantageous surgical modality. In particular, in comparison to the laparoendoscopic Single Site Surgery and total laparoscopic hysterectomy groups, the v-NOTES group had advantages in postoperative recovery and had more aesthetic surgical results.

Comparative outcomes between transvaginal endoscopic hysterectomy and total laparoscopic hysterectomy in patients with benign uterine disease: A single-center, retrospective, cohort, interrupted time-series study

OBJECTIVES

To compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and transvaginal endoscopic hysterectomy (TVEH) for benign uterine diseases.

METHODS

This retrospective, cohort, interrupted time-series study included patients who underwent TLH between January 2013 and September 2016 and TVEH between October 2016 and June 2020. Median difference regression was used to compare the hospital length of stay (LOS) and operative time between the groups. Risk difference regression was used to analyze the proportion of patients who developed postoperative fever or vaginal stump infection.

RESULTS

Of the total 171 patients enrolled, 101 and 70 underwent TVEH and TLH, respectively. The mean ages of patients in the TVEH and TLH groups were 46.49 and 46.17 years, respectively. No conversion was observed. Ureteric injury occurred in one patient in the TVEH group, whereas there was no organ injury in any of the patients in the TLH group. Compared with those in the TLH group, patients in the TVEH group had a significantly shorter median operative time, shorter hospital LOS, lower morphine use, and lower postoperative febrile morbidity rates. However, no significant difference was observed in the rate of vaginal stump infection between the groups.

CONCLUSION

Given the shorter operative time, shorter hospital LOS, less febrile morbidity, and lower morphine use in patients with TVEH than in those with TLH, TVEH should be considered as an alternative hysterectomy procedure for benign uterine diseases.

Clinical relevance of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecology

This study reviews the progress and recent advances in vaginal natural orifice transluminal endoscopic surgery (vNOTES) as a minimally invasive gynecologic procedure. The proposed advantages of vaginal natural orifice transluminal surgery include enhanced cosmesis due to a scarless procedure, better exposure compared with the pure vaginal approach, tolerable pain scores, fewer perioperative complications, and a shorter hospital stay. Recent advances in surgical instrumentation and technology have improved the feasibility of vNOTES as an innovative treatment option for gynecological conditions. However, technical challenges and training issues must be overcome before its widespread use. As a promising surgical innovation, further randomized comparative studies are required to clarify the safety and effectiveness of vNOTES in gynecology.

Impact of Uterine Weight and Shape on vNOTES Hysterectomy: Analysis of 238 Consecutive Cases

STUDY OBJECTIVE

To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes.

DESIGN

Observational study.

SETTING

Swiss teaching hospital.

PATIENTS

Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting ≥280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries).

INTERVENTIONS

All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups.

MEASUREMENT AND MAIN RESULTS

We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 ± 59.5 g in type 0, 398.0 ± 167.3 g in type 1, 603.5 ± 217.9 g in type 2, and 661.7 ± 281.6 g in type 3. Operative time in type 0 (65.1 ± 30.9 minutes) and type 1 (65.1 ± 24.0 minutes) was shorter than in type 2 (102.3 ± 60.0 minutes) and type 3 (115.2 ± 40.3 minutes). Blood losses were more significant in type 2 (158.5 ± 212.0 mL) and type 3 (158.5 ± 110.7 mL) than in type 0 (85.6 ± 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively).

CONCLUSION

The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate.

Obvious advantage of vaginal natural orifice transluminal endoscopic surgery hysterectomy against total laparoscopic hysterectomy in small uterus patients and the future prospects at a regional core institution: A retrospective study

Objective

Owing to the combination of benefits, including permanent visual guidance and no abdominal skin incision, vaginal natural orifice transluminal endoscopic surgery hysterectomy (vNOTES-H) is currently widely used. However, the introduction of vNOTES-H has been delayed in many Japanese regional core hospitals because of its specific device and skill requirements. Therefore, the characteristics and advantages should be explained for the widespread use of this technique.

Study design

We reviewed the medical records of 17 patients with vNOTES-H and 94 patients with total laparoscopic hysterectomy (TLH) from January 1, 2015 to December 31, 2022. In this analysis, to compare the results of vNOTES-H to TLH, we excluded certain patients with a relatively heavy uterus (>255 g) and the presence of abdominal adhesions. In this report, first, the characteristics of the vNOTES-H procedures using a transvaginal access platform are explained by referring to one representative patient. Second, the patient characteristics of the vNOTES-H and TLH groups, including operation time and blood loss amount, were compared. Then, to detect the influence of vNOTES-H on the difficulty of operation among all 111 patients, we performed a multivariate logistic regression analysis to assess the influence of each of 9 factors, including "vNOTES-H", "Advanced age", "High BMI", "3 parity", "Gynaecological operation history", "Adenomyoma", "Large leiomyoma", "Heavy uterus" and "Large uterus", on the two indexes, including "Short time operation" and "Massive blood loss".

Results

In the simple comparison between the groups with vNOTES-H and TLH, the operation time in the former group was significantly shorter than in the latter group, although other factors did not show significant differences, including blood loss amount. Moreover, in the multivariate logistic regression analysis of all 111 patients, the "vNOTES-H" factor showed a significantly high possibility of "short time operation", although no factor, including "vNOTES-H", showed a significant influence on "massive blood loss".

Conclusions

vNOTES-H showed advantages in terms of operation time without increasing blood loss for patients with a relatively small uterus. However, to expand the selection for vNOTES-H, we should accumulate further patients and perform more analyses.

Hysterectomy Using Vaginal Natural Orifice Transluminal Endoscopic Surgery Compared with Classic Laparoscopic Hysterectomy: A New Advantageous Approach? A Systematic Review on Surgical Outcomes

INTRODUCTION

Minimally invasive surgery aims to reduce surgical trauma and post-operative morbidity. Natural orifice transluminal endoscopic surgery is a safe and valid surgical option for hysterectomy. The present systematic review aims to compare hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) with laparoscopic hysterectomy in terms of efficacy, surgical outcomes, complications, and cost.

MATERIALS AND METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It includes randomized controlled trials, controlled clinical trials, prospective or retrospective cohorts, case-control studies, and previous systematic reviews. Inclusion criteria are as follows: female patients undergoing hysterectomy for benign pathologies by vNOTES or laparoscopic hysterectomy. The assessed outcomes were the following: conversion rate, mean uterus weight (g), operative time (mins), hospital stay (days), peri-operative complications, post-operative complications, peri-operative blood loss (mL), blood transfusion needs, post-operative day 1 hemoglobin (Hb) change (g/dL), post-operative pain level (VAS), and cost (USD) in both techniques.

RESULTS

Seven studies were included. vNOTES hysterectomy was not inferior to laparoscopic hysterectomy regarding surgical outcomes, with a shorter operative time, shorter recovery time, less post-operative pain, and fewer post-operative complications. There was no significant difference in the rate of peri-operative complications and no differences in peri-operative blood loss, post-operative day 1 Hb change, and transfusions. Nevertheless, vNOTES hysterectomy was shown to be more expensive than its laparoscopic counterpart.

CONCLUSIONS

While the feasibility and safety of the vNOTES hysterectomy were already established, this review also underlines the noninferiority of this technique when compared to laparoscopic hysterectomy in terms of surgical outcomes. In addition, vNOTES hysterectomy was associated with faster operating time, shorter hospital stay, and better post-operative pain scores compared with laparoscopic hysterectomy.

Implementing the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) "first" strategy in benign gynecological surgeries

PURPOSE

The use of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as the first choice of surgical route for patients scheduled to undergo conventional laparoscopy is still being debated. We aimed to evaluate and compare the outcomes of the "vNOTES first" strategy in benign gynecological cases.

METHODS

All benign gynecological surgeries were initiated using vNOTES during the study period, regardless of the difficulty. Surgical outcomes, short-term patient satisfaction and sexual pain were compared between hysterectomies, adnexal and diagnostic procedures. Visual Analog Score (VAS), Patients Global Impressions of Improvements scale (PGI-I) and Female Sexual Function Index (FSFI) were used to assess the postoperative pain, satisfaction and sexual pain, respectively.

RESULTS

A total of 105 vNOTES procedures were performed during the study period: 63 (60.58%) adnexal procedures, 36 (34.62%) hysterectomies, 5 (4.81%) diagnostic procedures and one (0.96%) myomectomy. The median 24th hour VAS scores for adnexal, hysterectomy, and diagnostic procedures were 1.29 ± 1.41, 2.06 ± 2.08, and 2.6 ± 2.41, respectively. The satisfaction rate was 96.19% at the 1st postoperative week and 97.14% at the first month. There was either no change or a slight improvement in the patients' total score on the FSFI/pain domain before and after surgery. There were two conversions (1.9%) from vNOTES to laparoscopy and laparotomy, and two (5.56%) bladder injuries in hysterectomy cases.

CONCLUSION

Implementing the vNOTES technique as an initial approach for all benign gynecological surgeries seems feasible, safe and satisfactory, even in those with a non-prolapsed or enlarged uterus and those that have previously undergone abdominal surgery. The pain scores were found to be low and patients stated a high satisfaction with no or better change in their sexual life.

The revival of vaginal surgery in the era of endoscopy: V-NOTES initial experience with a series of 32 patients

Background: Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) is an emerging surgical technique in the evolution of minimally invasive surgery. This technique allows different types of surgical procedures to be performed by vaginal access with endoscopic control. The combination of vaginal surgery and laparoscopy brings many advantages, especially the absence of incisions in the abdominal wall and better visualization of the abdominal cavity. Objectives: In this retrospective study we report our initial experience of V-NOTES in benign gynaecologic surgery by describing our first consecutive 32 surgeries. Materials and Methods: From June 2020 to January 2022, 32 gynaecological procedures were performed by V-NOTES by the same surgeon in a university hospital. Perioperative outcomes were evaluated retrospectively. Main outcomes measures: Conversion to laparoscopy or laparotomy and peri-operative and post-operative complications. Results: None of the 32 V-NOTES procedures required conversion to conventional laparoscopy or laparotomy. We observed 2 intraoperative complications managed by V-NOTES and 2 post-operative complications (Clavien-Dindo Grade 2). Conclusion: Our results are similar to studies previously published about this subject and are promising concerning the techniques efficacy and safety. We do believe that a short training allows to reach benefits safely. However, further prospective multicentre randomized trials comparing V-NOTES to totally laparoscopic hysterectomy and to vaginal hysterectomy are needed to strengthen the validity of this new approach. What’s new? V-NOTES widens the indications of vaginal hysterectomies by removing limitations such as large uterus, absence of prolapse, and history of caesarean. Moreover, this technique allows adnexal surgery to be performed by vaginal access.

The Feasibility and Safety of vNOTES Hysterectomy and Uterosacral Ligament Suspension: A Case Series

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a recently introduced surgical approach that is even less invasive than conventional laparoscopy or robotic surgery. We conducted this study to report our experience in vNOTES hysterectomy and uterosacral ligament suspension and determine the feasibility and safety of this approach. Surgeries on 23 women were performed by a single surgeon in 1 tertiary medical center. Patient demographics, perioperative data, and follow-up details of 23 women were collected prospectively. Average age was 56.7 ± 8.9 years. Median parity was 3. Nine patients were smokers, and 4 patients had diabetes. Median stage of prolapse was 3. One patient had extensive adhesions, and after vNOTES hysterectomy was completed, decision was made to perform uterosacral suspension by conventional vaginal access. Another patient had intraoperative identification by cystoscopy of unilateral kinking of the ureter that was resolved after the most distal uterosacral stitch was released. Mean uterine weight was 271.9 ± 131.9 g. Average estimated blood loss was 85.22 ± 55.6 mL. Median length of stay in the hospital was 1 day. Only 1 patient had intermittent voiding postoperatively and required an indwelling catheter for 3 days. Hysterectomy and uterosacral ligament suspension when performed via vNOTES is a safe and feasible procedure. Large prospective trials are on the way to continue shedding light on this new surgical modality.

Vaginal hysterectomy versus vaginal assisted NOTES hysterectomy (VANH): a protocol for a randomised controlled trial

Introduction

Natural Orifice Transluminal Endoscopic Surgery is a minimal invasive technique using natural body orifices like the vagina. Benefits of a vaginal assisted NOTES hysterectomy (VANH) are no visible scars, less blood loss, shorter surgery time and it allows more women to undergo a hysterectomy in a day-care setting compared with the total laparoscopic hysterectomy. Trials comparing vaginal hysterectomy (VH) and VANH are lacking. The aim of this study is to compare hysterectomy by VANH versus VH for same-day discharge (SDD), complications, surgical outcomes, postoperative recovery, quality of life, costs and cost-effectiveness.

Methods and analysis

The study is a single-blinded, multicentre, randomised controlled trial. Eligible women with benign indication for hysterectomy will be randomly allocated to the VH (control) group or the VANH (intervention) group. The primary outcome is SDD. We calculated a sample size of 124 women assuming 27% SDD difference with an alpha of 0.05 and power of 0.8. A total of 83 patients will be included in the VANH-group and 41 patients in the VH-group, using an enrolment ratio of 2:1. Secondary outcomes are; surgery-related complications, surgical outcomes, postoperative recovery, quality of life, costs and cost-effectiveness.

Ethics and dissemination

The study was approved on 27 May 2021 by the Ethics Committee of the Zuyderland Medical Centre Heerlen. The first patient was randomised on 8 July 2021. The last participant randomised should be treated before 31 December 2022. The results will be presented in peer-reviewed journals and at scientific meetings within 4 years after starting recruitment.

Trial registration number

NCT04886791.

Standardized 10-step approach for successfully performing a hysterectomy via vaginal natural orifice transluminal endoscopic surgery

Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES.

Comparison of Two Different Accesses Single Orifice Percutaneous Endoscopic Surgery in Diagnosis of Ascites of Unknown Origin: A Retrospective Study

Background

Ascites is a common clinical finding caused by many different diseases, so we developed a technique termed single orifice percutaneous endoscopic surgery (SOPES) which can access peritoneal cavity through the contralateral McBurney's point or umbilicus to seek the underlying causes. In this study, we describe the initial clinical experience of SOPES and compare the application of two accesses.

Methods

This is a retrospective study performed between 2007 and 2018. Patients with ascites of unknown origin who underwent these two kinds of SOPES were included. Main outcomes were measured by diagnostic accuracy, complication rate, procedure time, time till stitches removal, length of hospital stay, and hospital cost.

Results

148 patients successfully undergone SOPES via the contralateral McBurney's point (IM group, n = 70) or the umbilicus (UM group, n = 78). 63 patients in the IM group and 71 patients in the UM group reached clear diagnosis (90.0% vs. 91.0%, p = 0.831). The overall complication rate was 5.4%, while the UM group was higher than the IM group (10.3% vs. 0%, p = 0.017). All complications were resolved after medical treatment, and no mortality resulted from this procedure. The procedure time and the time until stitches removal in the UM group were longer than that in the IM group. There were no significant differences in length of hospital stay and hospital cost between the two groups.

Conclusions

SOPES, which combines the strength of minimally invasive single orifice incision and flexible angles of examination and instrumentation, is a newly developed flexible endoscopic surgical modality that provides new important clinical valuable in evaluation of ascites of unknown origin. Moreover, SOPES via the contralateral McBurney's point was safer than the umbilicus approach.

Comparison of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) and Laparoendoscopic Single-Site (LESS) Hysterectomy on Postoperative Pain Reduction: A Randomized Pilot Study

INTRODUCTION

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy has shown benefit in postoperative pain and operation time compared to laparoscopic hysterectomy in recent studies. However, no prospective studies comparing laparoendoscopic single-site (LESS) and vNOTES hysterectomy have been performed. This study aims to evaluate postoperative pain and safety of vNOTES hysterectomy compared to LESS hysterectomy for benign uterine disease.

METHODS

This study is a prospective, investigator-initiated randomized controlled pilot trial. A total of 26 patients were randomized and allocated to vNOTES group (n = 13) and LESS group (n = 13). The primary outcome was postoperative abdominal and vaginal pain evaluated 24 h after surgery. Secondary outcomes included the number of additional analgesics administered and the maintenance rate of patient-controlled analgesia (PCA).

RESULTS

No differences were shown in baseline characteristics between the two groups. Operation time was longer in the LESS group (median, 55 vs. 75 min; P = 0.027), and there were no differences in estimated blood loss, postoperative hemoglobin level, surgical indications, and hospitalization days. Postoperative abdominal pain intensity did not differ between the two groups, while the vNOTES group showed higher postoperative vaginal pain than the LESS group at 16 and 24 h after surgery (median, 3 vs. 1 and 2 vs. 0, P = 0.007 and P = 0.010, at 16 and 24 h respectively). No differences were shown in the number of additional analgesics and PCA use between the two groups.

CONCLUSIONS

vNOTES hysterectomy can be safely performed for benign uterine disease requiring hysterectomy. However, vNOTES hysterectomy might be associated with higher postoperative vaginal pain intensity compared to LESS hysterectomy.

TRIAL REGISTRATION

CRIS identifier KCT0004605.

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery versus single-port laparoscopy: Comparison of early outcomes

AIM

The study objective was to compare intraoperative and early postoperative outcomes among patients who underwent hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (and single-port lararoscopy for presumed benign gynecologic disorders).

METHODS

We retrospectively reviewed 40 patients who underwent single-port laparoscopic hysterectomy and 20 patients who underwent hysterectomy via natural orifice transluminal endoscopic surgery. Patients' age, body mass index, history of previous delivery and surgery, total operation time (from skin incision to closure), intraoperative and postoperative complications conversion to another surgical procedure, drop of hemoglobin level, postoperative pain at 1 and 18 h, average hospital stay, and clinical outcomes were analyzed.

RESULTS

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery was superior to single-port hysterectomy concerning the length of hospitalization (p < 0.001) and visual analog scale at 1 h (p = 0.024) and 18 h (p < 0.001). In transvaginal natural orifice transluminal endoscopic group, postoperative complications were lower than single-port laparoscopy group (p = 0.023). In transvaginal natural orifice transluminal endoscopy, group conversion to a standard vaginal hysterectomy occurred in two cases (10%). Four patients in the single-port laparoscopic hysterectomy group had umbilical herniation, three had port-site infections, and two patients had vaginal cuff hematoma. These patients required rehospitalization.

CONCLUSIONS

Despite hysterectomy via transvaginal natural orifice transluminal surgery has not yet found its place in routine practice in gynecology departments, it could be a prominent alternative approach to other minimally invasive surgical procedures in selected patients with many advantages including lesser pain and lower complication rates compared with single-port laparoscopic hysterectomy.

Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES)

STUDY OBJECTIVE

The first ever report of vaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynaecological was reported in 2012. There has been an exponential uptake of the number of surgeons performing such procedures worldwide with no official guidance to ensure the safe implementation of this technique into gynaecological practice due its recency. The objective of this study is to report an international consensus-based statement to help guide a basis for adopting vNOTES into clinical practice.

STUDY DESIGN

The consensus-based statement was developed amongst 39 international experts using the Delphi methodology over three successive rounds. Consensus was pre-defined as an agreement of 80% or more by the experts. Consensus sought over eight key concepts pertaining to vNOTES including patient selection, perioperative management, surgical technique, instruments, anatomy, training, registries and trials and definition of the surgical technique. Recommendations from an expert anaesthetist and urogynaecologist were also sought to give a broader perspective with respect to the implementation of vNOTES.

RESULTS

Fifty nine international surgeons were invited to participate and 39 (66%) agreed to participate based on being involved in a minimum of 20 vNOTES procedures. They were from 13 countries across 5 continents (Europe, North America, South America, Australia and Asia). Participation was 100% on all three rounds. Overall, consensus was reached in 50 of the 56 questions (89%) with the remaining 6 questions where consensus was not reached pertaining to the domain of patient selection.

CONCLUSION

An international expert based vNOTES statement is presented here to help guide adoption of vNOTES based on the experience of early adopters. Consensus was achieved on most components of this consensus statement. Given the recency of this technique, until high-level evidence becomes available, this statement provides an appropriate guidance to the safe implementation of vNOTES into gynaecological practice.

Hysterectomy via vaginal Natural Orifice Transluminal Endoscopic Surgery in virgin patients: a first feasibility study

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a minimally invasive, scar-free technique that uses a vaginal colpotomy to access the peritoneal cavity. Hysterectomy via vNOTES has shown to be technically feasible and safe, with shorter hospital stay and lower postoperative pain scores. Moreover, vNOTES adds the advantages of endoscopy to those of vaginal surgery and thereby broadens the indications of a conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, as vaginal accessibility can be severely reduced in virgin women. Therefore, cases of vNOTES hysterectomy in virgin patients have never been reported in the literature. The objective of this study is to assess the technical feasibility and safety of hysterectomy in virgin women. We performed a retrospective analysis of patient files of all vNOTES hysterectomies performed on virgin women in our centre (Imelda Hospital, Bonheiden, Belgium) from July 2016 until June 2020 (N = 9). Despite limited vaginal accessibility, vNOTES hysterectomy was successfully performed in all nine patients, without conversion to laparoscopy or laparotomy and without clinically relevant complications. In this first IDEAL stage 1 study, vaginal NOTES hysterectomy appears to be technically feasible and safe in virgin women.Impact statementWhat is already known on this subject? Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging, minimally invasive technique that offers a safe alternative to laparoscopy and open surgery. Besides better cosmetics (scar-free technique), advantages of vNOTES hysterectomy include shorter hospital stay and less postoperative pain compared to laparoscopic hysterectomy. Moreover, vNOTES adds the benefits of endoscopy (visualisation of anatomy) to conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, because the absence of uterine descent and narrow vagina in virgins is thought to complicate the vaginal approach. Therefore, vNOTES hysterectomy has never been reported in virgin patients.What do the results of this study add? In this study, we are the first to report the feasibility of performing a vNOTES hysterectomy in virgin patients. The results show that, in experienced hands, indications for vNOTES can be broadened and include virgin women.What are the implications of these findings for clinical practice and/or further research? This first report of vNOTES hysterectomy in virgin patients is only a small but important step in the evaluation of safety and efficacy of this emerging technique. Further research is needed to assess reproducibility of the findings and to carefully determine indications and contraindications of vNOTES.

Meta-analysis of Laparoendoscopic Single-site and Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy Compared with Multiport Hysterectomy: Real Benefits or Diminishing Returns?

OBJECTIVE

Because minimally invasive hysterectomy has become increasingly performed by gynecologic surgeons, strategies to further improve outcomes have emerged, including innovations in surgical approach. We sought to evaluate the intraoperative and perioperative outcomes and success rates of laparoendoscopic single-site surgery (LESS) and vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy in comparison with those of conventional multiport laparoscopic (MPL) hysterectomy.

DATA SOURCES

A librarian-led search of PubMed, Scopus, CINAHL, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials was performed for case-control, retrospective cohort, and randomized controlled trials through May 2020.

METHODS OF STUDY SELECTION

The inclusion criterion was publications comparing LESS or vNOTES hysterectomy with conventional MPL hysterectomy for the management of benign or malignant gynecologic disease. Four authors reviewed the abstracts and selected studies for full-text review. The manuscripts were reviewed, separately, by 2 authors for final inclusion and assessment of bias using either the risk-of-bias assessment tool or the Newcastle-Ottawa scale. Any disagreement was resolved by discussion with, or arbitration by, a third reviewer. The titles of 2259 articles were screened, and 108 articles were chosen for abstract screening. Full-text screening resulted in 29 studies eligible for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Extracted data were placed into REDCap (Vanderbilt University, Nashville, TN), and MPL hysterectomy was compared with single-port hysterectomy using meta-analysis models. The outcomes included estimated blood loss (EBL); operative (OP) time; transfusion; length of hospital stay (LOS); conversion to laparotomy; visual analog scale pain scores at 12 hours, 24 hours, and 48 hours; any complications; and 7 subcategories of complications. Random-effects models were built for continuous outcomes and binary outcomes, and the results are reported as standardized mean difference (SMD) or odds ratio (OR) and their corresponding 95% confidence intervals, respectively. Meta-analysis could not be performed for vNOTES vs MPL, given that only 3 studies met the eligibility criteria. When LESS and MPL were compared, there was a shorter OP time for MPL (SMD = -0.2577, p <.001) and lower rate of transfusion (OR = 0.1697, p <.001), without a significant difference in EBL (SMD = -0.0243, p = .689). There was a nonsignificant trend toward higher risk of conversion to laparotomy in the MPL group (OR = 2.5871, p = .078). Pain scores were no different 12 or 24 hours postoperatively but were significantly higher at 48 hours postoperatively (SMD = 0.1861, p = .035) in the MPL group. There were no differences in overall or individual complications between the LESS and MPL groups. In the vNOTES comparison, 2 studies demonstrated shorter OP times, with reduced LOS and no difference in complications.

CONCLUSION

In this meta-analysis, we identified that LESS hysterectomy has comparable and low overall rates of complications and conversion to laparotomy compared with MPL. Notably, the OP time seems longer, and the pain scores at 48 hours may be lower with LESS hysterectomy than with MPL hysterectomy. Limited data suggest that vNOTES hysterectomy may have shorter OP times and improved EBL, transfusion rates, LOS, and pain scores compared with MPL hysterectomy, but further study is needed. There remains a deficit in high-quality data to understand the differences in cosmesis among these surgical approaches. The quality of data for this analysis seems to be low to moderate.

Systematic Review and Meta-Analysis on Hysterectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Compared to Laparoscopic Hysterectomy for Benign Indications

(1) Objective: We aimed to report an update of the systematic review and meta-analysis by Baekelandt et al. (2016). (2) Method: We followed PRISMA guidelines to perform this systematic review. We searched MEDLINE, EMBASE, CENTRAL and additional sources and aimed to retrieve randomised controlled trials (RCTs), controlled clinical trials (CCTs) and prospective/retrospective cohort studies in human subjects that allowed direct comparison of vNOTES to laparoscopy. (3) Results: Our search yielded one RCT and five retrospective cohort trials. Pooled analysis of two subgroups showed that, compared to conventional laparoscopy, vNOTES is equally effective to successfully remove the uterus in individuals meeting the inclusion criteria. vNOTES had significantly lower values for operation time, length of stay and estimated blood loss. There was no significant difference in intra- and postoperative complications, readmission, pain scores at 24 h postoperative and change in hemoglobin (Hb) on day 1 postoperative.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Myomectomy Followed by Hysterectomy

Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure. A 67-year-old woman who had four children with vaginal deliveries and one abortion, with no underlying disease and a body mass index of 22.4 kg/m², came to the hospital due to menorrhagia. Her diagnosis was myoma uteri from an asymptomatic palpated mass at the lower abdomen. The ultrasonography showed a 9 cm × 5.9 cm myoma mass at the anterior wall of the uterus. After counseling, the transvaginal natural orifice transluminal endoscopic surgery (NOTES) operation was conducted on May 2018. The process was a transvaginal NOTES hysterectomy following a transvaginal NOTES-assisted myomectomy. The uterine weight was 376 g. In this case, the surgeons could not enter into the pelvic cavity completely because the myoma mass was attached to the bladder which led to the surgeons safely performing the transvaginal NOTES myomectomy before the hysterectomy.

Natural Orifice Transluminal Endoscopic Surgery-assisted Vaginal Hysterectomy versus Total Laparoscopic Hysterectomy: A Single-center Retrospective Study Using Propensity Score Analysis

Objectives

The aim of this study is to evaluate the safety and efficacy of natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy (NOTES-AVH) compared with total laparoscopic hysterectomy (TLH).

Materials and Methods

The population was a cohort of women who underwent NOTES-AVH and TLH for a nonprolapsed uterus and benign gynecological disease between October 2015 and December 2017 at Rajavithi Hospital, Thailand. Study outcomes included operative time, the requirement of blood transfusion, perioperative complications, and postoperative pain. Factors applied for propensity score matching included age, body mass index, parity, underlying disease, previous abdominal surgery, preoperative diagnosis, presence of endometriosis, and uterine weight. Mean difference (MD) and risk ratio with 95% confidence interval (CI) were calculated to represent relative measures of the comparison.

Results

Among the 50 pairs, there were no differences in operative time (MD 15.9 min; 95% CI - 9.3-41.1), intraoperative complications (relative risk [RR] 0.33; 95% CI 0.04-3.10) or requirement of blood transfusion (RR 1.50; 95% CI 0.26-8.60) between the NOTES-AVH and TLH groups. NOTES-AVH was associated with lower intensity of postoperative pain (MD - 1.5 at 6-h; 95% CI - 0.8-2.2 and MD - 1.0 at 24-h; 95% CI - 0.4--1.6) and shorter length of stay (MD - 0.3 day; 95% CI - 0.1-0.7 day).

Conclusion

NOTES-AVH was safe and feasible for an alternative approach for hysterectomy. This technique was superior to TLH in that no abdominal incision was required, and postoperative pain was less intense.

Learning curve analysis of transvaginal natural orifice transluminal endoscopic hysterectomy

Background

No data are available to assess the learning curve for transvaginal natural orifice transluminal endoscopic hysterectomy for non-prolapsed uteri in benign gynecologic diseases. The lack of exposure to transvaginal natural orifice transluminal endoscopic hysterectomy during training, in addition to a poorly defined learning curve, further deters interested physicians from applying this technique to daily practice. The aim of this study was to evaluate the learning curve and perioperative outcome of transvaginal natural orifice transluminal endoscopic hysterectomy by an experienced endoscopist.

Methods

A total of 240 cases of transvaginal natural orifice transluminal endoscopic hysterectomies with or without adnexectomy for various benign gynecologic diseases were included. Demographic data and various perioperative parameters were reviewed from the prospectively collected database. Operative time was set as a surrogate marker for surgical competency. The learning curve was evaluated using the cumulative sum method.

Results

The overall mean operative time (OT) was 76.5 min ± 22.4. Four unique phases of the learning curve were derived using cumulative sum analysis: the mean OT of phase I (the initial learning curve of 20 cases) was 86.3 ± 23.7 min, phase II (acquisition of competence of 80 cases) was 71.0 ± 21.4 min, phase III (proficiency and plateau of 80 cases) was 76.0 ± 20.4 min, and phase IV (post-learning in which more challenging cases were managed) was 81.3 ± 23.6 min. No major complications were encountered. One case in phase III converted to laparoscopy due to difficulty in performing anterior colpotomy.

Conclusion

Our data demonstrated four distinct phases of the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy. In a well-trained endoscopist, surgical competence in transvaginal natural orifice transluminal endoscopic hysterectomy can be reached after 20 cases.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0554-0) contains supplementary material, which is available to authorized users.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Gynecology

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging field in minimally invasive surgery. NOTES can be performed via a variety of approaches, including through the stomach, esophagus, bladder, and rectum, but the majority of cases have been performed transvaginally. Potential advantages of natural orifice surgery in gynecology include the lack of abdominal incisions, less operative pain, shorter hospital stay, improved visibility, and the possibility to circumvent extensive lysis of adhesion to reach the pelvic cavity. This chapter provides a historical overview and the potential application of NOTES.

Postoperative outcomes of natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy and conventional laparoscopic-assisted vaginal hysterectomy: a comparative study

Objective

The present study aimed to determine the differences in outcomes between natural orifice transluminal endoscopic surgery-assisted vaginal hysterectomy (NAVH) and conventional laparoscopy-assisted vaginal hysterectomy (LAVH).

Methods

We retrospectively reviewed the charts of patients who between July 2012 and September 2015, were diagnosed as having benign uterine disease such as uterine myoma, endometriosis, or adenomyosis and managed via NAVH or LAVH in a single-center (Eulji University Hospital). Data such as age, body weight, height, parity, operation time, intra/post-operative complications, and uterus weight were obtained from the clinical charts. NAVH and LAVH recipients were matched 1:3 in terms of baseline characteristics, and the 2 groups were compared regarding surgical outcomes.

Results

Of the 160 patients with benign uterine disease included in the present study. Forty received NAVH and remaining 120 received LAVH. There were significant differences between the groups regarding operation time and hemoglobin change. Notably, although the operation time was shorter for LAVH, hemoglobin change was lower for NAVH. Additionally, although maximum hospitalization duration was shorter for LAVH, the average length of hospitalization was similar between NAVH and LAVH. There were no significant differences between the groups in terms of other variables.

Conclusion

NAVH may become a new alternative surgical method of choice for hysterectomy, as it represents a clinically feasible and safe approach; moreover is superior to LAVH in terms of bleeding loss.

Hysterectomy and ovarian cystectomy using natural orifice transluminal endoscopic surgery: An initial experience at Tzu Chi General Hospital

OBJECTIVES

The objective of this study is to report our initial experience with patients undergoing transvaginal natural orifice transluminal endoscopic surgery (NOTES).

MATERIALS AND METHODS

From September 2016 to December 2016, patients who were not virgins and did not have pelvic inflammation or obliteration of the cul-de-sac who underwent NOTES hysterectomy or ovarian cystectomy (OC) were included in the study.

RESULTS

Transvaginal NOTES was performed smoothly in six patients, two patients (mean age 35 years, mean body mass index [BMI] 25) received an OC and four patients (mean age 49 years, mean BMI 27) underwent a hysterectomy. One patient with a hysterectomy received concurrent adhesiolysis. The mean surgical times were 74 and 75 min and blood loss was 50 and 87.5 ml in the OC and hysterectomy groups, respectively. One patient with a hysterectomy had a postoperative fever with 38°C last for 2 days. Pain scores were 0 at 48 h postoperatively in both groups.

CONCLUSION

Transvaginal NOTES is a feasible and safe technique for hysterectomy and OC in our patients and those in previous reports. This procedure was minimally invasive with no scars on the abdomen as well as little pain.

Hysterectomy and salphingoopherectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery(NOTES): Turkish surgeons' initial experience

BACKGROUND

The aim of this study was to evaluate the feasibility, safety, and early postoperative outcomes of hysterectomies and salpingo-oophorectomies using transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

MATERIALS AND METHODS

The women undergoing vNOTES hysterectomies and salpingo-oophorectomies at a tertiary referral medical center between April 2016 and April 2017 were retrospectively analyzed. In all of the vNOTES procedures, a handmade glove port system comprised of a glove-wound retractor NOTES port was used.

RESULTS

Thirteen patients underwent gynecological procedures with benign indications via vNOTES. Of the 13 operations, 6 of the patients had salpingo-oophorectomies and 7 had hysterectomies, and all of the surgeries were performed by the same surgeon (Dr. Ahmet Kale). No conversion to a conventional laparoscopy or even a laparotomy was needed in any of the procedures. The mean operation time was 73.14 min in the hysterectomy patients and 40.8 min in the salpingo-oophorectomy patients. The mean drop in the hemoglobin (Hb) level was 1.4 g/dl in the hysterectomy patients and 1.6 g/dl in the salpingo-oophorectomy patients. For these patients undergoing vNOTES, the mean postoperative visual analog scale (VAS) pain score at 6 h was 4.38 and at 24 h it was 0.62. There were no intraoperative complications in any of the cases. The mean length of the hospital stay was 1.8 days in the hysterectomy patients and 1.5 days in the salpingo-oophorectomy patients.

CONCLUSION

The vNOTES procedure overcomes the surgical and technical difficulties of conventional vaginal surgery by incorporating the advantages of endoscopic surgery. Moreover, vNOTES uses inexpensive, reusable, handmade conventional laparoscopic instruments and avoids those problems related to abdominal wall incisions and trocar-related complications. Overall, this procedure results in high patient satisfaction, cosmetic advantages, and decreased postoperative pain.

Learning Curve Analysis of Different Stages of Robotic-Assisted Laparoscopic Hysterectomy

Objective. To analyze the learning curves of the different stages of robotic-assisted laparoscopic hysterectomy. Design. Retrospective analysis. Design Classification. Canadian Task Force classification II-2. Setting. Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. Patient Intervention. Women receiving robotic-assisted total and subtotal laparoscopic hysterectomies for benign conditions from May 1, 2013, to August 31, 2015. Measurements and Main Results. The mean age, body mass index (BMI), and uterine weight were 46.44 ± 5.31 years, 23.97 ± 4.75 kg/m², and 435.48 ± 250.62 g, respectively. The most rapid learning curve was obtained for the main surgery console stage; eight experiences were required to achieve duration stability, and the time spent in this stage did not violate the control rules. The docking stage required 14 experiences to achieve duration stability, and the suture stage was the most difficult to master, requiring 26 experiences. BMI did not considerably affect the duration of the three stages. The uterine weight and the presence of adhesion did not substantially affect the main surgery console time. Conclusion. Different stages of robotic-assisted laparoscopic hysterectomy have different learning curves. The main surgery console stage has the most rapid learning curve, whereas the suture stage has the slowest learning curve.

New Developments in Robotics and Single-site Gynecologic Surgery

Within the last 10 years there have been significant advances in minimal-access surgery. Although no emerging technology has demonstrated improved outcomes or fewer complications than standard laparoscopy, the introduction of the robotic surgical platform has significantly lowered abdominal hysterectomy rates. While operative time and cost were higher in robotic-assisted procedures when the technology was first introduced, newer studies demonstrate equivalent or improved robotic surgical efficiency with increased experience. Single-port hysterectomy has not improved postoperative pain or subjective cosmetic results. Emerging platforms with flexible, articulating instruments may increase the uptake of single-port procedures including natural orifice transluminal endoscopic cases.

Review of transvaginal natural orifice transluminal endoscopic surgery in gynecology

Recent technologic advances in endoscopic instrumentation and optics have allowed the development of a less invasive alternative to conventional laparoscopic surgery. During the past decade, natural orifice transluminal endoscopic surgery (NOTES) flourished in the field of general surgery, and it has emerged as a new concept of minimally invasive surgery. NOTES yields access to the abdominal cavity without any incisions on the abdominal wall (scarless surgery), and the natural orifices of the body surface, such as the mouth and the vagina, serve as the gateway to the peritoneal cavity. In gynecology, the vagina of a woman can be considered as an additional route for surgery. Recently, clinical application of transvaginal NOTES has broadened significantly in gynecology. Using transvaginal NOTES by applying the method of single-incision laparoscopic surgery via the vaginal route, not only adnexal surgery and hysterectomy, but also myomectomy and oncologic surgery could be performed safely and effectively in selected patients. In future, further studies should be conducted to evaluate the true clinical feasibility and safety of transvaginal NOTES.

Case-Mix Variables and Predictors for Outcomes of Laparoscopic Hysterectomy: A Systematic Review

The assessment of surgical quality is complex, and an adequate case-mix correction is missing in currently applied quality indicators. The purpose of this study is to give an overview of all studies mentioning statistically significant associations between patient characteristics and surgical outcomes for laparoscopic hysterectomy (LH). Additionally, we identified a set of potential case-mix characteristics for LH. This systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. We searched PubMed and EMBASE from January 1, 2000 to August 1, 2015. All articles describing statistically significant associations between patient characteristics and adverse outcomes of LH for benign indications were included. Primary outcomes were blood loss, operative time, conversion, and complications. The methodologic quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. The included articles were summed per predictor and surgical outcome. Three sets of case-mix characteristics were determined, stratified by different levels of evidence. Eighty-five of 1549 identified studies were considered eligible. Uterine weight and body mass index (BMI) were the most mentioned predictors (described, respectively, 83 and 45 times) in high quality studies. For longer operative time and higher blood loss, uterine weight ≥ 250 to 300 g and ≥500 g and BMI ≥ 30 kg/m(2) dominated as predictors. Previous operations, adhesions, and higher age were also considered as predictors for longer operative time. For complications and conversions, the patient characteristics varied widely, and uterine weight, BMI, previous operations, adhesions, and age predominated. Studies of high methodologic quality indicated uterine weight and BMI as relevant case-mix characteristics for all surgical outcomes. For future development of quality indicators of LH and to compare surgical outcomes adequately, a case-mix correction is suggested for at least uterine weight and BMI. A potential case-mix correction for adhesions and previous operations can be considered. For both surgeons and patients it is valuable to be aware of potential factors predicting adverse outcomes and to anticipate this. Finally, to benchmark clinical outcomes at an international level, it is of the utmost importance to introduce uniform outcome definitions.

Transvaginal Surgical Management of Cesarean Scar Pregnancy II (CSP-II): An Analysis of 25 Cases

BACKGROUND

The aim of this study was to investigate the feasibility and clinical value of transvaginal surgical treatment for cesarean scar pregnancy (CSP-II).

MATERIAL AND METHODS

This study was a retrospective analysis of 25 CSP-II patients who received transvaginal surgical treatments. These patients were admitted in our hospital between January 2010 and June 2012.

RESULTS

All surgical treatments were successful without overt complications. The average operation time was 61.5 minutes, the average intraoperative blood loss was 60.5 ml, the average hospital stay was 9.4 days and the average time that blood β-human chorionic gonadotropin (β-HCG) returned to normal range was 15 days. In all 25 patients, the cesarean scar mass located at the anterior wall of the lower uterine segment disappeared by B-ultrasound examination within 1 or 2 weeks after surgery. Postoperatively, the normal menstrual period started again with an average time of 28.9 days. No menstruation-related abnormalities, such as menstrual dripping or an abnormal amount of blood, were reported after surgery.

CONCLUSIONS

Transvaginal surgery for CSP-II is a novel surgical approach. It has several advantages, including a thorough one-time treatment lesion clearance, short operation time, minimized trauma, minimal intraoperative blood loss, quick reduction of blood β-HCG, and rapid menstruation recovery. It is a simple and feasible surgical approach of great clinical value and few treatment-related complications.

Natural orifice transluminal endoscopic surgery-assisted versus laparoscopic ovarian cystectomy (NAOC vs. LOC): a case-matched study

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has shown its prospection as a minimally invasive endoscopic surgery. This study aimed to examine the safety and efficacy of combined NOTES and vaginal approach, natural orifice transluminal endoscopic surgery-assisted ovarian cystectomy (NAOC), in the conservative management of benign ovarian tumors.

METHODS

Records were reviewed for the 34 consecutive NAOC procedures between May 2011 and March 2014. Age, body mass index, parity, size of the mass, and bilaterality of the mass were used to select comparable patient who had undergone laparoscopic ovarian cystectomy (LOC).

RESULTS

A total of 277 patients were recruited in this study (243 LOCs and 34 NAOCs, respectively). There was no incidence of switching to abdominal laparotomy. Length of operation and length of postoperative stay were significantly greater in the LOC group than in the NAOC group, but total hospital charges were similar in both groups. There was no difference in febrile morbidity between the two groups but more estimated blood loss (EBL) in NAOC group, although EBL was <50 mL in the two groups. Linear correlations of mass size with operating time and EBL existed in LOC group, but not in NAOC group.

CONCLUSION

NAOC can be safely performed for benign and large ovarian tumors. Besides, NAOC offers a superior operative efficiency compared with LOC.