Feasibility and safety of vNOTES for gynecological procedures in obese patients

Safety and efficacy of transvaginal natural orifice endoscopic surgery (vNOTES) for gynecologic procedures in the elderly: A case series of 119 consecutive patients

INTRODUCTION

This study evaluates the feasibility and safety of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in patients aged ≥ 65, focusing on early surgical outcomes for benign and malignant gynecological conditions.

METHODS

A total of 119 patients aged 65 and older who underwent vNOTES procedures at Valais Hospital from May 2020 to November 2024 were included. Data collected encompassed demographic characteristics, intraoperative details (e.g., complications, operative time), and postoperative outcomes (e.g., pain scores, complications, length of hospital stay).

RESULTS

The mean age was 72.5 years; 59.7 % underwent total hysterectomies, and 30.3 % had adnexal procedures. Mean operative time was 81.6 min (range: 15-221), and mean blood loss was 66.5 ml (range: 0-500). Conversion to conventional laparoscopy occurred in four cases (3.4 %). Intraoperative complications occurred in 14 cases (11.8 %), with higher rates in patients with BMI > 30 (p = 0.01). ASA III and IV patients experienced higher complications rates both intraoperatively (17.1 % vs. 9.5 %, p = 0.24) and postoperatively (28.6 % vs. 11.9 %, p = 0.03) compared to ASA I and II patients. Complication rates increased with surgical complexity, reaching 33.3 % for three or more concomitant procedures. The mean hospital stay was 2.8 days. Patients 75 years of age or older did not have significantly higher complication rates, operating times, or longer hospital stays.

CONCLUSION

Our study confirms the feasibility and safety of vNOTES in elderly patients. However, increased number of concomitant procedures seems to correlate with higher complication rates, especially in patients with a high ASA score and high BMI. These findings offer valuable data for preoperative discussions with elderly patients.

The impact of body mass index on surgical complications in minimally invasive hysterectomy for uterine fibroids

RESEARCH QUESTION

We aimed to assess the impact of Body Mass Index (BMI) on 30-day postoperative complications in patients undergoing minimally invasive hysterectomy (MIH) for fibroids.

DESIGN

Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2012-2020), we analyzed major and minor 30-day postoperative complications, stratified by BMI, in patients with uterine fibroids who underwent MIH. Complications were stratified according to the Clavien-Dindo classification.

RESULTS

Among 61,192 patients, overall complication rates ranged from 6.3 % to 8.1 %, with the highest rates in obesity class 3. Significant differences were observed in minor complication rates across BMI groups, though major complication rates did not significantly vary. Higher BMI classes correlated with longer operative times, with mean durations ranging from 127.1 min in the lowest BMI group to 158.1 min in the highest BMI group (p < 0.001). In multivariable regression, higher BMI was associated with increased odds of minor complications [

CONCLUSION

After adjusting for confounding factors, overweight, obesity class 2 and 3 are associated with a decreased risk of major complications compared to normal BMI. In contrast, BMI categories were not associated with any- or minor complications. Higher BMI classes were associated with longer operative times.

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Key Words

• Minimally invasive hysterectomy (MIH)
• Myoma
• Obesity paradox
• Postoperative complications
• Uterine fibroids
• body mass index (BMI)

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MESH Headings

• Humans
• Female
• Leiomyoma/surgery
• Body Mass Index
• Hysterectomy/adverse effects
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Middle Aged
• Adult
• Uterine Neoplasms/surgery
• Obesity/complications
• Minimally Invasive Surgical Procedures/adverse effects
• Minimally Invasive Surgical Procedures/statistics & numerical data
• Operative Time
• Retrospective Studies

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Affiliation(s)

Michal Axelrod Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; The School of Medicine, Tel Aviv University, Israel.
Kacey M Hamilton Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Rebecca J Schneyer Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Gabriel Levin Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Quebec, Canada
Yotam Weiss The School of Medicine, Tel Aviv University, Israel; Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Israel
Matthew T Siedhoff Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Kelly N Wright Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States
Raanan Meyer Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; The School of Medicine, Tel Aviv University, Israel; Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States; The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel

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Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach

(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described and developed by Jan Baekelandt. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is in Stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: Description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: We describe a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL Stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary for evolving through future IDEAL Stage 2b (multi-center studies) and Stage 3 (randomized controlled trials) studies.

Anatomical Distribution of Sentinel Lymph Nodes Harvested by Retroperitoneal vNOTES in 34 Consecutive Patients With Early-Stage Endometrial Cancer: Analysis of 124 Lymph Nodes

STUDY OBJECTIVE

To determine the anatomical distribution of sentinel lymph nodes (SLNs), the overall, unilateral, and bilateral detection rates, and the bilateral SLN concordance in patients with endometrial cancer (EC) mapped through a retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach.

DESIGN

Prospective single-center observational study.

SETTING

Swiss teaching hospital.

PATIENTS

Patients with EC or endometrial complex atypical hyperplasia who had undergone surgical staging with SLN mapping by a retroperitoneal vNOTES approach between October 2021 and November 2023.

INTERVENTIONS

Patients were placed in a horizontal dorsal lithotomy position under general anesthesia, and indocyanine green (ICG) was injected into the cervix. Access to the retroperitoneal space was achieved through vaginal incisions. A 7 cm GelPoint V-Path Transvaginal Access Platform was used as a vNOTES port, and CO2 was insufflated to expand the retroperitoneal space. The pelvic retroperitoneal space was inspected for ICG uptake by lymph nodes. After identification, SLNs were removed and sent for definitive histological examination.

MEASUREMENT AND MAIN RESULTS

A total of 34 patients were included in this study; 33 (97.1%) had a successful procedure (unilateral or bilateral mapping), and 1 (2.9%) had failed mapping. A total of 124 SLNs were identified and removed. SLNs were observed in the obturator region (81.5%), the external iliac region (10.5%), the internal iliac region (4.8%), and the common iliac region (3.2%). Similar proportions were observed on both pelvic sides. No SLNs were detected in other regions. The SLN locations were symmetrical in 22/31 (71.0%) patients. SLNs were negatives in 120 cases (96.8%), while 2 lymph nodes (1.6%) presented isolated tumor cells, and 2 others (1.6%) presented macrometastases.

CONCLUSION

We report anatomical distributions and detection rates for SLNs mapped by retroperitoneal vNOTES. Our results suggest substantial differences in the localization of SLNs compared to those reported for laparoscopic mapping.