The Comparison of Surgical Outcomes following Laparoscopic Hysterectomy and vNOTES Hysterectomy in Obese Patients

Transvaginal natural orifice transluminal endoscopic surgery hysterectomy in patients with body mass index >50: An Asian experience

We present two cases of patients with body mass index (BMI) >50 undergoing transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy for gynecological indications. Case 1 involves a 52-year-old woman with post-menopausal bleeding and suspicion of ovarian torsion, while case 2 describes a patient with newly diagnosed endometrial adenocarcinoma. Both cases highlight the feasibility and challenges of vNOTES in this patient population. To date, this is the first paper to describe the use of vNOTES in patients of Asian ethnicity, with BMI >50.

Assessing Feasibility and Outcomes of Robotic Single Port Transvaginal NOTES(RSP-vNOTES) Hysterectomy: A Case Series

OBJECTIVE

To demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages.

DESIGN

Retrospective case series.

SETTING

Single academic tertiary care hospital in Houston, Texas, USA.

PARTICIPANTS

28 adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection.

INTERVENTIONS

Hysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform).

MAIN RESULTS

28 patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m2 (range 19.5-48.4 kg/m2), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0mL). One case required a mini-laparotomy as the irregularly-shaped 1668g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection.

CONCLUSION

Our findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries.

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.

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.

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery (RvNOTES) With Total Hysterectomy for Management of Stage IV Endometriosis With/Without Complete Cul-de-Sac Obliteration: 23-Case Pilot Feasibility Study

STUDY OBJECTIVE

To show feasibility and short-term outcomes of robot-assisted vaginal NOTES (RvNOTES) for the treatment of stage IV endometriosis during total hysterectomy with/without complete cul-de-sac obliteration.

DESIGN

Retrospective case series.

SETTING

Single academic tertiary care hospital in Houston, Texas, USA.

PATIENTS

Twenty-three adult women with stage IV endometriosis.

INTERVENTIONS

RvNOTES with total hysterectomy for excision of severe endometriosis.

MEASUREMENTS AND MAIN RESULTS

Patients were assessed for various metrics including total operative time, robot dock time, robot console time, hysterectomy time, estimated blood loss, perioperative pain using the Visual Analogue Scale (VAS), and complications. The mean total operative time was 224.3 minutes. The study also found that patients with complete cul-de-sac obliteration had significantly longer operative times and higher estimated blood loss compared to those with partial or no obliteration. Postoperative VAS pain scores showed a significant reduction over a 6-week period. Complications included one case of complete ureteral transection, pelvic hematoma with infection, vaginal abscess, urinary tract infection, and pneumonia.

CONCLUSION

Our findings suggest that RvNOTES may be a feasible surgical approach in expert hands for treating stage IV endometriosis, even in cases with complete obliteration of the cul-de-sac.

Retrospective analysis between total laparoscopic and vNOTES hysterectomy in obese patients: single-center study

INTRODUCTION

Hysterectomy is one of the most common major gynecological surgeries, and it is performed for benign and malignant reasons. Currently, five types of hysterectomies are described: vaginal (VH), abdominal (AH), laparoscopic (LH), robotic, and vNOTES (vaginal natural orifice transluminal endoscopic surgery). This paper compares these two types of surgery in obese patients by analyzing the surgeries performed by our team.

MATERIALS AND METHODS

The research was conducted from January 2022 to December 2023 at the Department of Gynecology and Obstetrics of the General Hospital in Zadar. The study included female patients aged 18-75 years with a BMI > 30 kg/m2, regardless of parity, who were operated on for benign pathology.

RESULTS

There were 24 patients included in total. One conversion was observed in the TLH group because of excessive bleeding. Median operative time (IQR) was significantly lower in the vNOTES group (p < 0.05) than in the TLH group 35 (10.9) vs 125 (74.0) min.

CONCLUSION

The results concerning the duration of surgery, conversion rate, and postoperative bleeding and complications show that vNOTES hysterectomies seem to be feasible for obese patients. Further studies are needed to confirm these observations.

vNOTES surgical staging for endometrial carcinoma in overweight patients: a case series

OBJECTIVES

The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and obese patients with endometrial cancer.

MATERIALS AND METHODS

Four patients had undergone pelvic lymphadenectomy with a sentinel lymph node. Three patients were overweight, and one was obese with a BMI of 34.6 kg/m2. By using NMR mode sentinel lymph node was visualized, excised and marked separately for pathohistological analysis from the rest of the visualized lymph nodes that were then consecutively excised.

RESULTS

The mean number of overall excised lymph nodes was 12.5, and the mean number on the right side was 5.75 and 6.25 on the left side. There were no metastases verified in the pathohistological evaluation.

CONCLUSION

vNOTES retroperitoneal isolation of sentinel lymph nodes is good alternative and has its benefits, especially in overweight and obese patients with satisfying low intra- and postoperative complications.

Discharge within 24 h, transvaginal natural orifice transluminal endoscopic surgery- more suitable for ambulatory surgery in gynecology procedures: a retrospective study

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) is an achievement in the field of minimally invasive surgery. However, the vantage point of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologicalprocedures remains unclear. The main purpose of this study was to compare vNOTES with laparo-endoscopic single-site surgery, and to determine which procedure is more suitable for ambulatory surgery in gynecologic procedures.

METHODS

This retrospective observational study was conducted at the Department of Gynecology, Chengdu Women's and Children's Central Hospital. The 207 enrolled patients had accepted vNOTES and laparo-endoscopic single-site surgery in gynecology procedures from February 2021 to March 2022. Surgically relevant information regarding patients who underwent ambulatory surgery was collected, and 64 females underwent vNOTES.

RESULTS

Multiple outcomes were analyzed in 207 patients. The Wilcoxon Rank-Sum test showed that there were statistically significant differences between the vNOTES and laparo-endoscopic single-site surgery groups in terms of postoperative pain score (0 vs. 1 scores, p = 0.026), duration of anesthesia (90 vs. 101 min, p = 0.025), surgery time (65 vs. 80 min, p = 0.015), estimated blood loss (20 vs. 40 mL, p < 0.001), and intestinal exhaustion time (12.20 vs. 17.14 h, p < 0.001). Treatment with vNOTES resulted in convenience, both with respect to time savings and hemorrhage volume in surgery and with respect to the quality of the prognosis.

CONCLUSION

These comprehensive data reveal the capacity of vNOTES to increase surgical efficiency. vNOTES in gynecological procedures may demonstrate sufficient feasibility and provide a new medical strategy compared with laparo-endoscopic single-site surgery for ambulatory surgery in gynecological procedures.

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.

Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Deconstructed: Expanding Minimally Invasive Gynecologic Surgeons' Toolbox

Background

The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines.

Methods

This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field.

Results

The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials.

Conclusions

vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).

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.

vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience

PURPOSE

To analyze our experience with vNOTES gynecologic procedures in women with morbid and super morbid obesity to determine feasibility and compare outcomes with standard minimally invasive techniques.

METHODS

Gynecologic procedures performed by three surgeons on women with a body mass index (BMI) ≥ 40 kg/m2 from 2017 to 2023. A subset of women with a BMI ≥ 50 kg/m2 was also analyzed.

RESULTS

103 women with a BMI ≥ 40 kg/m2 were identified (Class IV), 19 of whom had a BMI ≥ 50 kg/m2 (Class V). For the entire population the mean BMI was 45.7 kg/m2 (40-62). 29 women were nulliparous and 23 had at least one prior cesarean delivery. 51 had no prior abdominal surgery. The procedures performed were hysterectomy and removal of adnexae in 77 patients, hysterectomy alone in six, adnexal surgery alone in nine, and hysterectomy with adnexectomy and lymph nodes in five. Two surgeries were converted to laparoscopy and five to laparotomy. Average surgical time was 87 min (30-232). Average blood loss was 82 mL (10-400). Mean uterine weight was 206 g (29-2890). 53 procedures were performed as outpatient, 44 had overnight observation, four had a length of stay of 2 days, one each for 4 days and 5 days. The laparoscopies occurred in one patient with an obliterated cul-de-sac and in one patient for lymph node removal. The laparotomies occurred for adnexal adhesions in one, bleeding in two, a cystotomy in one requiring urology consultation, and an obliterated cul-de-sac One patient developed a postoperative vaginal cuff hematoma not requiring intervention.

CONCLUSION

vNOTES gynecologic procedures are feasible in this high-risk population and may result in shorter recovery times and fewer complications than standard laparoscopy or transvaginal surgery. What does this study add to the clinical work: VNOTES approach is feasible in morbidly obese women and may have distinct advantages over conventional laparoscopic, vaginal or open techniques.

Analysis and suggestions on the complications in 2000 cases of transvaginal natural orifice transluminal endoscopic surgery: Can it be a conventional surgery?

OBJECTIVE

To reflect on the complications of transvaginal natural orifice transluminal endoscopic surgery (vNOTES), identify the corresponding risk factors, and provide caution to surgeons when performing this novel surgery.

METHODS

A retrospective study was carried out among 2000 patients in our hospital who underwent vNOTES between May 2019 and May 2022. Perioperative complications were stratified in chronological order and divided into those developed while establishing the vNOTES approach, during surgery, postoperatively, and 1 month after discharge. The complications were classified based on the Modified Clavien-Dindo classifications. The causes of each type III/IV complication were analyzed.

RESULTS

Of the 2000 patients, 88 (4.4%) experienced complications, which is not higher than that reported in laparoendoscopic surgery in previous studies. Grade I, II, III, IV, and V complications developed in 19 (0.95%), 57 (2.85%), 11 (0.55%), 1 (0.05%), and 0 (0%) patients, respectively. Complications were developed while establishing the approach platform, during the surgery, postoperatively, and within 1 month after discharge in 5 (0.25%), 30 (1.50%), 50 (2.50%), and 3 (0.15%) patients, respectively. Eight patients (0.4%) underwent conversion, including five cases of rectal injury repair.

CONCLUSION

The summarized suggestions were divided into three levels. Considering the security and effectiveness of vNOTES, it can be routinely used in various gynecologic operations. However, surgeons should focus on preoperative evaluation, strictly conduct preoperative disinfection, conform to prompt conversion during surgery, call for the presence of experienced doctors, and have routine use of antibiotics to prevent postoperative infections.

TRIAL REGISTRATION

ChiCTR2100053483.

Transvaginal natural Orifical transluminal Endoscopy for sacrocolpopexy: A case series report

Background

To describe the surgical technique and operative outcomes of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for sacrocolpopexy with or without robotic surgical system in patients with pelvic organ prolapse (POP).

Methods

Patients with POP undergoing traditional transvaginal natural orifice transluminal endoscopic surgery (TV-NOTES) or robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) for sacrocolpopexy performed by one surgeon from Sep 2020 to Jan 2023 in our hospital were included in this study. The baseline demographics and operative outcomes were collected and analyzed. In addition, some surgical skills were presented. The operative outcomes of V-NOTES for sacrocolpopexy performed by three beginners were also presented.

Results

Eight patients who underwent TV-NOTES, and two patients who underwent RV-NOTES were included in this study. The mean operative time was 180 ± 49 min, and the estimated blood loss was 107 ± 82 ml for these ten cases. Particularly, the operative time of the two patients who underwent RV-NOTES was 275 and 132 min, while the estimated blood loss (EBL) was 100 and 50 ml respectively. During the follow-up period, no mesh exposure and recurrence were observed. In addition, five cases of TV-NOTES for sacrocolpopexy by beginners were all successfully completed.

Conclusion

Both TV-NOTES and RV-NOTES appeared to be feasible and safe for sacrocolpopexy.

Feasibility and safety of vNOTES for gynecological procedures in obese patients

INTRODUCTION

This study aimed to determine the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to treat benign and malign gynecological conditions in obese patients.

MATERIAL AND METHODS

We analyzed data from 79 obese patients with a body mass index (BMI) > 30 Kg/m2 operated by vNOTES for gynecological conditions between May 2020 and April 2023. The primary outcome was the feasibility of performing the surgery as initially planned. Data were presented for subgroups of patients with obesity class I (BMI 30.1 - 34.9 Kg/m2), class II (BMI 35.0 - 39.9 Kg/m2), and class III (BMI ≥ 40.0 Kg/m2).

RESULTS

Patients presented obesity class I in 39 cases (49.4 %), class II in 27 cases (34.2 %), and class III in 13 cases (16.4 %). Fifty-two patients (65.8 %) underwent vNOTES hysterectomy, 26 patients (32.9 %) underwent procedures limited to the adnexa, and 1 patient (1.3 %) underwent myomectomy. The conversion rate was 0 %, 11.1 %, and 7.7 % in obesity class I, II, and III, respectively. Intraoperative bladder injury was observed in 1 case (1.3 %) and rectal serosal tear in 2 cases (2.5 %). Postoperatively, we observed 3 cases (3.8 %) of wound infection, 2 cases (2.5 %) of cystitis, and 1 case (1.3 %) of deep vein thrombosis.

DISCUSSION

This study demonstrated the feasibility and safety of performing gynecological vNOTES procedures in obese patients. However, obesity could be associated with longer and more complex interventions, especially in obesity class II and III patients.

Impact of gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease: study protocol of a randomized controlled trial

BACKGROUND

Literature regarding the advantages of gasless vNOTES is insufficient. The aim of our study is to compare gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease. We hypothesize that compared with those in the traditional vNOTES group, hemodynamic profiles will be changed less during gasless vNOTES, while safety can be promised.

METHODS

This is a single-center, prospective, single-blind, randomized controlled clinical trial, which has been approved by the Institutional Review Board of Chengdu Women's and Children's Hospital on September 27, 2022. One hundred and twenty patients will be recruited and randomly assigned to either the traditional vNOTES group or the gasless vNOTES group in a 1:1 ratio. For patients allocated to the traditional vNOTES group, after insertion of one port through the vagina, CO2 gas is infused with a pressure of 12-14 mmHg; while for those allocated to the gasless vNOTES group, a special device is used as an abdominal wall-lifting device to facilitate gasless surgery. CO2 pneumoperitoneum will not be used during the whole gasless vNOTES procedure. The primary outcome is vital signs at different time points. The secondary outcomes include surgical conversion rate, duration of surgery and anesthesia, anesthetic consumption, intraoperative estimated blood loss, VAS and PONV scores at postoperative 2 h and 24 h, administration of vasopressor drugs from the beginning of general anesthesia induction to 15 min after endotracheal intubation, including times, dosage, and type, intraoperative and postoperative complications, time of first getting out of bed after surgery, and time of first eating after surgery, including light drink.

DISCUSSION

This is the first randomized controlled trial to compare the impacts of gasless vNOTES vs. traditional vNOTES on hemodynamic profiles and outcomes in patients with benign gynecological disease. If a favorable effect and safety of gasless vNOTES for hemodynamic profiles and outcomes in patients are shown, gasless vNOTES would be an optimal treatment option for patients with benign gynecological disease.

TRIAL REGISTRATION

The trial was registered at https://www.chictr.org.cn/showproj.html?proj=182441 with registration No. ChiCTR2200064779 on Oct 17, 2022.

Development and validation of nomograms to predict preoperative anxiety and postoperative pain in patients undergoing gynecological surgery: An observational analysis

BACKGROUND

Perioperative anxiety and pain are associated with patient dissatisfaction, postoperative complications, and prolonged hospital stay. Early identification of high-risk patients with preoperative anxiety and postoperative pain will be useful for the implementation of preventive management.

METHODS

Patients, who underwent gynecological surgery in our hospital between March 2022 and September 2022, were consecutively enrolled. Perioperative anxiety and pain were evaluated with the Visual Analogue Scale of Anxiety (VAA) and Visual Analogue Scale of Pain (VAS), respectively. Step Akaike Information Criterion analysis was performed to identify risk factors and logistic regression was used to establish nomograms, followed by discrimination, calibration, and clinical utility evaluation.

RESULTS

A total of 197 patients were included for analysis, including 116 and 81 patients who were randomized to training and test groups, respectively. The prediction model of preoperative moderate to severe anxiety identified four preoperative relevant factors: age, sleep duration, preoperative pain, and regular exercise before gynecological surgery. The model had an area under the receiver operating characteristics curve of 0.808 (0.729, 0.887) and 0.754 (0.634, 0.875) in the training and test groups, respectively. The prediction model of postoperative moderate to severe pain identified four relevant factors: preoperative pain, surgery type, VAA before anesthesia, and patient-controlled analgesia. The model had an area under the receiver operating characteristics curve of 0.867 (0.798, 0.935) and 0.852 (0.761, 0.943) in the training and test groups, respectively.

CONCLUSIONS

The established nomograms accurately identified high-risk patients with preoperative anxiety and postoperative pain before gynecological surgery. Clinical registration at: www.chictr.org.cn (ChiCTR2200057757).

Comparison of Outcomes following Vaginal Natural Orifice Transluminal Endoscopic Surgery and Laparoendoscopic Single-site Surgery in Benign Hysterectomy: A Systematic Review and Meta-analysis

Gradually increasing interest in laparoscopic surgeries has led to the advent of various lesser invasive techniques in the form of vaginal natural orifice transluminal endoscopic surgery (vNOTES) and laparoendoscopic single-site (LESS) surgery. Very few studies have analyzed the advantages and disadvantages of vNOTES over LESS surgeries in hysterectomy. After a comprehensive search, full texts of relevant manuscripts were obtained to assess eligibility for recruitment. A comprehensive meta-analysis was subsequently performed to compare the outcomes of vNOTES and LESS in hysterectomy, and forest plots were constructed. Four articles were rendered for review (three retrospective cohort studies and one randomized controlled trial). Three studies showed lesser postoperative pain in vNOTES compared to LESS. In one study, postoperative vaginal pain was higher in vNOTES due to additional suture between uterine artery and vaginal wall. The meta-analysis concluded that vNOTES could be better alternative to LESS hysterectomies. However, further large multicentric randomized trials are required for the standardization of the surgical method.

Robotic vNOTES Techniques for Hysterectomy in a Patient with a 16-week Sized Uterus and a Body Mass Index of 70

STUDY OBJECTIVE

To demonstrate the surgical techniques for robotic vNOTES hysterectomy with bilateral salpingo-oophorectomy (BSO) in a World Health Organization class 3 obesity patient (body mass index = 70) as well as large fibroid uterus (16 weeks sized).

DESIGN

Stepwise demonstration with narrated video footage.

SETTING

An academic tertiary care hospital. Our patient is a 50-year-old G0 with postmenopausal vaginal bleeding with an enlarged uterus; her endometrial biopsy showed complex endometrial hyperplasia with atypia.

INTERVENTIONS

The surgical exposure for extremely obese patients with a concomitantly large uterus can be very challenging transabdominally due to the patient being unable to tolerate the Trendelenburg position and abdominal gas pressure [1-5]. Therefore, transvaginal NOTES can be an alternative option for these types of challenging patients. However, although there are clear benefits of vNOTES surgery in obese patients, we still need to be thoughtful and deliberate in handling this kind of surgery [6]. Several key success factors that aid in the completion of the surgery include 1. Appropriate patient positioning (Trenguard Position) as tolerated. 2. Initial vaginal section of hysterectomy. 3. Successful port placement. 4. Trendelenburg, as far as tolerated. 5. Harnessing the robotic camera for anterior colpotomy. 6. Utilizing alternative surgical exposure techniques: air seal for maintaining gas pressure for optimizing exposure, lap pad for thermal isolation, and maintaining the uterus for safe exposure during BSO. 7. After identification of the bilateral ureters, the broad, round, and uterine ovarian ligaments were transected with vessel sealer (less thermal spread), and the cystectomy was completed. (Supplemental Video 1) 8. BSO was completed. 9. In-bag uterine tissue extraction. 10. Vaginal cuff closure with V-Loc barbed suture.

CONCLUSION

Robotic-assisted NOTES hysterectomy with BSO is feasible and safe in extremely obese patients with large uterus. The combination of all these strategies could aid in the feasibility and safety of patients with these challenging pathology and morbidity.

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.

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.

Perioperative outcomes of and predictors for conversion from transvaginal natural orifice transluminal endoscopic tubal surgeries: A retrospective cohort study of 619 patients

OBJECTIVE

To assess the perioperative outcomes of vNOTES tubal surgeries and to identify predictors of surgical conversion.

METHODS

A single-center retrospective cohort study was performed on 619 patients who underwent vNOTES tubal surgeries in our institute from December 2018 to October 2021. Patients were categorized into "converted" or "non-converted" groups based on whether conversion occurred. t-test and χ² test were performed on demographic and clinicopathologic data to compare their perioperative outcomes. Logistic regression was built to identify predictors for surgical conversions.

RESULTS

The conversion and complication rates of the vNOTES tubal surgeries in the present study were 3.07% and 4.85%, respectively. The "converted group" has a significantly higher percentage of patients with severe pelvic adhesions (9/19 [47.4%]) and pelvic endometriosis (2/19 [10.5%]), which significantly predicates surgical conversion. The "converted group" also had a longer duration of surgery (140.94 ± 88.73 min, P = 0.002) and an increased proportion of "converted from vNOTES" patients experienced more than 50 ml of intraoperative blood loss (7/19 [36.9%]). Four patients had intraoperative rectal injuries, and no Clavien-Dindo III-V postoperative complications occurred.

CONCLUSION

vNOTES tubal surgeries are safe due to low conversion and complication rates. Severe pelvic adhesion and endometriosis are predictors for surgical conversions.

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

OBJECTIVE

To provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy and vault suspension, using two access platform methods.

DESIGN

Narrated surgical video based on two cases of vNOTES for abnormal uterine bleeding and endometrial intra-epithelial neoplasia.

SETTING

A single tertiary-care academic centre.

INTERVENTIONS

Step-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, Rancho Santa Margarita, CA, USA), are illustrated. The surgical steps are summarized as: (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; (10) vaginal vault closure and tying of the suspension sutures.

CONCLUSION

This video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy and uterosacral ligament suspension with two access techniques. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favourable recovery profile, making it an attractive surgical route in appropriate candidates.

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.

Description and Comparison of Acute Pain Characteristics After Laparoscope-Assisted Vaginal Hysterectomy, Laparoscopic Myomectomy and Laparoscopic Adnexectomy

Purpose

To determine the characteristics of the acute pain after laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM), and laparoscopic adnexectomy (LA) and compare them with each other.

Patients and Methods

Patients undergoing LAVH, LM, and LA under general anaesthesia at the First Affiliated Hospital of Wenzhou Medical University between December 2017 and December 2019 were selected. Their data were collected before, during, and after the surgery. We evaluated the degrees of pain in each group of patients and compared them.

Results

There were differences in the baseline characteristics of the patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain were higher in the LAVH group than in the LM and LA groups, followed by the LM and LA groups. Compared with the LA group, the postoperative pain in the LAVH and LM groups was more complicated. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incisional pain. Shoulder pain had the lowest incidence in the three groups.

Conclusion

There were different postoperative pain characteristics after the LAVH, LM, and LA, and we should clinically adjust analgesia programs for different gynaecological laparoscopic surgeries.