Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Gynecology

What is the applicability of tubal ligation with the vaginal natural orifice transluminal endoscopic surgery technique and its value in patient comfort?

OBJECTIVE

The aim of this study was to observe the feasibility of the tubal/adnexal approach using vaginal natural orifice transluminal endoscopic surgery and compare its contribution with surgeon ergonomics and postoperative patient comfort with that of conventional laparoscopy.

METHODS

We completed this study retrospectively with 47 patients. Patients were followed at their postoperative first month. We analyzed the usability of the vaginal natural orifice transluminal endoscopic surgery method over conventional laparoscopy by comparing the demographics, surgical data, and postoperative findings collected between the two groups.

RESULTS

Patients in the conventional laparoscopy group were older (39.1±3.3 years) than those in the vaginal natural orifice transluminal endoscopic surgery patient group (p=0.005). Pain intensity 24 h after surgery was lower in the vaginal natural orifice transluminal endoscopic surgery group (p=0.003), while sexual function and dyspareunia did not differ between the two groups in the first month. Patients in the vaginal natural orifice transluminal endoscopic surgery group were more relieved about painlessness and the comfort it brought than the conventional laparoscopy group (p=0.027, χ2=12.56).

CONCLUSION

Patients subjected to the vaginal natural orifice transluminal endoscopic surgery procedure showed higher levels of satisfaction, less postoperative pain, and greater comfort than those subjected to conventional laparoscopy.

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.

Surgical Frontiers: A Comparative Review of Robotics Versus Laparoscopy in Gynecological Interventions

This review comprehensively examines the current state and future directions of gynecological surgery, focusing on the comparative analysis of laparoscopy and robotic surgery. The overview highlights the evolution of these surgical techniques, emphasizing their impact on patient outcomes, procedural efficiency, and safety profiles. The analysis encompasses critical factors such as cost-effectiveness, learning curves, and implications for postoperative recovery. The future of gynecological surgery is envisioned through emerging technologies, including augmented reality, single-incision laparoscopy, and artificial intelligence. The coexistence of laparoscopy and robotics is explored, acknowledging their respective strengths and roles in shaping women's healthcare. In conclusion, the dynamic nature of the field is underscored, emphasizing the need for a patient-centered and adaptable approach. Collaboration between healthcare professionals, engineers, and researchers is pivotal in unlocking these innovations' full potential, ensuring continued advancements in gynecological surgery for improved outcomes and enhanced patient care.

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.

Single-port laparoscopic sacrospinous ligament suspension via the natural vaginal cavity (SvNOTES) for pelvic prolapse: The first feasibility study

Objective

This study aims to investigate the feasibility and short-term efficacy of single-port laparoscopic-assisted transvaginal natural cavity endoscopic sacrospinous ligament suspensions (SvNOTES).

Methods

A total of 30 patients diagnosed with anterior or/and middle pelvic organ prolapse Stages III and IV underwent natural vaginal cavity (SvNOTES), and 30 patients who underwent conventional sacrospinous ligament (SSLF) were used as a control group. The operation time, blood loss, postoperative POP-Q score, length of hospital stay, and complications were compared between the two groups.

Results

The operation time for SvNOTE was (60 ± 13) min, which was longer than (30 ± 15) min for SSLF (P = 0.04). However, the bleeding amount in SvNOTE was 29.44 ± 2.56, significantly lower than that in the SSLF group (80 ± 10; P = 0.02), and the postoperative hospital stay in the SvNOTE group was (4 ± 2) days, longer than (3 ± 1) days in SSLF (P = 0.02). However, there were no intraoperative complications in the SvNOTE group, whereas one ureteral injury occurred in the SSLF group; in addition, the postoperative POP-Q score was significantly better in the SvNOTE group than that in the SSLF group with increasing time (P < 0.001).

Conclusion

Compared with SSLF, single-port laparoscopic sacrospinous ligament suspension via the natural vaginal cavity is visualized, greatly improving the success rate of sacrospinous ligament fixation, with less blood loss and fewer complications, arguably a safer and minimally invasive surgical approach.

Comparison of vNOTES technique with conventional laparoscopy in gynecological emergency cases

BACKGROUND

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a minimally invasive approach. This study aimed to evaluate the feasibility and surgical outcomes of the vNOTES method and compare it with conventional laparoscopy (CL) in gynecological emergency cases.

MATERIAL AND METHODS

A retrospective study was conducted to compare vNOTES with CL regarding pre-/intra-/postoperative outcomes. The women who were operated on for emergency indications such as ectopic pregnancy, ovarian torsion, ovarian cyst rupture and acute abdominal pain were evaluated. Patients' age, gravidity, parity, medical/surgical history, height, weight, blood pressure, heart rate, pre-/postoperative hemoglobin and hematocrit levels, the quantity of aspirated hemoperitoneum, visual analog scale (VAS) pain scores six and 12 h postoperatively, duration of surgery and hospital stay were recorded.

RESULTS

The study was conducted with 90 women. Sixty of them underwent CL, while 30 women had vNOTES. The vNOTES group had a significantly shorter duration of surgery -28.5 min (15-48 min) vs. 77 min (29-155 min), respectively, p < .001), shorter hospital stay - 32 h (11-125 h) vs. 38 h (12-201 h), respectively, p = .007), lower VAS scores after 6 h - 5 (4-7) vs. 6 (2-8), respectively, p < .001), and after 12 h - 2 (1-3) vs. 2 (1-5), respectively, p < .001) and a lower dose of postoperative analgesic administration - 2 (2-3) vs. 3 (1-5), respectively, p < .001) than the CL group.

CONCLUSION

vNOTES surgeries can be considered an alternative technique to CL by providing shorter surgery duration, lower postoperative pain scores, shorter hospital stays and better cosmetic outcomes.

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

OBJECTIVE

The study aimed to assess the efficacy of abdominal compression and pulmonary recruitment maneuver (CPRM) after transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to alleviate post-laparoscopic shoulder pain (PLSP).

MATERIALS AND METHODS

In this retrospective cross-sectional study conducted in a tertiary referral medical center, women who underwent vNOTES between January 2018 and May 2019 were classified into control group and CPRM group with CO₂ force expelled. Data on the demographic characteristics, indications for surgery, and surgical history were collected. Postoperative pain was assessed 24 and 48 h postoperatively using the visual analog scale (VAS, 0-10). Chest radiography was used to determine the residual air volume 24 h after surgery.

RESULTS

Of 10 patients, 6 and 4 underwent vNOTES adnexal surgeries and vNOTES hysterectomy, respectively. The median volumes of residual pneumoperitoneum were 9.02 mL and 28.11 mL in the CPRM and control groups, respectively (p = 0.001). The intensity of PLSP in the CPRM and control groups were 0 ± 0 vs. 3.4 ± 3.4 and 0.4 ± 0.8 vs. 2.2 ± 2.2 24 and 48 h after surgery, respectively (p = 0.005 for 24 h and p = 0.04 for 48 h).

CONCLUSION

CPRM might facilitate decrease in residual gas volume and PLSP after vNOTES. CPRM might be considered using in vNOTES to decrease PLSP.

The Comparison of Transvaginal Natural Orifice Transluminal Endoscopic Surgery and Conventional Laparoscopy in Opportunistic Bilateral Salpingectomy for Permanent Female Sterilization

STUDY OBJECTIVE

To compare the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach with conventional laparoscopy (CL) in opportunistic bilateral salpingectomy (BS) alone for permanent female sterilization as an opportunistic cancer prevention strategy.

DESIGN

Prospective cohort study.

SETTING

Two-centered tertiary hospitals.

PATIENTS

Ninety-six women with a nonprolapsed uterus seeking definitive surgical permanent contraception.

INTERVENTIONS

Patients were scheduled for BS and assigned to a study arm in a 2:1 fashion (CL:vNOTES allocation ratio) concerning patient's choice.

MEASUREMENTS AND MAIN RESULTS

Patients were followed at their postoperative first week and first month. The visual analog score (VAS), Patient Global Impression of Improvement, and Female Sexual Function Index scales were used to assess the pain, patient satisfaction, and discomfort/pain after vaginal penetration, respectively. Patients who underwent to vNOTES had a significantly higher number of previous abdominal surgery (median difference, 1.97; 95% confidence interval [CI], 1.12-3.48; p = .016). Compared with CL, vNOTES was associated with lower 6-hour (rate ratio [RR], 0.63; 95% CI, 0.50-0.77) and 24-hour (RR, 0.33; 95% CI, 0.23-0.46) postoperative VAS scores and less amount of postoperative analgesics (RR, 0.54; 95% CI, 0.36-0.78). The slope of change in postoperative VAS scores was in a shorter time in the vNOTES group (RR, 0.47; 95% CI, 0.36-0.60). The rate of postoperative improvement was higher in the vNOTES group than the CL group at the postoperative first week (87.5% vs 68.2%, χ² = 4.232, p = .032) and first month (96.9% vs 87.9%, χ² = 2.091, p = .140). The rate of patients reporting postoperative decline in Female Sexual Function Index /pain scores (RR, 0.97; 95% CI, 0.47-1.96) was found to be similar in both of the study groups, and no postoperative complication was observed in either group.

CONCLUSION

Women seeking permanent sterilization and who underwent BS for ovarian cancer risk reduction purposes had higher satisfaction, less postoperative pain, lower analgesic requirement, and similar surgical outcomes in the vNOTES group than the CL group, even in patients with previous surgeries and a nonprolapsed uterus. vNOTES approach could be the preferred method for the opportunistic BS in female sterilization.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Apical pelvic organ prolapse repair via vaginal-assisted natural orifice transluminal endoscopic surgery: Initial experience from a tertiary care hospital

INTRODUCTION

Natural orifice transluminal endoscopic surgery has been used for gynecologic operations in recent years. The aim of the study is to describe our initial experience using vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) for apical pelvic organ prolapse repair.

METHODS

After patients underwent vaginal hysterectomy, vNOTES sacrocolpopexy (n = 4) or vNOTES high uterosacral ligament suspension (n = 7) were performed to treat symptomatic apical pelvic organ prolapse. Sociodemographic and clinical characteristics, Pelvic Organ Prolapse Quantification results, and recorded surgical data (eg, duration of surgery, intraoperative complications, additional prolapse and incontinence surgeries) were obtained from patient files and the hospital's database. Information from postoperative follow-up visits, including complications and anatomical results, were also recorded.

RESULTS

The mean age of the patients was 60.7 ± 9.1 years. The mean total operative time was 121.3 ± 22.7 minutes. The mean operative time for vaginal hysterectomy, vNOTES sacrocolpopexy, and vNOTES uterosacral ligament suspension was 46 ± 11.9, 65 ± 38, 25 ± 8.2 minutes, respectively. There were no intraoperative and postoperative complications observed. The mean postoperative 24-hour visual analog scale score was 3.5 ± 1.9 for vNOTES sacrocolpopexy patients and 3.2 ± 0.9 for vNOTES uterosacral ligament suspension patients. Only one patient in the vNOTES sacrocolpopexy group had a recurrence; she experienced stage 2 anterior compartment prolapse 8 months after surgery.

CONCLUSION

As a treatment for apical pelvic organ prolapse, vNOTES is a feasible approach in both sacrocolpopexy and uterosacral ligament suspension.

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.

The current status of sacrocolpopexy in the management of apical prolapse

Pelvic organ prolapse (POP) is a prevalent condition that negatively affects women' s quality of life. There is growing recognition that adequate support for the vaginal apex is an important component of a durable surgical repair for women with advanced prolapse, including the anterior and posterior wall prolapse. Surgical treatment options include abdominal and vaginal approaches, the former of which can be performed open, laparoscopically, and robotically. Sacrocolpopexy is a common procedure designed for the treatment of prolapse including uterine or vaginal vault prolapse and multiple-compartment prolapse. Although traditionally performed as an open abdominal procedure, minimally invasive sacrocolpopexy, whether laparoscopic or robotic, has been successfully performed in the clinical practice by many pelvic reconstructive surgeons. In order to require an outstanding cosmetic result, transumbilical/transvaginal single-port sacrocolpopexy has been developed to achieve the goal and initial outcomes have demonstrated their efficacy, safety and feasibility. However, up to date, there are many variations to these procedures, with different levels of evidence to support each of them. Herein we reviewed the current literatures on current surgical choices for women with apical prolapse.

Recent advances in minimally invasive surgery for gynecologic indications

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy in a Woman with Uterine Adenomyosis and Multiple Severe Abdominal Adhesions

Natural orifice transluminal endoscopic surgery (NOTES) had been used for many gynecologic surgeries without pelvic adhesions. We report a 30-year-old female with multiple abdominal adhesions underwent NOTES hysterectomy successfully. A 30-year-old female (para 2, gravida 3, abortus 1) presented with menorrhagia and dysmenorrhea. She had multiple abdominal surgical histories. Computed tomography scan revealed multiple adhesions between the abdominal wall and small intestine. On pelvic ultrasonography, an enlarged uterus 8.3 cm × 3.5 cm with adenomyosis was visualized. Because of the extensive intra-abdominal adhesions, we decided to use a transvaginal NOTES approach to perform hysterectomy. We performed the surgery successfully without complication. Pathological examination confirmed adenomyosis of uterus. NOTES hysterectomy may be feasibly and safely performed in gynecologic patients with extensive abdominal adhesions.