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

Comparing outcomes of ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery versus laparoendoscopic single-site surgery: A retrospective cohort study

BACKGROUND

We aimed to compare the outcomes of ovarian cystectomy (OC) performed by vaginal natural orifice transluminal endoscopic surgery (vNOTES) vs transumbilical laparoendoscopic single-site surgery (LESS).

METHODS

We retrospectively analyzed the data of patients in our hospital who underwent OC either by vNOTES or LESS between January 2015 and September 2021. Demographic data were collected. The primary outcome was the conversion rate. The secondary outcomes were the duration of surgery, length of hospital stay, estimated blood loss, maximum body temperature within 48 hours after operation, and duration of maximum body temperature (hours), among others. Statistical analysis was done using the SPSS software.

RESULTS

Exactly 284 patients were screened. The vNOTES and LESS groups consisted of 21 and 47 patients, respectively. There was no significant difference in the conversion rates between the two groups (0 vs 8.5% in vNOTES and LESS, respectively; p = 0.303). Compared with the vNOTES group, the LESS group had a larger cyst diameter (6.00 ± 2.32 vs 4.69 ± 1.29 cm; p = 0.004), more endometriotic cysts (42.6% vs 9.5%; p < 0.001), and more pelvic adhesions requiring adhesiolysis (57.4% vs 19.0%; p = 0.003). At baseline, there were no other differences between the groups. The secondary outcomes included a shorter duration of surgery (70.14 ± 27.30 vs 99.57 ± 36.26 minutes; p = 0.001) and lower estimated blood loss (64.29 ± 39.19 vs 163.43 ± 251.20 mL; p = 0.011) in the vNOTES group. Regression analysis showed the diameter of the ovarian cyst correlated with surgical time. The complication was comparable between the two groups.

CONCLUSION

Above all, the advantages of vNOTES include an absence of visible scars, shorter surgical duration, and less blood loss when compared with LESS. Further large-scale prospective trials should confirm the results of our study.

Hysterectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery versus Transumbilical Laparoscopic Single-Site Surgery: A Single-Center Experience from East China

Objective

To compare hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (VNOTES) versus transumbilical laparoscopic single-site surgery (LESS) as a minimal invasive technique. Materials and Method. The women undergoing hysterectomy for benign diseases by VNOTES and LESS from January 2020 to June 2021 in a tertiary hospital in Shanghai were retrospectively analyzed.

Results

361 women were included in our study, with 228 in the VNOTES groups, 129 in the LESS groups, and 4 conversions from VNOTES to LESS technique. The length of a VNOTES hysterectomy was shorter than that of LESS (80.76 min versus 112.09 min; MD -31.34 min; 95% CI -40.24 to -22.43 min; P < 0.001). VNOTES hysterectomy has a quicker gas passage by the anus (18.80 versus 36.49 hours, MD -17.68 hours, 95% CI -20.23 to -15.14 hours, P < 0.001) and associated with a shorter length of hospital stay (2.31 versus 3.77 days, MD -1.46 days, 95% CI -1.75 to -1.17 days, P < 0.001), while with no increase in blood loss during the operation (median 50 versus 50 ml, P = 0.25). Besides, the VAS pain score in the 24^th hour after the operation was lower (median 0 versus 0.5, P < 0.001) in the VNOTES group. Four unique phases of the learning curve were identified using cumulative analysis: the mean operation time of phase I was 82.81 ± 31.45 min (the initial learning curve of 43 cases), phase II was 72.48 ± 23.66 min (the acquisition of command of 91 cases), phase III was 103.77 ± 45.69 min (the further learning of 26 cases), and phase IV was 73.18 ± 26.89 min (postlearning in 68 cases).

Conclusions

VNOTES is noninferior to LESS as a new minimal invasive procedure for hysterectomy, which also allows patients a faster recovery from surgery and to suffer less pain, and its efficiency and feasibility in large uterine need further exploring.

Applications of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologic surgery

PURPOSE OF REVIEW

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging approach used across surgical disciplines. This review seeks to assess the growing body of literature on experiences and outcomes using vaginal NOTES (vNOTES) in gynecologic surgery.

RECENT FINDINGS

Many limitations of vaginal surgery including lack of descensus or restricted vaginal space can be overcome with vNOTES whereas avoiding risks of abdominal incisions in traditional laparoscopy. vNOTES may have superior outcomes in pain, length of stay, and satisfaction for multiple gynecologic indications however additional data is needed to assess cost-effectiveness and long-term outcomes. Surgeons implementing this technique should have adequate experience with both traditional vaginal and laparoscopic approaches. The current body of high-quality studies is heavily influenced by single site, single surgeon studies and as such may not be fully applicable to all practices incorporating this novel technique, and adequate training should precede implementation of Vnotes.

SUMMARY

Vaginal surgery is considered the least invasive approach, however, may not be appropriate in all cases. vNOTES presents a novel approach that combines the access and visualization afforded by endoscopy whereas avoiding the risks associated with transabdominal entry and can be considered as a feasible option in gynecologic surgery.

vNOTES for adnexal procedures

This work aims to describe the technique and review all transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for adnexal procedures performed and to acknowledge vNOTES as an alternative to conventional laparoscopy. The procedure consisted of an incision in the Pouch of Douglas, insertion of a single port device, laparoscopic surgery through the device, extraction of specimens through the vagina and closure of the vaginal apex with a direct suture. Eighteen procedures have been successfully completed, 1 patient required conversion to conventional abdominal surgery due to intolerance to pneumoperitoneum. Surgeries' length range was 45-210 minutes. The estimated blood loss was less than 100 mL. The patients required minimal analgesia, were discharged the day after and had no postoperative complications. No patients complained of dyspareunia. Two patients conceived after surgery. vNOTES is a safe and desirable approach to the adnexa and a reasonable alternative to conventional laparoscopy or vaginal surgery.Impact statementWhat is already known on this subject? Natural Orifice Transluminal Surgery (NOTES) is a technique used to access the abdominal cavity through natural orifice. Compared to conventional laparoscopy, it's expected to have fewer complications.What do the results of this study add? This is one of the few works addressing vNOTES adnexal surgery, which appears to be a good alternative to conventional laparoscopy.What are the implications of these findings for clinical practice and/or further research? vNOTES may be a desirable approach to the adnexa. This work opens a door to new research regarding vNOTES in more complex gynaecologic procedures.

A Simple Gasless Direct Suturing Technique to Achieve Ovarian Hemostasis During Transvaginal Natural Orifice Transluminal Endoscopic Surgery Ovarian Cystectomy

Background: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) was introduced in 2012, but the technique is not yet widely used for ovarian cystectomy. We aim to introduce a new gasless ovarian hemostatic suturing technique for ovarian cystectomy using vNOTES. Methods: We conducted a prospective study using a novel technique for vNOTES ovarian cystectomy. Our vNOTES port (a wound retractor and a disposable glove) was inserted transvaginally through a posterior colpotomy. After ovarian cystectomy, removal of the glove created a gasless state. Hemostatic suturing of the ovary was performed through a vaginal speculum inserted through the wound retractor, under direct observation. Results: Twenty ovarian cystectomies were performed through vNOTES at our institution between June 2019 and February 2020. The mean patient age was 34.2 years (range, 24-51 years). Four patients (20%) underwent bilateral cystectomy and 16 patients (80%) underwent unilateral cystectomy. The mean operative time was 58.7 minutes (bilateral, 57.5 minutes; unilateral, 58.9 minutes), and the mean ovarian hemostatic suturing time was 4.3 minutes (bilateral, 5 minutes; unilateral, 4.1 minutes). Ten patients (50%) received additional medication for pain control within 30 minutes of surgery. All patients were discharged within 24 hours, and 11 were discharged within 12 hours. Conclusion: The gasless hemostatic suturing technique for vNOTES, using a speculum to observe the suturing process, is easy to perform and allows for rapid ovarian hemostasis.

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.

Bladder Safety during Natural Orifice Transluminal Endoscopic Surgery Hysterectomy in the Patients with Extensive Vesicouterine Adhesion

Adhesion at the vesicouterine fold presents a great challenge when performing hysterectomy through transvaginal natural orifice transluminal endoscopy surgery (NOTES) in women with a history of cesarean section. An attempt to lyse adhesions often prolongs the procedure and may inadvertently result in cystostomy. The purpose of this report is to demonstrate a safe technique for the lysis of vesicouterine adhesions during NOTES hysterectomy. We present the cases of two patients with a history of cesarean section. Severe adhesions at the vesicouterine peritoneum were encountered in both cases, and one patient had an extensive adhesion involving lower half of the uterus. Although the lateral approach is sufficient in most cases, it does not allow a surgeon to approach the peritoneal cavity if there is extensive adhesion. In cases such as these, direct dissection of the adhesion on the uterus is required.

New Continuous Barbed Suture Device with Stratafix for the Vaginal Stump in Laparoscopic Hysterectomy

Aims:

Closure of the vaginal stump in total laparoscopic hysterectomy (TLH) performed by interrupted suture is time-consuming and requires sufficient experience. Stratafix (SF) is a new type of antibacterial monofilament absorbable suture which has multiple small anchors on the string surface. There is no information concerning the efficacy of SF for vaginal stump suture in minimally invasive hysterectomy.

Materials and Methods:

We retrospectively evaluated the operative complications and SF (n = 20) advantages for the vaginal stump in TLH and compared with a cohort of patients with conventional sutures (n = 20). The differences in performance based on operators’ skill levels were also considered.

Results:

The time taken to close vaginal stump in the SF suture group was significantly lower than the conventional group (median times: 13.1 vs. 18.0 min, respectively; P = 0.038). Closure by a less experienced operator using SF suture was reduced by 7.2 min. The junior operator median vaginal suture time was only 2.6 min longer than the senior operator median time in SF suture group (P = 0.218), whereas an 8.4 min difference was recorded in the conventional suture group (P = 0.043). Total operation times did not significantly correlate with vaginal suturing techniques (median times: 126 vs. 145 min, respectively; P = 0.718). Complications regarding the vaginal stump closure techniques including organ injury, bleeding, wound separation, and pain did not occur in both groups.

Conclusions:

SF suturing facilitates the vaginal stump closure in TLH without increasing the complications. SF allowed vaginal stump approximation and reduced the operative burden, especially in less experienced operators.