Author's Reply

Abstract

On behalf of all authors of the article entitled, “Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Pregnancy and a Device Innovation from Our Institution” [ 1 Chen X Liu H Sun D et al. Transvaginal natural orifice transluminal endoscopic surgery for tubal pregnancy and a device innovation from our institution. J Minim Invasive Gynecol. 2018; 23 ([Epub ahead of print]) Google Scholar ], we thank Dr. Kaya and colleagues for their interest in our report about the device innovation. Many articles of transvaginal natural orifice transluminal endoscopic surgery (NOTES) use a wound retractor to support the vaginal wall besides Kaya et al [ 2 Kaya C Alay İ Ekin M Yaşar L Hysterectomy by vaginal-assisted natural orifice transluminal endoscopic surgery: initial experience from 12 cases. J Turk Ger Gynecol Assoc. 2018; 19: 34-38 Crossref PubMed Scopus (13) Google Scholar ] and Baekelandt and Vercammen [ 3 Baekelandt J Vercammen J IMELDA transvaginal approach to ectopic pregnancy: diagnosis by transvaginal hydrolaparoscopy and treatment by transvaginal natural orifice transluminal endoscopic surgery. Fertil Steril. 2017; 107: e1-e2 Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar ]. In our initial exploration, salpingectomy by using only a wound retractor could also be performed, but the procedure sometimes was relatively laborious. All patients in our study had a history of vaginal delivery [ 1 Chen X Liu H Sun D et al. Transvaginal natural orifice transluminal endoscopic surgery for tubal pregnancy and a device innovation from our institution. J Minim Invasive Gynecol. 2018; 23 ([Epub ahead of print]) Google Scholar ]. Although vaginal elasticity could help expose the operative field, excessive vaginal laxity might limit the movement of instruments. Achieving appropriate triangulation is a fundamental principle of laparoscopic surgery. But in transvaginal NOTES the “in-line” placement of instruments invariably results in clashing, suboptimal exposure, and imprecise tissue handling [ 4 Xue Y Zou X Zhang G et al. Transvaginal natural orifice transluminal endoscopic nephrectomy in a series of 63 cases: stepwise transition from hybrid to pure NOTES. Eur Urol. 2015; 68: 302-310 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar ]. The plastic ring is effective in reducing interference among instruments by providing a larger operative space. Meanwhile, the inner ring of the wound retractor may collapse with large incisions or excessive vaginal laxity. Under this circumstance, we can push the plastic ring to the vaginal vault to hold the inner ring in place. We barely encountered the plastic ring collapse during operation.