Robotic vaginally assisted NOTES hysterectomy: the first case series demonstrating a new surgical technique

Abstract

The objective of this case report is to demonstrate a new hysterectomy technique via transvaginal natural orifice transluminal endoscopic surgery (NOTES) using robotic surgery. Previous experience with the Da Vinci Xi (Intuitive Surgery) for gynaecological oncology, and with NOTES for adnexal surgery and hysterectomy, led to the decision to combine the advantages of these techniques, namely to reduce the invasiveness of robotic surgery and improve the ergonomics of NOTES. A robotic vaginally assisted NOTES hysterectomy (VANH) was performed in five patients with a myomatous uterus. The circumcision of the cervix, the opening of the anterior and posterior peritoneum and the transection of both sacro-uterine ligaments were performed by classical vaginal surgery. A NOTES port was constructed by assembling a surgical glove, a wound protector, 4 Da Vinci 8-mm trocars and 1 reusable 5-mm trocar. The ring of the wound protector was then inserted transvaginally into the peritoneal cavity to create a pneumoperitoneum. The hysterectomy was performed via transvaginal NOTES using the surgical robot. Subsequently, a bilateral adnexectomy was performed in the same way. Once the hysterectomy and bilateral adnexectomy were completed, the robot and gloveport were removed. When the uterus was too large to extract in toto, it was manually morcellated so that it could be removed vaginally. The colpotomy was closed as in classical vaginal surgery. This is the first case report demonstrating that vaginal robotic surgery is possible and that it can be used to perform a hysterectomy. Robotic vaginally assisted NOTES hysterectomy (RVANH) makes use of the advantages of robotic surgery to broaden the indications for vaginal hysterectomy and can help overcome its limitations, while the NOTES approach avoids abdominal wall wounds and trocar-related complications. Further developments in robotic technology will help overcome the problem of robotic arm collision. Robotic hysterectomy via vaginal access is a novel approach that requires further validation. The extra cost and setup time of RVANH will also need to be assessed in comparison to the advantages it provides over a vaginally assisted NOTES hysterectomy or total laparoscopic hysterectomy.