Natural Transluminal Endoscopic Surgery Research Articles

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

BackgroundNatural 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.MethodsThis 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.ResultsMultiple 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.ConclusionThese 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.

Effectiveness of NOTES versus traditional techniques on surgical outcomes in adults with diverticulitis: a systematic review protocol.

This review will evaluate the effectiveness of natural orifice transluminal endoscopic surgery (NOTES)/hybrid NOTES versus traditional surgical techniques in the management of diverticular disease. Diverticular disease can have a significant impact on a patient's quality of life, especially the changes affecting bowel function. Recurrent/severe symptoms may require surgery. Resections are invasive and can have significant operative complications. There has been a shift from an open resection to a more minimally invasive technique such as laparoscopy. Furthermore, the use of natural orifice transluminal endoscopic resection, using a transanal/transvaginal approach, has begun to be used in colorectal resections. Eligible studies will include patients who underwent surgical resection for diverticular disease or diverticulitis. The review will consider studies that evaluate NOTES in the management of diverticular disease or diverticulitis. This will include hybrid procedures involving both NOTES and natural orifice specimen extraction (NOSE), with the aid of laparoscopy/endoscopy/robotic equipment. Studies on participants under 18 years of age and presenting with non-diverticular pathologies will be excluded. This review will follow the JBI methodology for systematic reviews of effectiveness and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Databases to be searched will include PubMed, MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane Library, Web of Science, Scopus, ProQuest, ClinicalTrials.gov, and ANZCTR, with no language limitations. The reference lists of included studies will be screened for additional studies. This review will preferentially consider experimental and quasi-experimental study designs. Two reviewers will conduct critical appraisal and data extraction. Studies will, where possible, be pooled in statistical meta-analyses. PROSPERO CRD42023420771.

Vaginal Hysterectomy and Pelvic Organ Prolapse: History and Recent Developments.

Vaginal hysterectomy (VH) was described as far back as 120 CE. However, it was not till the mid-1900s when reconstructive procedures were introduced to mitigate the risk of, or treat, pelvic organ prolapse in relation to VH. Furthermore, routine hysterectomy, particularly VH, has long been advocated in prolapse surgery. However, this indication is now questionable. Literature review to provide an overview of current evidence and experts' opinion regarding the relationship between VH and pelvic organ prolapse. The review presents a historical perspective on the role of VH in the management of pelvic organ prolapse, the current debate on the usefulness of the procedure in this context, a practical guide on operative techniques used during VH and the impact of recent surgical developments on its use. Vaginal hysterectomy is a well-established technique that is still superior to laparoscopic hysterectomy for benign gynecological disease, although more surgically challenging. However, it is possible that some contemporary techniques, such as vaginal natural orifice transluminal endoscopic surgery, may overcome some of these challenges, and hence increase the number of hysterectomies performed via the vaginal route. Although patients should be counselled about uterine-sparing reconstructive surgery, vaginal hysterectomy continues to be a major surgical procedure in reconstructive pelvic floor surgery. Therefore, it is prudent to continue to train residents in vaginal surgical skills to ensure that they continue to provide safe, cost-effective, and comprehensive patient care.

Surgical outcomes of transvaginal natural orifice transluminal endoscopy in treating ovarian cysts and risk factors for surgical conversions

ObjectiveThis study aimed to assess the surgical outcomes and identify the conversion risk factors of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in treating ovarian cyst. MethodsThis was a retrospective study of 505 patients who underwent vNO TES for treating ovarian cyst from March 2019 to February 2022 wherein the patients were classified into “converted” or “nonconverted” groups. T-tests, χ2 tests, and logistic regression were used for statistical analyses. ResultsThere were 16 (3.17 %) surgical conversions and 12 (2.38 %) other surgical complications in our study cohort. Teratomas accounted for 56.8 % of complications in nonconverted cases and 18.8 % in converted cases. Adenocystomas were found in 12.3 % of nonconverted cases and 18.8 % of converted cases. Other types included paraovarian cysts (3.3 % and 0 %), fibroma, granulosa cell tumor, Brenner tumor (1.2 % and 0 %), corpus luteum cysts, follicular cysts (7.6 % and 6.3 %), old abscess (0.2 % and 0 %), and simple cysts (17.6 % and 12.5 %) in the nonconverted and converted groups, respectively. The converted group included more cases of endometriotic cysts (43.8 % vs 12.3 %, p = 0.023), bilateral cysts (37.5 % vs 8.2 %, p < 0.001), severe pelvic adhesion (68.8 % vs 3.3 %, p < 0.001), deep endometriosis (12.5 % vs 0.4 %, p < 0.001), and at least two cysts (37.5 % vs 8.81 %; p < 0.001). Severe pelvic adhesion (adjusted odds ratio [OR], 86.96; range, 18.33–431.77; p < 0.001), bilateral cysts (adjusted OR, 4.75; range, 1.05–21.57, p = 0.043) and endometriotic cysts (adjusted OR, 7.69; range, 3.11–17.08; p < 0.001) were also predictors of surgical conversion. ConclusionvNOTES demonstrates low complication and conversion rates in treating ovarian cyst compared with TU-LESS. Surgical conversion is associated with severe pelvic adhesions, bilateral cysts, and endometriotic cysts.

Non-descent vaginal hysterectomies: a brief report

Non-descent vaginal hysterectomies: a brief report

Colonoscopy in the diagnosis and management of appendiceal disease

In this editorial, we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy . We focused on the understanding of appendiceal disease, and the various options for diagnosis and treatment via endoscopy. Some factors affecting the diagnosis and management of appendiceal diseases are also discussed. The existence of any organ has its natural rationality, and the appendix is such a magical organ. A growing number of experts and scholars have gradually come to a consensus that the appendix is not a useless evolutionary relic. There are many lymphocytes and lymph nodes in the appendix wall, which has a strong immune function, and this function is particularly important for children and adolescents. Many intestinal probiotics in the appendix are very helpful for maintaining the balance of the intestinal flora. With the continuous progress of endoscopic technology, endoscopic treatment involving preservation of the appendix has shown great advantages over surgery. In the diagnosis of appendiceal inflammation and neoplasms, colonoscopy, endoscopic retrograde appendicography and choledochoscopy help assess conditions of the appendix. Endoscopic retrograde appendicitis therapy, abscess drainage under colonoscopy, fenestration of abscess under colonoscopy, and endoscopic or natural orifice transluminal endoscopic surgery resection of appendiceal neoplasms are safe and effective endoscopic treatments for appendiceal disease. New breakthroughs in the application of endoscopy in the appendix are expected to occur in the near future.

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

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. 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. 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. 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).

Ovarian tissue biopsy for cryopreservation by vaginal natural orifice transluminal endoscopic surgery: a new approach for a minimal invasive ovarian biopsy

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging surgical procedure that combines the advantages of the vaginal approach with laparoscopic vision and instrumentation [1]. Shorter hospitalization and lower postoperative pain associated to vNOTES [2] may be explained by the advantages of this innovative surgical approach (such as absence of abdominal incisions, shorter operating time, lower insufflation pressure) [2;3]. Ovarian tissue cryopreservation allows to preserve reproductive and endocrine functions in young women with oncological disease at risk of premature ovarian insufficiency (POI) caused by gonadotoxic treatments [4]. Ovarian tissue biopsy for cryopreservation consists of a large biopsy of one or both ovaries [4] that is usually performed by laparoscopy. Then, the removed ovarian tissue is cryopreserved for the future transplant after cancer remission. Volume of ovarian biopsy ranges from 50% of the ovary for women at moderate risk of POI to 70 % or whole ovary for women at high risk [5]. Inclusion criteria for ovarian tissue cryopreservation are women aged less than 35 who cannot delay start of oncological treatments for follicles cryopreservation, with a moderate or high risk of POI and good chance of 5-year survival [6]. Ovarian tissue cryopreservation cannot be performed if tumor treatments include uterine irradiation or for tumors at risk of ovarian metastases (as in case of ovarian cancer, leukemia, neuroblastoma, Burkitt lymphoma) [7]. Despite widespread adoption of vNOTES in gynecology, ovarian biopsy for cryopreservation has never been performed using this route. Step-by-step explanation of the procedure with descriptive text and narrated video footage. Tertiary level referral academic center. A 27-years-old patient recently diagnosed with low grade follicular non-hodgkin lymphoma was referred to our center for ovarian tissue cryopreservation before chemotherapy. The patient included in this study gave informed consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. Due to the nature of the study, IRB approval was not required. Access to peritoneal cavity was created by a 3 cm posterior colpotomy. Peritoneum was then opened using cold scissors and temporarily fixed to the posterior vaginal wall. The Gelpoint Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA, USA), with one 10 mm and two 5 mm trocars, was used as vNOTES port. The inner Alexis ring of the Gelpoint was inserted through the colpotomy into the pouch of Douglas. An hysterometer was placed into the uterine cavity to keep the uterus anteverted during the surgery. A pneumoperitoneum was created to a pressure of 8 mmHg and the operating table was tilted to 20° Trendelenburg position. A 10-mm rigid 30° camera was inserted in the inferior and larger trocar and both the ovaries were visualized. 70 % of the left ovary was removed with cold scissors, in order to minimize trauma on the surgical specimen. After removal of the Gelpoint cap, ovarian biopsy was immediately picked-up by the biologist of our fertility center. The ovary was coagulated with bipolar instrument. Hysterometer was then replaced by a uterine manipulator to perform tubal patency test and blue dye passage through both the salpinges was observed. Finally, the Alexis retractor and the stich on the posterior peritoneum were removed and the vagina was sutured using interrupted stiches. Total operative time was 25 minutes. Ovarian tissue biopsy for cryopreservation by vNOTES. No intraoperative and postoperative complications were reported and the patient was discharged after 24 hours from surgery. VNOTES may be a feasible alternative approach to laparoscopy for ovarian tissue cryopreservation: it allows an easy access to the ovaries and removal of different tissue volumes. Patients undergoing ovarian cryopreservation may benefit of vNOTES approach since a rapid post-operative recovery is crucial to start chemotherapy in a short time. As for other vNOTES surgical procedures, accurate selection of patients seems to be crucial for a successful ovarian tissue cryopreservation [8]. We think that inclusion and exclusion criteria reported for other gynecologic procedures performed through vNOTES may also be valid for ovarian tissue cryopreservation by vNOTES [9]. Women at high risk of pelvic adhesions (such as coexistent endometriosis, previous pelvic surgery or inflammatory pelvic disease), with elevated Body Mass Index or enlarged uterus as well as women with cervical, vaginal or uterine cancer cannot be considered for this approach since all these factors are associated to failure of vNOTES. On the other hand, women with no history of surgery, endometriosis and large myomas may benefit from vNOTES approach and these women represent most of patients who undergo ovarian tissue cryopreservation.

VNOTES Radical Hysterectomy: A New Approach to Cervical Cancer

To demonstrate how a radical hysterectomy with sentinel node resection for cervical cancer can be performed via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). Demonstration of the technique in 10 steps. making use of narrated original video footage SETTING: The surgical treatment of cervical cancer is traditionally performed via one of the following techniques: Wertheim radical hysterectomy via laparotomy, Schauta radical hysterectomy vaginally, laparoscopic radical hysterectomy or robotic radical hysterectomy. The results of the LACC trial showed that minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open radical hysterectomy among women with early-stage cervical Cancer [1]. For endometrial cancer, a vNOTES retroperitoneal approach to sentinel node resection was first published in 2019 [2]. Based on the experience with this approach and with Schauta-Stoeckel radical hysterectomy for cervical cancer [3], a new approach was developed to perform a radical hysterectomy via vNOTES whereby most of the procedure is performed retroperitoneally [4]. This video article demonstrates in 10 steps how a radical hysterectomy via vNOTES is performed. Radical hysterectomy via vNOTES demonstrated making use of original video footage of a 57-year-old woman operated on for cervical adenocarcinoma 7 weeks after a LEEP cone. The steps of the procedure are: 1. Vaginal cuff creation, 2. Development of lateral retroperitoneal space and sentinel node resection, 3. Uterine artery and vein transection, 4. Hypogastric nerve dissection, 5. Development of central retroperitoneal space and rectum dissection, 6. Posterior colpotomy, 7. Parametrium dissection, 8. Bladder pillar dissection, 9. Anterior colpotomy, 10. Salpingo-oophorectomy or salpingectomy. 3 Patients were so far treated by this new technique that allowed for good hemostatic control. vNOTES enables a potentially less invasive approach to radical hysterectomy performed largely retroperitoneally and completely transvaginally, leaving no visible scars. The endoscopic approach offers excellent visualization of the retroperitoneal and parametrial anatomy. This is a new approach that requires further validation and should only be performed in a research setting, taking into account the current reservations about endoscopic surgery for cervical cancer resulting from the LACC trial. VIDEO ABSTRACT.

Vaginal colpotomy for traditional and natural orifice transluminal endoscopic surgery (NOTES) vaginal procedures

Vaginal colpotomy for traditional and natural orifice transluminal endoscopic surgery (NOTES) vaginal procedures

Comparison of Prone With Lithotomy Position in Removal of Posterior Myoma in Transvaginal Natural Orifice Endoscopic Surgery: A Prospective Cohort Study

ObjectiveVaginal natural orifice transluminal endoscopic surgery (vNOTES) is considered to have the advantages of completely scarless, less postoperative pain, earlier flatus, and faster postoperative recovery. However, posterior myoma are relatively difficult to operate through vNOTES in the conventional lithotomy position. Thus, we innovated the application of prone position in the removal of posterior myoma in vNOTES. The aim of this study is the comparison of myomectomy outcomes of patient for single posterior myoma in prone and lithotomy position. DesignA single-center, prospective study. SettingA university teaching hospital. PatientsA total of 81 patients with posterior myoma who underwent myomectomy in vNOTES from January 2021 to December 2022. InterventionsThe patients underwent myomectomy in vNOTES in prone or lithotomy position. Measurements and Main ResultsAmong the patients who underwent vNOTES myomectomy, 29 (35.8%) were in the lithotomy position group, and 52 (64.2%) in the prone position group. Of note, 4 (4.9%) patients underwent a conversion to LESS during the operation—3 in the lithotomy and 1 in the prone position group. And a patient in the lithotomy position group underwent resurgery for hemostasis due to postoperative pelvic bleeding. Compared with the lithotomy position, prone position significantly shortens the operation time (12.3, 95% CI: 6.811, 17.761. p = .009) without increasing the complications and postoperative discomfort of patients. ConclusionCompared to the lithotomy position, the prone position provides greater convenience for operation and exhibits a lower rate of surgical conversion during the removal of single posterior myomas via vNOTES. Further, for patients selecting vNOTES, surgeons need to conduct sufficient preoperative evaluation, timely hemostasis during surgery, and timely surgical conversion if necessary to ensure patient safety.

Pain following vaginal natural orifice transluminal endoscopic surgery (vNOTES) in obese compared to non-obese women

Pain following vaginal natural orifice transluminal endoscopic surgery (vNOTES) in obese compared to non-obese women

VaNoLaH trial: a study protocol—a multinational randomised controlled trial including two identical substudies comparing vaginal versus vNOTES (vaginal natural orifice transluminal surgery) hysterectomy or laparoscopic versus vNOTES hysterectomy

IntroductionHysterectomy is one of the most common surgeries performed in women. Minimally invasive methods are on the rise globally as they have been shown to decrease surgical morbidity compared with...

A Retrospective Cohort Study of vNOTES Extraperitoneal Versus Laparoscopic Sacral Hysteropexy With Uterine Preserving Regarding Surgical Outcomes and 2 Year Follow-up Results

Study ObjectiveTo explore the effectiveness of transvaginal natural orifice transluminal endoscopic surgery extraperitoneal sacral hysteropexy (vNOTES-ESH) in women with symptomatic uterine prolapse over a 2 year follow-up. DesignRetrospective cohort study. SettingGynecological minimally invasive center. PatientsWomen undergoing sacral hysteropexy either by vNOTES (n = 25) or laparoscopic (n = 74) between November 2016 and December 2020. InterventionsBoth vNOTES-ESH and laparoscopic sacral hysteropexy (LAP-SH) were used for uterine prolapse. Demographic data, operative characteristics, perioperative outcomes, and follow-up information 2 years postsurgery in the 2 groups were retrospectively evaluated. ResultsBoth procedures showed similar operation time, estimated blood loss, hospital stays, and pain scores (p >0.05). During a median follow-up of 59 (24–72) months, the surgical success rate was 96% for vNOTES-ESH and 97.3% for LAP-SH (p >0.05), with no differences in anatomical position or pelvic organ function after the operation. Women in the LAP-SH group experienced more bothersome symptoms of constipation compared to those in the vNOTES-ESH group (5.41% vs 0, p <0.05). Lastly, 1 case in the vNOTES-ESH group had a mesh exposed area of less than 1 cm2, and 1 patient in the LAP-SH group experienced stress incontinence. ConclusionsIn this retrospective study, vNOTES-ESH met our patients’ preference for uterine preservation and was a successful and effective treatment for uterine prolapse, providing good functional improvement in our follow-up. This procedure should be considered as an option for patients with pelvic organ prolapse.

Resident’s training in vaginal natural orifice transluminal endoscopic surgery (vNOTES)

Resident’s training in vaginal natural orifice transluminal endoscopic surgery (vNOTES)

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

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. 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 18-75years with a BMI > 30kg/m2, regardless of parity, who were operated on for benign pathology. 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. 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.

Comparison of hysterectomy cases performed by transvaginal natural orifice transluminal endoscopic surgery: A paired sample cross-sectional study.

This study aimed to investigate the feasibility, indications, and benefits of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) hysterectomy for nonmalignant gynecological diseases. The clinical data, including the baseline information and surgical conditions of 81 patients who underwent v-NOTES hysterectomy for nonmalignant gynecological diseases in a tertiary university hospital from October 2018 to August 2022, were retrospectively analyzed and compared with the total laparoscopic hysterectomy group (200 cases) and the transumbilical laparoendoscopic Single Site Surgery group (150 cases). In comparison with the other 2 groups, the highest proportion of patients in the v-NOTES group had cervical intraepithelial neoplasia. Accordingly, mean preoperative uterine volume measured by sonography was significantly smaller in the v-notes group. In the v-NOTES group, the mean number of vaginal deliveries and age were significantly higher, while the mean number of previous abdominal surgeries was lower compared to the other 2 groups. The V-NOTES group had a shorter operation time, shorter postoperative urinary catheter insertion time, earlier intestinal recovery days, shorter hospital stay, and lower visual analogue scale scores after surgery, and the differences were statistically significant. When indicated appropriately, v-NOTES hysterectomy can be a feasible and advantageous surgical modality. In particular, in comparison to the laparoendoscopic Single Site Surgery and total laparoscopic hysterectomy groups, the v-NOTES group had advantages in postoperative recovery and had more aesthetic surgical results.

Evaluation of two liver biopsy and rectal sealing techniques in dog cadavers undergoing Natural Orifices Transluminal Endoscopic Surgery (NOTES) by transrectal access

The aim of this study was to evaluate two liver biopsy techniques by transrectal Natural Orifice Transluminal Endoscopic Surgery (NOTES) and compare tensiometric parameters of rectal sealing using 2-octyl cyanoacrylate glue or conventional rectal sutures in a dog cadaver model. In sixteen dog cadavers two liver biopsy techniques were performed via transrectal NOTES using either polypectomy diathermy forceps or endoscopic oval biopsy forceps. The cadavers were divided into two groups: Glue Group (GG) where rectal sealing was performed with 2-octyl cyanoacrylate glue and Suture Group (SG) with the rectal defect sealed with simple continuous extracorporeal 3-0 polydioxanone sutures. The rupture pressure of the seals was measured on a rectal burst test. The diathermy polypectomy endoscopic forceps biopsy technique was significantly faster (p&lt;0.001) and provided larger diameter samples. Rectal sealing was significantly faster (p&lt;0.001) in the GG. There was no difference between the two groups with regard to rupture pressure (258.5 mmHg) with air insufflation. Using endoscopic oval biopsy forceps, biopsy samples can only be collected from the surface of the liver, whereas polypectomy forceps with a diathermy loop can be used to collect samples from the tip of the hepatic lobe. There was no difference in rectal rupture pressure in the burst test between the cadavers where sealing was performed with rectal sutures and those where cyanoacrylate adhesive was used.

Application of natural orifice transluminal endoscopic surgery with ENDOCRAB system for stomach perforation model: ex vivo porcine study

Iatrogenic stomach perforation is a detrimental, irreversible, and fatal condition. Traditional surgery and endoscopic suturing clips and devices have been introduced to seal holes and prevent sepsis and disease progression. However, the development of endoscopic devices for perforations remains challenging, with no standard device available. This study investigates the superficial layer approximation strengths of the newly designed ENDOCRAB system for gastric wall defects. Thirty porcine stomachs were prepared ex vivo for the perforation model and distributed equally into three groups: ENDOCRAB system, Through-the-Scope Clip (TTSC), and hand suturing (HS). Both ENDOCRAB and TTSC achieved mucosal–submucosal layer apposition, whereas HS allowed a full-thickness layer. Their air leakage pressure and procedural duration were measured. The analysis of air-leakage pressure demonstrated comparable suture strength between ENDOCRAB (118.5 ± 41.7 mmHg) and HS (127.4 ± 30.2 mmHg, P = 0.812), but inferior strength with TTSC (73.6 ± 21.6 mmHg, P = 0.012). HS achieved the shortest procedural duration, whereas ENDOCRAB and TTSC showed no significant differences. The ENDOCRAB system showed significantly greater strength than the TTSC, was comparable to HS in strength, and required a procedural duration similar to that of the TTSC. Furthermore, long-term in vivo experiments and histological evaluations are essential.

Pathological Insights on Polypropylene Mesh Complications From Laparoscopic Sacrocolpopexy: A Case Series.

Background The use of polypropylene mesh in laparoscopic sacrocolpopexy (LSC) is a common treatment for pelvic organ prolapse (POP). Despite its widespread application, postoperative complications such as mesh pain and infection sometimes necessitate the removal of the mesh. However, it remains unclear in which cases mesh removal is warranted. Our research focused on the pathological changes at the sacral fixation point of the mesh. We sought to evaluate the pathological alterations of the sacral mesh removed through an innovative approach of transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Methods This retrospective study included nine patients who underwent mesh removal surgery at the Yokosuka Urogynecology and Urology Clinic in 2023. Extraction surgery was performed using vNOTES with the GelPoint Access Platform (Applied Medical JAPAN HEADQUARTERS, Tokyo, Japan). Non-ablative Erbium YAG and Neodymium YAG lasers (RenovaLase, SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia) were utilized for persistent stress urinary incontinence, fecal incontinence, vaginal erosion, and bleeding after surgery. Patients were categorized based on mesh fixation conditions, including unintended mesh overlap (Group I), excessive traction (Group II), and signs of mesh aging (Group III). This categorization helped to understand the distinct pathological outcomes associated with each condition. Results Pathological findings from the mesh removed via vNOTES varied significantly across the groups. In Group I, characteristic large vacuole formation and accumulation of atypical giant cells were observed, attributed to mesh overlap. Group II presented with vacuole formation, fiber degradation, and tissue destruction as a result of excessive mesh traction. In Group III, the aging of the mesh was marked by cracks in the surrounding tissues and granuloma formation. These detailed observations provide crucial insights into the underlying causes of mesh-related pain and other complications, highlighting the complexity of bodily responses to mesh implants. Conclusion This study demonstrated the effectiveness of vNOTES for polypropylene mesh removal in patients with post-LSC complications, resulting in significant pain reduction. Pathological analysis revealed that mesh-related issues stem from the surgical techniques, mesh properties, and long-term bodily reactions. These findings provide valuable insights for improving mesh design and POP treatment strategies. Despite the technical challenges, vNOTES is recommended for mesh removal in patients with pain. Additionally, the combination of UEL, VEL, targeted laser irradiation, AEL, and Nd:YAG laser treatments showed promising results in managing post-mesh removal complications such as stress urinary incontinence, vaginal erosion, bleeding, and fecal incontinence, offering hope for improved patient outcomes.