Transvaginal Natural Orifice Transluminal Endoscopic Surgery Research Articles

Assessing Feasibility and Outcomes of Robotic Single Port Transvaginal NOTES(RSP-vNOTES) Hysterectomy: A Case Series

ObjectiveTo demonstrate the feasibility and short-term outcomes of Robot-Assisted Single Port vaginal NOTES (RSP-vNOTES) for total hysterectomy, with or without endometriosis resection for all stages. DesignRetrospective case series. SettingSingle academic tertiary care hospital in Houston, Texas, USA. Participants28 adult women with chronic pelvic pain who underwent RSP-vNOTES hysterectomy, with or without endometriosis resection. InterventionsHysterectomy with or without excision of endometriosis via single-port robot-assisted vNOTES platform (Intuitive Da Vinci SP Platform). Main Results28 patients with a mean age of 40.1 years (range 24.0-54.0 years), mean BMI 28.5 kg/m2 (range 19.5-48.4 kg/m2), underwent RSP-vNOTES from November 11, 2023 to May 7, 2024. Five (17.9%) patients underwent solely a hysterectomy, while 23 (82.1%) patients underwent additional endometriosis resection; 28.6% with stage I, 25.0% stage II, 7.1% stage III, and 21.4% with stage IV. Mean total operative time was 188.7 minutes (range 135.0-427.0 minutes), with robot dock time of 2.9 minutes (range 1.0-10.0 minutes), robot console time of 97.3 minutes (range 51.0-221.0 minutes), and hysterectomy time of 55.3 minutes (range 24.0-170.0 minutes). Estimated blood loss averaged 32.1 mL (range 25.0-50.0mL). One case required a mini-laparotomy as the irregularly-shaped 1668g fibroid uterus was unable to be removed vaginally. Complications included one case of vaginal cuff cellulitis and one case of urinary tract infection. ConclusionOur findings indicate that RSP-vNOTES, a novel single-port surgical approach, presents a promising alternative surgical platform in vaginal surgeries.

Robotic vNOTES Techniques for Hysterectomy in a Patient with a 16-week Sized Uterus and a Body Mass Index of 70

To demonstrate the surgical techniques for robotic vNOTES hysterectomy with bilateral salpingo-oophorectomy (BSO) in a World Health Organization class 3 obesity patient (body mass index=70) as well as large fibroid uterus (16 weeks sized). Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 50-year-old G0 with postmenopausal vaginal bleeding with an enlarged uterus; her endometrial biopsy showed complex endometrial hyperplasia with atypia. The surgical exposure for extremely obese patients with a concomitantly large uterus can be very challenging transabdominally due to the patient being unable to tolerate the Trendelenburg position and abdominal gas pressure [1-5]. Therefore, transvaginal NOTES can be an alternative option for these types of challenging patients. However, although there are clear benefits of vNOTES surgery in obese patients, we still need to be thoughtful and deliberate in handling this kind of surgery [6]. Several key success factors that aid in the completion of the surgery include 1. Appropriate patient positioning (Trenguard Position) as tolerated. 2. Initial vaginal section of hysterectomy. 3. Successful port placement. 4. Trendelenburg, as far as tolerated. 5. Harnessing the robotic camera for anterior colpotomy. 6. Utilizing alternative surgical exposure techniques: air seal for maintaining gas pressure for optimizing exposure, lap pad for thermal isolation, and maintaining the uterus for safe exposure during BSO. 7. After identification of the bilateral ureters, the broad, round, and uterine ovarian ligaments were transected with vessel sealer (less thermal spread), and the cystectomy was completed. (Supplemental Video 1) 8. BSO was completed. 9. In-bag uterine tissue extraction. 10. Vaginal cuff closure with V-Loc barbed suture. Robotic-assisted NOTES hysterectomy with BSO is feasible and safe in extremely obese patients with large uterus. The combination of all these strategies could aid in the feasibility and safety of patients with these challenging pathology and morbidity.

Design and analysis of an intra-abdominal wall-lifting device for vNOTES

Natural orifice transluminal endoscopic surgery (NOTES) associated with less pain, shorter hospital stay, and outstanding cosmetic results has drawn considerable attention from the academic community. For NOTES, pneumoperitoneum is an essential technology to obtain intraperitoneal surgical space, which, however, can have some serious adverse hemodynamic effects. In this paper, we propose a novel intra-abdominal wall-lifting device that can replace the pneumoperitoneum functionally for transvaginal NOTES (vNOTES). The device consists mainly of two layers of elastic strips, namely, the outer strips that are used to lift the abdominal wall for surgical exposure and the inner strip with a camera mounted that can rotate to provide a wide surgical field of view. With the design, gasless vNOTES can be carried out with 82.74% of the operative field provided by pneumoperitoneum, eliminating all complications associated with gas insufflation. The design principle and kinematic analysis of the device are discussed in detail and validated by experiments. Finally, a prototype is fabricated to demonstrate the feasibility of the proposed concept.

Indocyanine Green–Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff.Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side.Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc.The patient was discharged in one day with reports of minimal pain (Videos 1-3). Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

The Pure Extraperitoneal Approach for Sacrocolpopexy in Transvaginal Natural-Orifice Transluminal Endoscopic Surgery.

The goal of this research was to investigate the feasibility, safety, and short-term clinical outcome of pure extraperitoneal sacrocolpopexy with transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for treating central pelvic defects. A total of 9 patients with central pelvic prolapse underwent extraperitoneal sacrocolpopexy with V-NOTES, at the Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China, between December 2020 and June 2022. The patients' demographic characteristics, perioperative parameters, and clinical outcomes were analyzed retrospectively. Each patient had the following major surgical procedures: (1) Establishing a platform for an extraperitoneal approach with V-NOTES; (2) separating the extraperitoneal path to the sacral promontory region; (3) suturing the long arm of the mesh to the anterior longitudinal ligament S1; and (4) suturing and fixating the short arm of the mesh at the top of the vagina. The median patient age was 55, the median operative time was 145 minutes, and the median intraoperative blood loss was 150 mL. The operations were successful for all 9 cases, with a median preoperative Pelvic Organ Prolapse-Quantification score of C: +4, and a 3-months postoperative score of C: -6. There were no recurrences during a follow-up of 3-11 months, and no complications occurred, such as mesh erosion, exposure, and infection. As a new surgical approach, extraperitoneal sacrocolpopexy with V-NOTES is safe and feasible. (J GYNECOL SURG 39:108).

Women's Perception of Transgastric and Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) - Impact of Medical Education, Stage of Life and Cross-Cultural Aspects.

Despite that NOTES produces at least matchable clinical long-term results when compared to laparoscopy, still a restraint within the medical community and among patients is evident. Consequently, it might be meaningful to evaluate factors of patient's NOTES perception to promote its acceptance. NOTES is still quite novel and questionnaires regarding its perception by the public is still lacking even so in the Middle East. Aim of our survey is to investigate the viewpoint of female healthcare staff on NOTES. A total of 350 questionnaires along with written information about Minimally Invasive Surgery and NOTES were distributed among the female staff in a Tertiary-care Hospital in Abu Dhabi, 257 were returned completely anonymously and voluntarily and entered into a database with a response rate of 73%. We surveyed factors like religion, medical background, age as well as history of previous laparoscopy, endoscopy, birth and other aspects that may impact a woman's perception of both transgastric and transvaginal NOTES for cholecystectomy and ovariectomy, respectively. Univariate analyses revealed the majority of Muslim women to be more receptive to NOTES as a choice of surgical technique for cholecystectomy and for ovariectomy, respectively, when compared to Christians and Hindus. However, when compared to Muslims, Christian and Hindu groups had a larger share of medical professions. Women with a medical background would opt significantly less for NOTES. Among younger women, NOTES cholecystectomy was refused due to anxiety concerning future pregnancies and sexual dysfunction. Multinomial logistic regression analysis determined medical background and with independent predictive value for the overall choice of interventional technique (p<0.001). Marital status played a significant role only in the comparison of laparoscopy vs transgastric NOTES when performing cholecystectomy and ovariectomy (p<0.01). In this first study emanating from the Middle East, medical education and partly life stage rather than cross-cultural differences seem to influence NOTES perception in women.

Robotic transvaginal NOTES: A step-by-step approach to surgical technique

Robotic transvaginal NOTES: A step-by-step approach to surgical technique

Safety and Feasibility of Vaginal Delivery in Full-Term Pregnancy After Transvaginal-Natural Orifice Transluminal Endoscopic Surgery: A Case Series.

Study ObjectiveThe aim was to investigate the outcome of vaginal delivery of full-term pregnancies in patients after transvaginal-natural orifice transluminal endoscopic surgery (vNOTES) treatment for gynecological disorders.DesignA case series report.SettingA medical university hospital.Patients12 cases of successful delivery after transvaginal-natural orifice transluminal endoscopic surgery.InterventionsLong-term follow-up of patients with fertility needs after transvaginal-natural orifice transluminal endoscopic surgery.Measurements and Main ResultsFrom 2018 to 2021, 163 cases of gynecological diseases were treated by vNOTES. One hundred forty-seven patients were followed up, with a follow-up rate of 90.1%. The average follow-up time was 28 (15–47) months, including 66 cases with fertility requirements. Among these 66 patients, 12 patients successfully got pregnant and completed delivery, including 10 cases of vaginal delivery and 2 cases of cesarean section, with no adverse pregnancy outcomes associated with vNOTES arising.ConclusionVaginal delivery of a full-term pregnancy after transvaginal-natural orifice transluminal endoscopic surgery appears to be safe and feasible and would not be one of the bases for elective cesarean delivery.

Comparison of two different anesthesia methods on the quality of surgical condition in transvaginal natural-orifice transluminal endoscopic surgery (vNOTES): A prospective single-blind randomized clinical trial

BackgroundThe purpose of the current study is to compare the quality of surgical condition of combined epidural-general anesthesia (EGA) versus general anesthesia (GA) in patients undergoing transvaginal natural orifice transluminal endoscopic surgery (vNOTES). MethodsPatients undergoing vNOTES were randomly allocated to receive GA or EGA. The primary outcome was evaluate the quality of surgical condition. We further assessed patients’ medical data regarding the need and consumption of intraoperative analgesics and vasoactive drugs. The visual analogue scale (VAS) and postoperative nausea and vomiting (PONV) scores were assessed at 2 h and 24 h postoperatively. We have registered the number of patients who needed rescue analgesics and antiemetics within 24 h after surgery. ResultsThe scores of the quality of surgical condition was 1.9 ± 0.8 in the GA group and 1.4 ± 0.7 (P = 0.001) in the EGA group. The PONV scores were not significantly different in the first two 2 h following surgery between the groups. The obviously differences in the PONV scores between the EGA group and GA group were detected at the 24th postoperatively. Moreover, there were no significant differences in the consumption of atropine, sufentanil, cisatracurium, propofol, sevoflurane and neostigmine between the two groups. Regarding the duration of extubated time, operative time, duration of anesthesia time and postoperative length of hospital stay (PLOS), our findings did not showcase significant differences between the two groups. Similarly, we did not detect significant changes in the postoperative pain at the two time points between the groups. ConclusionOur results showed that compared with GA, EGA improved the quality of surgical condition in patients undergoing vNOTES. As epidural block is an additional invasive procedure with its attendant risks, we should weigh the pros and cons when combined epidural-general anesthesia is used for vNOTES in the future. Trial registrationThis study was registered at Chinese Clinical Trial Registry chictr.org.cn (http://www.chictr.org.cn/) with No. 2000032406 on April 27, 2020.

Comparative analysis of postoperative pain after transvaginal hybrid NOTES versus traditional laparoscopic cholecystectomy in obese patients

PurposeEven though obesity is a known risk factor for needing cholecystectomy, most research excludes patients with higher degrees of obesity. The aim of this retrospective study was to compare postoperative pain and analgesic consumption in obese patients, who underwent either transvaginal hybrid Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy (NC) or traditional laparoscopic cholecystectomy (LC).MethodsBetween 12/2008 and 01/2017, 237 NC were performed, of which 35 (14.8%) showed a body mass index (BMI) of 35 kg/m2 or more (obesity II and III according to the World Health Organization). Of these, procedural time, postoperative pain, analgesic requirements, and other early postoperative parameters were collected and compared with 35 matched LC patients from the same time period.ResultsThere were no differences in the baseline characteristics between the two groups, but we found significant benefits for the hybrid NOTES technique in terms of less pain (P = 0.006), coherent with significantly less intake of peripheral (paracetamol; P = 0.005), and of centrally acting analgesics (piritramide; P = 0.047) within the first two-day post-surgery. We also found that those in the NC group had shorter hospital stays (P < 0.001). The postoperative complication rates and the procedural time did not differ between the two groups.ConclusionWith regard to postoperative pain and analgesic requirements and without an increase in postoperative complications, obese patients experience short-term benefits from the hybrid NOTES technique compared to traditional laparoscopic cholecystectomy.

Hysterectomy and bilateral adnexectomy using transvaginal natural orifice transluminal endoscopic surgery: The role of multichannel abdominal PORT and vaginal support ring.

Although transvaginal natural orifice transluminal endoscopic surgery (NOTES) is gaining importance, knowledge on transvaginal NOTES procedures in gynecologic practice is limited. We aimed at evaluating the feasibility and safety of performing hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) via transvaginal NOTES using a self-developed multichannel abdominal port and vaginal support ring. A prospective, single-center, cohort pilot study was conducted from May to December 2017 in patients with benign uterine diseases or endometrial atypical hyperplasia or cervical intraepithelial neoplasia (n=30) scheduled for laparoscopic hysterectomy. The procedure was performed using a self-developed five-channel port and a vaginal support ring. Hysterectomy and bilateral adnexectomy (or bilateral salpingectomy) in all 30 cases (mean age: 51.43 ± 4.60 years and body mass index: 23.42 ± 1.45 kg/m2 ) were successfully performed completely under transvaginal NOTES. Mean operation time was 95.90 ± 14.60 minutes and mean blood loss during the procedure was 52.50 ± 19.20 mL. Average weight of specimen was 79.97 ± 35.48 g. Only one complication of bladder injury was noted and was rectified accordingly. Visual Analog Score (VAS) at first day after operation was 2.70 ± 0.72. After follow-up for 4.50 ± 1.85 months, all the patients' vaginal stump healed well without scar formation. Our study showed that use of multichannel abdominal port could make laparoscopic instruments easier to fix and operate wherein the vaginal support ring reduces the leakage of carbon dioxide pneumoperitoneum. There was no scar on the abdomen and VAS was much lower. This study also demonstrated cosmetic benefits and rapid postoperative recovery.

Transvaginal Hybrid-NOTES procedures\u2014do they have a negative impact on pregnancy and delivery?

PurposeWe conducted a retrospective observational study in order to identify negative effects of NOTES procedures (Natural Orifice Transluminal Endoscopic Surgery) with transvaginal specimen removal on pregnancy and delivery.MethodsFrom the total population of 299 patients in our NOTES registry, we tried to contact the 121 patients who were of reproductive age (≤ 45 years) at the time of a transvaginal NOTES procedure. They were interviewed by telephone regarding their desire for children, post NOTES-operation pregnancies, and type of delivery using a structured questionnaire. The collected data was analyzed and compared with current data.ResultsWe were able to contact 76 patients (follow-up rate: 62.8%) with a median follow-up of 77 months after surgery (33–129 months). Twenty of 74 participating patients had a desire for children (27.0%). One of them and another's male partner were diagnosed as infertile. Regarding the remaining 18 patients, 14 became pregnant, and three of them became pregnant twice. Considering these 17 pregnancies, there was one miscarriage (5.9%) and one twin birth (5.9%). On average, childbirth occurred 44 months after the NOTES procedure. With regard to the type of delivery, 10 vaginal births (58.8%) and 7 caesarean sections (41.2%) occurred. Thus, the rate of fulfilled desire for children was 77.8%. Compared with the literature, no difference to the normal course could be detected.ConclusionThere is no sign that the transvaginal approach in Hybrid-NOTES, with removal of the specimen through the vagina, has a negative effect on conception, the course during pregnancy, or the type of delivery.

Integration of a Robotic Platform for Sacrocolpopexy in Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Novel Surgical Technique

ObjectiveTo demonstrate the feasibility and the simplified surgical techniques of intraabdominal suturing and knot–tying in robotic transvaginal natural orifice transluminal endoscopic surgery (RV–NOTES) sacrocolpopexy. Materials and MethodsWe report on two patients with symptomatic stage II apical pelvic organ prolapse who underwent a new technique of RV–NOTES sacrocolpopexy. Case one: A 69-year-old G2P2002 with a history of two prior vaginal deliveries presented with a vaginal bulge and pressure symptoms. She was initially fitted for a pessary but was unsatisfied and elected to proceed with surgical intervention. Case two: A 50-year-old G2P0011 female with a history of one prior vacuum-assisted vaginal delivery presented with symptoms of vaginal mass and bleeding due to an endometrial polyp. She was noted to have stage 2 apical prolapse and opted for transvaginal sacrocolpopexy. ResultsBoth patients were observed overnight and discharged home twelve hours after surgery on postoperative day 1, after completing a voiding trial. For both patients, the postoperative course was unremarkable, and they only required one day of pain medications. At the three–week follow–up visit, they endorsed no postoperative pain or complications, and the POP-Q stage was noted to be 0. Patients had telemedicine visits at eight weeks postoperatively, at which time they had returned to their regular activities and denied symptoms of vaginal bulge or pressure. ConclusionRobotic assisted transvaginal NOTES sacrocolpopexy is a feasible and an alternative to traditional laparoscopic NOTES sacrocolpopexy.

Techniques for Apical Prolapse Management in Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension

To demonstrate practical tips and tricks for successful use of the transvaginal natural orifice transluminal endoscopic surgery (NOTES) technique for performing high uterosacral ligament suspension (HUS). Stepwise demonstration with narrated video footage (Canadian Task Force classification III). An academic tertiary care hospital. A 58-year-old G2P2, NSVDx2 with stage III anterior vaginal prolapse, stage II uterine prolapse, and posterior vaginal prolapse. The preoperative vaginal length was 7-cm. Transvaginal NOTES is a creative yet difficult approach that averts an abdominal incision while simultaneously providing enhanced visualization in comparison with traditional vaginal surgery [1]. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and bilateral salpingo-oophorectomy was subsequently performed. The following key techniques were used to perform NOTES-HUS: tagging the sutures for bilateral uterosacral ligament before single-site port placement, identifying the ischial spine and ureters, pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament, grasping and lifting the uterosacral ligament while placing a suture, and giving the suture a tug after placement to confirm the correct location [2-4]. The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 5-cm. Postoperative pelvic organ prolapse quantification was stage 0. Transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. There is an increased cost to using laparoscopically assisted NOTES surgery as well as a risk of pneumoperitoneum. Applying the tips and tricks presented here, such as tagging the uterosacral ligament before port placement and so on, the challenging transvaginal NOTES-HUS technique can be performed efficiently and safely.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension (NOTES-HUS) for Apical Prolapse

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal NOTES technique for preforming HUS. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Patients or Participants A 58-year-old G2P2, NSVDx2 with Stage III anterior vaginal prolapse, Stage II uterine prolapse & posterior vaginal prolapse. The preoperative vaginal length was 7 cm. Interventions High uterosacral ligament suspension (HUS) is well accepted for apical prolapse due to its advantages of good apical support and simplification of intraperitoneal suture passage. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel minimally invasive approach that avoids an abdominal incision while providing improved visualization, leading to simplified intraperitoneal suture placement. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and BSO was subsequently performed. The following key techniques were utilized to perform NOTES-HUS: ○ Tagging the sutures for bilateral uterosacral ligament before single-site port placement ○ Identifying the ischial spine and ureters ○ Pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament ○ Grasping and lifting uterosacral ligament while placing a suture ○ Giving the suture a tug after placement to confirm the correct location Measurements and Main Results The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion The transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. Applying the tips and tricks presented here, such as tagging uterosacral ligament before port placement, etc., the challenging transvaginal NOTES-HUS can be performed efficiently and safely.

The Novel Application of Transvaginal Notes for Hysteroscopic Polypectomy and Cervicalmyomectomy

Study Objective To demonstrate the advantages of using transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for both hysteroscopic polypectomy and cervical myomectomy. Design Video presentation of the surgical procedure. Setting University hospital. Patients or Participants A sexually inactive patient with numerous comorbidities presented with irregular vaginal bleeding in the setting of worsening pelvic pain and bladder pressure for three year. Pelvic MRI showed multiple cervical fibroids and an endometrial polyp. Interventions After the patient was anesthetized, a narrow vagina with no visibility of the cervical os was detected. vNOTES hysteroscopic polypectomy and cervical myomectomy were determined to be more appropriate than conventional methods. A GelPOINT mini port was first placed in the vagina, which allowed for entrance into the uterine cavity. A Myosure hysteroscope and laparoscopic tenaculum were inserted through the port, and polyps in the uterine cavity were then removed. After polypectomy, a transverse incision was made on the anterior cervix through the same port for cervical myomectomy. The tenaculum was used to grab the fibroid and a harmonic scalpel was then applied for enucleation. V-loc was used to close the incision and reconstruct the cervical canal. After suturing, hysteroscopy was performed again to confirm normal anatomy. A Foley catheter was placed to prevent cervical stenosis. Measurements and Main Results Complete resection of cervical myoma and uterine polyp were performed, with postoperative relief of symptoms (i.e. bladder pressure). The surgery was 70 mins with Conclusion For patients with cervical polyps and/or myomas who cannot be operated by conventional methods, NOTES hysteroscopy and myomectomy may be an attractive option and lead to less surgical complications, reduced pain, and faster recovery.

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Hysterectomy: A Novel Route for Uterus Removal

Study Objective To demonstrate the feasibility of Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) hysterectomy. Design Stepwise demonstration with narrated surgical video. Setting A university-affiliated center. Patients or Participants A 52-year-old gravida 2, para 2 woman with a 10 cm fibroid presented with a 2-year history of frequent micturition. Ultrasound showed fibroids and bilateral ovarian cysts. Interventions After injecting dilute vasopressin in the cervix, the vaginal mucosa was incised circumferentially. Posterior and anterior colpotomy was made. Then bladder pillars were clamped. Single-site port was successfully placed and pneumoperitoneum was established. After the survey of upper abdomen, progressive clamping from the cardinal ligaments to the level of the broad ligament was performed. Then the proper ligaments of ovary were clamped and bilateral oophorosalpingectomy was performed. The specimen was then delivered to the vagina. The vaginal cuff was closed with running stich. Measurements and Main Results The surgery was successfully conducted with operating time of 120 minutes and blood loss of 20 ml. The uterus weighed 410 g. The patient recovered well and had resolution of frequent micturition. Conclusion vNOTES is feasible for hysterectomy. Combined with traditional transvaginal colpotomy, vNOTES allows the access to the entire abdomen and completion of hysterectomy through a transvaginal single port. Transvaginal NOTES Hysterectomy benefits specimen removal and leads no abdominal incision.

Transvaginal natural orifice endoscopic surgery for extremely obese patients with early-stage endometrial cancer.

The purpose of this study was to assess the feasibility and efficacy of transvaginal natural orifice transluminal endoscopic surgery (v-NOTES) staging surgery for extreme obese patients with early-stage type-1 endometrial cancer. Study included cases of extreme obese patients with early-stage endometrial cancer who underwent v-NOTES between January 2019 and June 2019 at a tertiary referral medical center. The following parameters were noted: patient age, body mass index (BMI), operating time, conversion to conventional laparoscopy or laparotomy, any intraoperative or postoperative complications, estimated blood loss, pre- and postoperative hemoglobin levels, postoperative pain scores of the patients using visual analogue scale (VAS) at 6th, 12th and 24th h, length of hospital stay and final pathology report. Six cases of extreme obese patients with early-stage endometrial cancer underwent hysterectomy and bilateral salpingo-oophorectomy via the transvaginal NOTES. These six patients had a mean body mass index of 51.4 kg/m2 (SD = 6,13). No conversion to conventional laparoscopy or even laparotomy was needed in any of these patients. No adjuvant therapy was needed since all of the patients had early-stage endometrial carcinoma. Given the increased risk of surgical morbidity and mortality associated with increasing BMI, it is paramount importance to establish safe surgical approaches to gynecological pathologies. We think that v-NOTES offers greater benefit to obese patients when performed by an experienced surgeon and v-NOTES is a safe, effective and feasible minimally invasive surgery in extreme obese patients with early endometrial cancer.

Natural orifice transluminal endoscopic surgery with sentinel lymph node mapping for endometrial cancer

Objective: In the last few years, there has been a remarkable shift from traditional open surgery to minimally invasive surgery for the management of endometrial cancer especially in disease confined to the uterus. Included in the minimally invasive options is the natural orifice transluminal endoscopic surgery (NOTES) approach with integration of sentinel lymph node (SLN) mapping. This report describes the experience with the largest series of endometrial cancer patients who underwent transvaginal NOTES with SLN mapping using indocyanine green (ICG).

Application of the prone position in myomectomy by transvaginal natural orifice transluminal endoscopic surgery.

IntroductionNatural orifice transluminal endoscopic surgery (NOTES) is a new concept of minimally invasive surgery. It could prevent complications related to the trocar in laparoscopic surgery, and help achieve ideal cosmetic outcomes.AimTo describe the safety and feasibility of the prone position in transvaginal NOTES (V-NOTES) resection of posterior uterine myoma.Material and methodsSeventeen patients were included in the study from February to December 2019. All the patients were diagnosed with solitary posterior uterine myoma and underwent V-NOTES myomectomy in the prone position. We measured the characteristics and the surgical outcomes of these patients, to evaluate the safety and feasibility of the prone position in V-NOTES myomectomy.ResultsThe mean age of the patients was 38.71 ±7.68 years and the mean body mass index was 22 ±2.02 kg/m2. Five patients had a cesarean section once, and 1 patient had a history of two operations (cesarean section and laparoscopic cholecystectomy). The remaining patients had no history of surgery. The mean myoma volume in the ultrasound report was 121.99 ±125.24 cm3. The mean operation time was 107.48 ±34.16 min. The mean hemoglobin decrease 48 h after the operation was 1.37 ±0.66 g/dl. The mean weight of the myoma was 183.88 ±144.29 g. The mean VAS score 12 h and 24 h after surgery was 2 ±0.87 and 1.18 ±0.73, respectively. The mean postoperative hospital stay was 3.18 ±0.39 days. One patient was converted to TU-LESS. No other complications such as massive hemorrhage, infection or injury occurred.ConclusionsThe prone position in V-NOTES myomectomy is safe and feasible. It expands the operative space and reduces the difficulty of surgery. Perhaps it can be used as a standard position for posterior uterine myomectomy by V-NOTES.