vNOTES Hysterectomy Research Articles

Surgical Approach for Enlarged Uteri: Further Tailoring of vNOTES Hysterectomy

This article refers to:Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri

Comparison of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) and Laparoendoscopic Single-Site (LESS) Hysterectomy on PostoperativePain Reduction: A Randomized Pilot Study.

IntroductionVaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy has shown benefit in postoperative pain and operation time compared to laparoscopic hysterectomy in recent studies. However, no prospective studies comparing laparoendoscopic single-site (LESS) and vNOTES hysterectomy have been performed. This study aims to evaluate postoperative pain and safety of vNOTES hysterectomy compared to LESS hysterectomy for benign uterine disease.MethodsThis study is a prospective, investigator-initiated randomized controlled pilot trial. A total of 26 patients were randomized and allocated to vNOTES group (n = 13) and LESS group (n = 13). The primary outcome was postoperative abdominal and vaginal pain evaluated 24 h after surgery. Secondary outcomes included the number of additional analgesics administered and the maintenance rate of patient-controlled analgesia (PCA).ResultsNo differences were shown in baseline characteristics between the two groups. Operation time was longer in the LESS group (median, 55 vs. 75 min; P = 0.027), and there were no differences in estimated blood loss, postoperative hemoglobin level, surgical indications, and hospitalization days. Postoperative abdominal pain intensity did not differ between the two groups, while the vNOTES group showed higher postoperative vaginal pain than the LESS group at 16 and 24 h after surgery (median, 3 vs. 1 and 2 vs. 0, P = 0.007 and P = 0.010, at 16 and 24 h respectively). No differences were shown in the number of additional analgesics and PCA use between the two groups.ConclusionsvNOTES hysterectomy can be safely performed for benign uterine disease requiring hysterectomy. However, vNOTES hysterectomy might be associated with higher postoperative vaginal pain intensity compared to LESS hysterectomy.Trial RegistrationCRIS identifier KCT0004605.

Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri

Aim This study aimed to compare the surgical outcomes of laparoscopic hysterectomy (LH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in women with undescended-enlarged uteri. Materials and methods This cross-sectional study was conducted with 78 women who underwent LH (48 patients) or vNOTES hysterectomy (30 patients) for benign gynecological pathologies. The dimension of the uterus, operation time, intraoperative blood loss, the presence of peri-, postoperative complications, conversion to laparotomy, pre-, postoperative hemoglobin (Hb), and hematocrit (Hct) levels, postoperative hospital stay, total dose of postoperative analgesics, VAS scores at the postoperative 6th and 24th hours, and the final pathology reports were recorded. Results There was no significant difference between LH and vNOTES hysterectomy groups regarding age (47 vs. 47.5 years, p = 0.92), parity (2 vs. 2, p = 0.74), and BMI (30.8 vs. 28.2 kg/m2, p = 0.31). The patients in the vNOTES hysterectomy group had significantly shorter durations of surgery (45 vs. 160 min) and hospitalization (48 vs. 72 h) than the LH group (p < 0.001, p < 0.001, respectively). The 24th hour VAS score was lower (VAS score 2 vs. 3, p = 0.003) in favor of the vNOTES hysterectomy group. In matched group analysis, the 24th hour VAS score (2 vs. 3, p = 0.008), operation time (45 vs. 157, p < 0.001), and hospitalization (48 vs. 72, p < 0.001) were lower in the vNOTES hysterectomy group than the LH group. Conclusion vNOTES hysterectomy provides favorable outcomes compared to conventional LH considering the shorter operation time, hospitalization, and lower 24th h VAS score.

VNOTES Hysterectomy: Can It Be Considered the Optimal Approach for Obese Patients?

Vaginally assisted Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a recent and newly introduced technique which has a wide application in gynecologic surgery and other medical specialt...

The Comparison of Surgical Outcomes following Laparoscopic Hysterectomy and vNOTES Hysterectomy in Obese Patients

Aim This study aimed to compare the surgical outcomes of total laparoscopic hysterectomy (TLH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in obese patients. Materials and methods This cross-sectional study was conducted with 83 obese women (BMI > 30 kg/m2) who underwent TLH (35 patients) or vNOTES hysterectomy (48 patients) for benign gynecological indications. The duration of surgery, intra/postoperative complications, intra- and postoperative hemoglobin (Hb) and hematocrit (Hct) levels, hospital stay, Visual analogue scale (VAS) scores at the postoperative 6th and 24th hours of the patients were compared. Results There was no significant difference between TLH and vNOTES groups regarding age (49 vs. 52 years, p = 0.35), parity (2 vs. 3, p = 0.17), and uterine weight (290 vs. 230 g., p = 0.13) The median BMI was 31.6 kg/m2 (30–42.2 kg/m2) in the TLH group and 31.9 kg/m2 (30–54.6 kg/m2) in the vNOTES group (p = 0.31). The vNOTES hysterectomy group had significantly shorter durations of surgery (67.5 vs. 136 min) and postoperative hospitalization than the TLH group (p < 0.05 for all comparisons). Besides, the 6th-hour (6 vs. 7, p = 0.02) and 24th-hour (4 vs. 3, p < 0.001) VAS scores were significantly lower in the vNOTES hysterectomy group. The propensity-matched group analysis showed significantly lower 6th-hour and 24th-hour VAS scores and shorter duration of surgery (80 vs. 135 min, p < 0.001) in the vNOTES hysterectomy group than the TLH group. Conclusion vNOTES is a feasible technique in obese women who require a hysterectomy and provides favorable outcomes considering the shorter duration of surgery and postoperative hospitalization and lower pain scores.

Surgical Outcomes of Hysterectomy via Robot-assisted versus Traditional Transvaginal Natural Orifice Transluminal Endoscopic Surgery

To evaluate the safety and feasibility of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) hysterectomy when compared with traditional vNOTES (T-vNOTES) hysterectomy. Retrospective chart review. Academic tertiary setting. Total of 114 patients with benign gynecologic indication for hysterectomy. T-vNOTES or R-vNOTES hysterectomy performed by a single minimally invasive gynecologic surgeon in the study period. The primary outcome of this study was surgical equivalence, measured principally by total operative time between T-vNOTES and R-vNOTES hysterectomy. Secondary operative outcomes that were measured included estimated blood loss, length of hospital stay, reported postoperative pain levels, and number of conversions. A total of 79 women underwent T-vNOTES hysterectomy, and 35 women underwent R-vNOTES hysterectomy without differences in operative time (p=.37), estimated blood loss (p=.27), length of hospital stay (p=.06), or reported postoperative pain levels at weeks 1, 2, and 3 after surgery (p=.78, p=.36, p=.38, respectively). A total of 6 patients underwent conversion in the T-vNOTES hysterectomy group compared with 0 in the R-vNOTES hysterectomy group; however, this was not statistically significantly different, and there were no conversions to laparotomy. R-vNOTES hysterectomy is a feasible approach to surgery when compared with T-vNOTES hysterectomy and warrants further consideration as a skill set in a gynecologic surgeon's toolbox. Wristed instruments may allow surgeons who are inexperienced in single-site laparoscopy to adopt vNOTES more quickly as a new technique when performing hysterectomy through a comparable minimally invasive approach.

Hysterectomy via vaginal Natural Orifice Transluminal Endoscopic Surgery in virgin patients: a first feasibility study

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a minimally invasive, scar-free technique that uses a vaginal colpotomy to access the peritoneal cavity. Hysterectomy via vNOTES has shown to be technically feasible and safe, with shorter hospital stay and lower postoperative pain scores. Moreover, vNOTES adds the advantages of endoscopy to those of vaginal surgery and thereby broadens the indications of a conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, as vaginal accessibility can be severely reduced in virgin women. Therefore, cases of vNOTES hysterectomy in virgin patients have never been reported in the literature. The objective of this study is to assess the technical feasibility and safety of hysterectomy in virgin women. We performed a retrospective analysis of patient files of all vNOTES hysterectomies performed on virgin women in our centre (Imelda Hospital, Bonheiden, Belgium) from July 2016 until June 2020 (N = 9). Despite limited vaginal accessibility, vNOTES hysterectomy was successfully performed in all nine patients, without conversion to laparoscopy or laparotomy and without clinically relevant complications. In this first IDEAL stage 1 study, vaginal NOTES hysterectomy appears to be technically feasible and safe in virgin women. Impact statement What is already known on this subject? Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is an emerging, minimally invasive technique that offers a safe alternative to laparoscopy and open surgery. Besides better cosmetics (scar-free technique), advantages of vNOTES hysterectomy include shorter hospital stay and less postoperative pain compared to laparoscopic hysterectomy. Moreover, vNOTES adds the benefits of endoscopy (visualisation of anatomy) to conventional vaginal hysterectomy. Virginity has been contraindicated for vNOTES so far, because the absence of uterine descent and narrow vagina in virgins is thought to complicate the vaginal approach. Therefore, vNOTES hysterectomy has never been reported in virgin patients. What do the results of this study add? In this study, we are the first to report the feasibility of performing a vNOTES hysterectomy in virgin patients. The results show that, in experienced hands, indications for vNOTES can be broadened and include virgin women. What are the implications of these findings for clinical practice and/or further research? This first report of vNOTES hysterectomy in virgin patients is only a small but important step in the evaluation of safety and efficacy of this emerging technique. Further research is needed to assess reproducibility of the findings and to carefully determine indications and contraindications of vNOTES.

Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse

ObjectiveThe objective of this study was to compare surgical and short-term postoperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) uterosacral ligament suspension (USLS) surgery. Study designA retrospective cohort study was conducted on 135 patients who underwent hysterectomy with USLS via CV (n = 70) or via vNOTES (n = 65). Patients’ baseline characteristics, surgical characteristics, and surgical outcomes were retrieved. The primary outcome was total operative time. Secondary outcomes include intra- and post-operative complications. ResultsSalpingectomy was performed in all vNOTES procedures and in only 27 % of conventional vaginal procedures (p < 0.005). Compared to the conventional vaginal procedures (n = 65), the vNOTES (n = 70) showed lower mean operative time and mean anesthesia time (101.4 ± 22.3 vs 125.5 ± 27.6 min and 141.4 ± 29.6 vs. 174.0 ± 32.9 min, respectively); and slightly longer median hospital stay (3 [range 2−4] vs. 2 [range 2−4] days, p < 0.05). Compared to women who underwent conventional vaginal hysterectomy with USLS, women who underwent vNOTES hysterectomy with USLS had lower incidences of intraoperative complications (6% vs. 18 %, p < 0.05) and intraoperative ureteral obstruction (0% vs. 8%, p < 0.05); and less estimated blood loss (58 ± 68 ml vs. 143 ± 87 ml, p < 0.05). ConclusionvNOTES hysterectomy with USLS is associated with reduced incidence of intraoperative complications, shorter surgical and anesthesia time, and slightly longer hospital stay, compared to the traditional vaginal surgical approach. Post-operative complications during hospital stay were similar and infrequent following the two procedures.

Repeat Vaginal Natural Orifice Transluminal Endoscopic Surgery: A First Feasibility Study

Objectives: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive technique in benign gynaecologic surgery whereby surgical access to the peritoneal cavity is achieved through natural orifices, namely through a vaginal colpotomy. Experience in repeat vNOTES cases is limited and so far, repeat vNOTES cases have not been described in the literature. The purpose of this study was to demonstrate the feasibility of vNOTES hysterectomy in women with a history of previous vNOTES adnexal surgery. Design: We performed a retrospective cohort study of the first 11 repeat vNOTES cases in our centre. All vNOTES procedures, primary adnexal surgery as well as repeat vNOTES hysterectomy, were performed by one surgeon (J.B.). Materials, Setting, Methods: Between March 2016 and May 2020, 11 patients underwent a vNOTES hysterectomy after prior vNOTES adnexectomy or cystectomy in Imelda Hospital, Bonheiden, Belgium. Relevant patient characteristics and outcome data were collected after written informed consent. Results: Median age was 49 years (range 44–65) at the moment of the first vNOTES procedure. Two patients had one or more caesarean sections in history, and 2 women were nulliparous. Median interval between primary and repeat vNOTES procedure was 15 months (range 0.8–37 months). All patients underwent a vaginally assisted NOTES hysterectomy (VANH) as repeat vNOTES procedure. Performing a colpotomy and entering the peritoneal cavity after prior vNOTES was technically feasible in all cases. All VANHs were successfully performed. There were 3 minor complications after repeat vNOTES, of which one was anaesthesia-related. The 2 complications associated with the surgical procedure were both cystitis. In one of these 2 patients, there were high post-void residues, which were easily managed by bladder training. There were no conversions to laparoscopy or laparotomy, neither serious nor life-threatening complications. No ureteric, bladder, or intestinal injuries have occurred. Limitations: The retrospective design and small sample size are the main limitations of this study. Moreover, the follow-up period of the most recently operated patients was too short to draw conclusions on long-term outcomes, including sexual function. Conclusions: In all patients in this case series, vNOTES hysterectomy after prior vNOTES adnexal surgery was successfully performed. Large-scale prospective trials with long-term follow-up are needed to evaluate the safety and feasibility of multiple consecutive vNOTES procedures in 1 patient.

VNOTES Hysterectomy with Sentinel Lymph Node Mapping for Endometrial Cancer: Description of Technique and Perioperative Outcomes

To explore the technique and clinical value of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in hysterectomy and sentinel lymph node (SLN) mapping for endometrial cancer by comparing its perioperative outcomes with those of laparoscopic staging. Retrospective cohort study. Department of gynecology at a tertiary medical center. All women diagnosed with endometrial cancer who underwent minimally invasive surgery at our center between August 2017 and May 2020. Both vNOTES and laparoscopic approaches were used for hysterectomy and SLN mapping. The success of SLN detection as well as perioperative outcomes were subsequently analyzed. This study included 74 patients; 23 patients underwent vNOTES surgery, whereas 51 underwent standard laparoscopic surgery. The total successful SLN detection was 95.7% in the vNOTES group and 92.2% in the laparoscopy group (p >.05), whereas the bilateral success rates were 87.0% and 90.2%, respectively. No difference in SLN detection was observed between the 2 groups in terms of the side-specific mapping efficacy quotient (91.3% vs 91.2%, p = .47). The number of harvested SLNs, operative time, estimated blood loss, and intraoperative complications in the 2 groups were similar. One (4.3%) postoperative complication occurred in the vNOTES group vs 4 (7.9%) in the laparoscopy group (p = .029), and the median postoperative hospital stay was 3 days vs 4 days (p = .003). This study suggests that the vNOTES procedure is feasible, with a potentially decreased postoperative hospital stay, faster recovery, and better cosmetic results. However, prospective research is needed to validate its broader clinical application.

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.

VNOTES Hysterectomy for Large Uteri: A Retrospective Cohort Study of 114 Patients

To evaluate the outcome of hysterectomy through vaginal natural orifice transluminal endoscopic surgery (vNOTES) in cases with a large uterus. A retrospective cohort study. Belgian teaching hospital. Women who underwent a vNOTES hysterectomy from March 2015 to March 2020 for benign gynecologic disease with a uterine weight of 280 g or more on pathologic examination (N = 114). All women underwent vaginally assisted NOTES hysterectomy. We performed a retrospective analysis of baseline patient characteristics and clinical outcomes. The mean age was 50 ± 3.5 years. Twenty-two (19%) patients were obese (body mass index ≥30 kg/m2), and 4 (3.5%) were morbidly obese (body mass index ≥40 kg/m2). Thirty-five (31%) patients were nulliparous, and 15 (13%) women had 1 or more cesarean sections in their medical history. Uterine weight varied from 281 g to 3361 g, with a mean weight of 559 ± 425 g. Mean surgical time was 63 ± 34 minutes. Surgical time was positively associated with uterine size. There were 4 complications: 3 bleeding complications in the first 24 hours after surgery and 1 minor late complication. Conversion to laparotomy for specimen extraction was performed in 1 case (conversion rate 0.9%). There were no conversions to laparoscopy. No ureteric, bladder, or intestinal injuries occurred in this case series, and there were neither life-threatening complications nor intensive care unit admissions. The vNOTES technique can offer a safe and effective alternative to laparoscopy or laparotomy in cases with a large to very large uterus, even if the patient has a history of cesarean section, obesity, or nulliparity. In 99% of all women in this study, hysterectomy was successfully performed through vNOTES without conversion. By making use of the advantages of endoscopic surgery, vNOTES might broaden the indications of vaginal hysterectomy. Randomized controlled trials are needed to evaluate whether vaginally assisted NOTES hysterectomy is superior to laparoscopic or abdominal hysterectomy in large uteri cases.

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy for uterus weighing \u22651\u2009kg

BackgroundThe transvaginal natural orifice transluminal endoscopic surgery (vNOTES) applied in gynecology has been developed recent years and been evolving. In this study, we aimed to evaluate the feasibility and effect of the vNOTES hysterectomy for uterus ≥1 kilogram (kg).MethodsFrom January 2019 to March 2020, patients with benign indications in cases of uterus weighing ≥1 kg, underwent vNOTES hysterectomy were studied retrospectively. The patients’ demographics, indications for surgery, operation outcomes and follow-up details were recorded.Results39 patients were performed vNOTES hysterectomy for large uterus (mean weight 1141.8 gram, range from 1000 to 1720), indications for surgery included bulky uterine myomas or adenomysosis. The mean age was 48 years (range 42–66) and mean BMI was 24 kg/m2 (range 18.4–38). Mean operating time was 123.3 min (rang 40–400) and the mean estimated blood loss was 206.7 milliliters (range 10–1300). The mean pain assessment was 2.1 (range 0–5). The mean length of stay was 2.4 nights (1–11). 1 patient experienced ureteral injury and was performed ureteral anastomosis. 3 patients were converted to vaginal-assisted trans-umbilicus single-port laparoscopy. The learning curve was analyzed to show that 20 cases were needed to achieve proficiency in vNOTES hysterectomy for large uterus ≥1 kg.ConclusionOur preliminary experience suggested that vNOTES hysterectomy for large uterus weighing ≥1 kg was feasible and safe, meanwhile this procedure had the advantages of all the minimal invasive approach such as fast recovery and aesthetic advantage.

Comparison of hysterectomy cases performed via conventional laparoscopy or vaginally assisted natural orifice transluminal endoscopic surgery: a paired sample cross-sectional study

Hysterectomy is one of the most frequent gynaecological procedures performed for various uterine pathologies. There are several approaches for conducting hysterectomies, including abdominal, vaginal, laparoscopic and robotic. Recently, natural orifices transluminal endoscopic surgery (NOTES) has emerged as an alternative approach for conducting hysterectomies. In this study, we aimed to compare the results of total laparoscopic hysterectomy (TLH) and vaginally assisted-NOTES (vNOTES) hysterectomy procedures for the treatment of benign gynaecological diseases. Ninety-nine patients, who underwent conventional TLH or vNOTES hysterectomies, were included in this study. The operation time, presence of per/postoperative complications, visual analogue scale (VAS) scores at postoperative sixth and 24th hours, and the duration of hospital stays were all analysed. The duration of surgery was significantly shorter in the vNOTES hysterectomy group (79.56 ± 32.54 min) compared to the TLH group (120.67 ± 38.35 min) (p: < .001). Also, postoperative hospital stays were significantly shorter in favour of the vNOTES hysterectomy group (44 ± 16.47 h) compared to the TLH group (57.86 ± 21.31 h) (p: .002). These results indicate that vNOTES hysterectomy can be a promising approach for treating a variety of different uterine pathologies and, furthermore, that it can be an alternative to TLH. Impact statement What is already known on this subject? A hysterectomy can be done in a variety of different ways, such as abdominal, laparoscopic, vaginal, and robotic. Even though the standard practice guidelines recommend that a vaginal hysterectomy (VH) should be the first choice of treatment, it can be challenging in cases of non-descendent and large uteruses. In such cases, NOTES hysterectomy can be an alternative option. What do the results of this study add? The study has shown that vNOTES is associated with a shorter operation and briefer postoperative hospitalisation time, in comparison to TLH. What are the implications of these findings for clinical practice and/or further research? This study speculates that vNOTES is an approach which may offer better outcomes than a conventional laparoscopy. Further randomised controlled trials with larger sample sizes, however, should be conducted in order to establish the place of vNOTES in hysterectomy surgeries.

Feasibility and Learning Curve of Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Hysterectomy and Uterosacral Ligament Suspension in Apical Compartment Prolapse.

The aim of this study was to describe our experience with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) uterosacral ligament suspension (USLS) and to evaluate the learning curve of mastering the skills to operate this procedure. This is a prospective study of the first 35 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) (n = 26) and Imelda Hospital (Belgium) (n = 9). The primary outcome was surgical time. Secondary outcomes included intraoperative bleeding, length of hospitalization, pain during the first 24 hours postoperative pain, and the need for analgesia, intraoperative, and postoperative adverse events. The median age was 55 years (range, 40-81). The median operative time was 113 minutes (range, 89-233). For the procedures performed at Rambam, total operative time decreased from the first 13 to the following 13: from 149 minutes (range, 89-233 minutes) to 103 (89-170) (<0.001); Pearson correlation demonstrated a moderate negative significant correlation of surgery duration with surgeon experience (rho = -0.445, P < 0.001). The median estimated blood loss was 30 mL (20-200). The median hospital stay was 2 days (1-3). There were no intraoperative adverse events. The median visual analogue scale score for pain assessment during the first 24 hours after surgery was 1 (range, 1-3). vNOTES USLS is a feasible procedure that showed marked improvement in surgical performance in a short period, as evidenced by the decrease in surgical time and the low rate of minor associated perioperative complications. Outcomes of long-term follow-up should be investigated.

1397 Vnotes Hysterectomy for Multiple Fibroid Uterus by Atrium Technique

Video Objective To describe technique of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) of hysterectomy in a case of multiple fibroid uterus with the aid of transcervical instrumental uterine manipulation- ATRIUM technique. Setting Minimally invasive gynecological surgery department, Naval Multi Speciality Hospital, Jalgaon, India. Interventions Transvaginal natural orifice transluminal endoscopic surgery of hysterectomy. Conclusion During vNOTES hysterectomy, using a laparoscopy instrument placed transcervically into the uterus for manipulation gives a leverage that helps in good exposure of all uterine attachments. It prevents unintentional rotation of uterus and its attachments. Therefore, the surgeon is not required to use second hand for retraction of uterus during surgery. This allows surgeon to use second hand for retraction of bowel and adnexa. As the tip of instruments is not completely visible in vNOTES surgery, manipulation helps to deflect the uterus and its attachments away from important structures thus preventing inadvertent thermal damage from the tip of the instrument. This is a feasible and safe technique of vNOTES hysterectomy. To describe technique of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) of hysterectomy in a case of multiple fibroid uterus with the aid of transcervical instrumental uterine manipulation- ATRIUM technique. Minimally invasive gynecological surgery department, Naval Multi Speciality Hospital, Jalgaon, India. Transvaginal natural orifice transluminal endoscopic surgery of hysterectomy. During vNOTES hysterectomy, using a laparoscopy instrument placed transcervically into the uterus for manipulation gives a leverage that helps in good exposure of all uterine attachments. It prevents unintentional rotation of uterus and its attachments. Therefore, the surgeon is not required to use second hand for retraction of uterus during surgery. This allows surgeon to use second hand for retraction of bowel and adnexa. As the tip of instruments is not completely visible in vNOTES surgery, manipulation helps to deflect the uterus and its attachments away from important structures thus preventing inadvertent thermal damage from the tip of the instrument. This is a feasible and safe technique of vNOTES hysterectomy.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (VNOTES) For Endometrial Carcinoma: A Feasibility and Safety Study

Study Objective To investigate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for endometrial carcinoma (EC). Design Retrospective study. Setting The First Affiliated Hospital of Third Military Medical University, Chongqing, China Patients or Participants Women with federation international of gynecology and obstetrics (FIGO) stage IA endometrial cancer. Interventions vNOTES surgery consist of hysterectomy, bilateral salpingo- oophorectomy and bilateral pelvic and para-aortic lymph node dissection were performed by by a gynecologic oncologist. Clinicopathologic, surgical, and perioperative outcomes were analyzed. Measurements and Main Results All the 12 patients were successfully operated. Vaginal hysterectomy was performed in five patients, and vNOTES hysterectomy was performed in seven patients. All the 12 cases underwent bilateral salpingo-oophorectomy under vNOTES. Pelvic lymph node dissection was performed in six patients, sentinel lymph node biopsy was performed in four patients, and pelvic lymph node dissection plus para-aortic lymphadenectomy was performed in two patients. The median operative time was 172 minutes (94-235 minutes), the median blood loss was 117 (50-200) ml, and the median postoperative hospital stay was 5 (4-9) days. The median time for postoperative recovery of gastrointestinal function was 21 hours (12-40 hours), the median pain score at postoperative 12 hours was 2 (1-4) and 1 (1-2) at postoperative 24 hours. The median follow-up time was 5 months. The vaginal stump incision healed well in all the patients. Conclusion vNOTES is a safe and effective method for comprehensive surgical staging of EC. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice. To investigate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for endometrial carcinoma (EC). Retrospective study. The First Affiliated Hospital of Third Military Medical University, Chongqing, China Women with federation international of gynecology and obstetrics (FIGO) stage IA endometrial cancer. vNOTES surgery consist of hysterectomy, bilateral salpingo- oophorectomy and bilateral pelvic and para-aortic lymph node dissection were performed by by a gynecologic oncologist. Clinicopathologic, surgical, and perioperative outcomes were analyzed. All the 12 patients were successfully operated. Vaginal hysterectomy was performed in five patients, and vNOTES hysterectomy was performed in seven patients. All the 12 cases underwent bilateral salpingo-oophorectomy under vNOTES. Pelvic lymph node dissection was performed in six patients, sentinel lymph node biopsy was performed in four patients, and pelvic lymph node dissection plus para-aortic lymphadenectomy was performed in two patients. The median operative time was 172 minutes (94-235 minutes), the median blood loss was 117 (50-200) ml, and the median postoperative hospital stay was 5 (4-9) days. The median time for postoperative recovery of gastrointestinal function was 21 hours (12-40 hours), the median pain score at postoperative 12 hours was 2 (1-4) and 1 (1-2) at postoperative 24 hours. The median follow-up time was 5 months. The vaginal stump incision healed well in all the patients. vNOTES is a safe and effective method for comprehensive surgical staging of EC. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Utero-Sacral Ligament Learning Curve: Our Experience with the First 30 Cases

Study Objective The objective of this study is to describe our experience with Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) utero-sacral ligament apical suspension and to evaluate the learning curve of mastering the skills to operate this procedure. Design A retrospective multicenter study of the first 30 vNOTES hysterectomy and USLS surgeries performed between October 2018 and April 2019 at Rambam Health Care Campus (Israel) by a single surgeon (L.L) and Imelda Hospital (Belgium) by (J.B). Setting Retrospective study Patients or Participants Women who underwent sutero-sacral ligament suspension for treatment of uterovaginal or vaginal apical prolapse Interventions Vaginal hysterectomy and utero-sacral ligament suspension Measurements and Main Results The primary outcomes were hysterectomy and USLS times. Secondary outcomes included intra-operative bleeding, length of hospitalization, post-operative pain and need for analgesia. Sociodemographic and clinical data were retrieved from patients’ electronic charts. Patients` median age was 55 years (range 40-81); Median hysterectomy time was 38 minutes (range 15-55) from first cut to completion of hysterectomy; Median USLS time was 17 minutes (range 14-27). The median estimated intra-operative blood loss was 20 ml (range 20-250). Length of hospital stay was 2 days (2-3). Comparisons between median USLS time in the first 15 and in the 15 sequential procedures demonstrated a significant decrease: 25 minutes (range 18-39) vs. 15 minutes (range 13-28) respectively (P=0.03). The median estimated intraoperative blood loss decreased from 70 ml (range 40-100) in the first 15 suspensions to 20 ml (range 10-70) in the 15 sequential procedures (P=0.011) Conclusion vNOTES hysterectomy followed by USLS is a feasible procedure with an marked improvement in surgical performance in a short period as expressed by the improvement in surgical times with minor associated perioperative complications. This technique allows surgeon to expose the ureter well and lower the risk of ureter injury. Outcomes of long-term follow-up should be investigated.

1942 Transvaginal Natural Orifice Transluminal Endoscopic (Vnotes) Hysterectomy Learning Curve: The Feasibility in the Hands of Skilled Gynecologists

1942 Transvaginal Natural Orifice Transluminal Endoscopic (Vnotes) Hysterectomy Learning Curve: The Feasibility in the Hands of Skilled Gynecologists

Hysterectomy and Adenextomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES): A UK perspective with a case series of 33 patients

Objective: To evaluate operative outcomes of hysterectomy +/- adnexectomy by Trans-vaginal Natural Orifice Endoscopic Surgery (vNOTES) in a case series of 33 patients. Study Design: It was a prospective case series study carried out in Darent Valley and Benenden Hospital, to our knowledge, the first units in the United Kingdom to have undertaken VNOTE Hysterectomy.We collected data on a private shared drive noting patient demographics, indications for surgery, operation outcomes and patient follow-up details. Results and Conclusions: Between January and December 2018, 33 patients underwent surgery between two units. Indications for surgery included dysfunctional uterine bleeding, endometrial hyperplasia, pelvic pain, post-menopausal bleeding, prophylactic surgery in BRCA positive patients and one grade 1 stage 1 endometrial cancer in whom laparoscopic hysterectomy was technically difficult and complicated by previous midline laparotomy. Ages ranged from 35 to 75 and BMI from 20-53.Mean operation time was 68.5 min and mean blood loss intraoperatively was 269mls. 15.2% (n = 5) had a blood loss equal or more than 500 mls. There were no intraoperative complications and no conversions to open surgery.The median visual analogue pain score at 6 h post operatively and at discharge was 0. All patients received regular Paracetamol and Ibuprofen and opiate based analgesics were only used on an as required basis.Postoperative complication which included failed trial without catheter, urinary tract infection and urinary dysfunction were reported by four women (12.4%).Only 2 patients re-presented to hospital over a 30-day period and neither required inpatient management.Hysterectomy by vNOTES has advantages over traditional laparoscopic and vaginal hysterectomy that include reduced requirement for intra-abdominal insufflation and head down, absence of trocar related injuries and easier operative access in patients with morbid obesity, or previous abdominal surgery such as midline laparotomy or mesh hernia repair. In addition, both tubes and ovaries can be removed easily due to easier access and visibility and there is no requirement for vaginal descent in order to do so.Plans for a comparative study between laparoscopic hysterectomy and vNOTES hysterectomy are underway.