Transvaginal specimen removal in minimally invasive surgery

vNOTES chromopertubation: a new method for assessing tubal patency and peritubal anatomy

BACKGROUND

We conducted a retrospective cohort study of women with suspected tubal factor infertility who underwent vaginal natural orifice endoluminal surgery (vNOTES) chromopertubation and adnexal anatomy assessment at a large referral hospital.

METHODS

Twelve women aged between 29 and 38 years with suspected tubal factor infertility who underwent vNOTES chromopertubation were retrospectively examined. Demographic data, as well as clinical and surgical characteristics, were reviewed and the surgical technique was defined.

RESULTS

The mean BMI was 34.2 ± 7.12 kg/m2 (range 24.7-42.6). No conversion to laparotomy or laparoscopy was required. The median operative time was 39 (26.5-42) minutes. The median VAS scores at six and 12 h postoperatively were 3.5 (3-4) and 2 (1-2), respectively. There were no complications and all patients were discharged at the 12th postoperative hour.

CONCLUSIONS

Considering the increased risk of surgical morbidity and mortality associated with increasing BMI and the difficulty in gaining access to the abdominal cavity not only in obese women but also in cases with previous extensive midline incisions, where dense intra-abdominal adhesions are likely, or in cases where esthetic considerations are important, vNOTES appears to be a useful alternative to assess tubal patency and adnexal anatomy and even to perform concomitant adnexal surgery.

The vaginal route for minimally invasive surgery: a practical guide for general surgeons

INTRODUCTION

Vaginal approaches have become routine in the field of gynecologic surgery, whereas in general surgery vaginal wall transection is an infrequent practice typically reserved for extensive tumor resections. Approximately two decades ago, natural orifice transluminal endoscopic surgery (NOTES) revolutionized conventional boundaries by accessing the peritoneal cavity transorally, transrectally, or transvaginally, enabling general surgery without visible scars. Although transvaginal approaches have been successfully used for various abdominal procedures by general surgeons, a gap remains in comprehensive training to fully exploit the potential of this route.

MATERIAL AND METHODS

PubMed, Google Scholar, and Scopus databases were searched to retrieve relevant articles illustrating how general surgeons can adeptly manage vaginal approaches.

RESULTS

The article presents a practical framework for general surgeons to execute a complete vaginal approach, addressing the management of vaginal specimen extraction and vaginal cuff closure, even in the absence of an experienced gynecologist.

CONCLUSION

The evolution of abdominal surgery is moving towards less invasive techniques, emphasizing the importance of understanding the nuances and challenges associated with the vaginal route. This approach is linked to minimal oncological, sexual, and infective complications, and to the absence of pregnancy-related complications. Such knowledge becomes increasingly crucial, particularly with the renewed demand for transvaginal access in robot-assisted NOTES procedures.

Sexual quality of life and postoperative deep dyspareunia after vNOTES benign adnexal procedures

OBJECTIVE

This study aimed to investigate the impact of vNOTES on postoperative sexual dysfunction in patients undergoing adnexal procedures.

METHODS

We analyzed data from patients who underwent vNOTES adnexal surgeries for benign conditions between May 2020 and May 2023. The primary outcome was the presence of new postoperative deep dyspareunia (DD) or other sexual dysfunctions, which were assessed through a phone survey conducted 6 to 24 months after surgery. Secondary outcomes included surgical feasibility, operative times, complications rate, and postoperative pain evaluation.

RESULTS

We included 103 patients for primary and secondary outcomes and 111 patients for secondary outcomes analysis only. Newly postoperative DD was reported by three patients (2.9%), remained present at 12 postoperative months in one case (1.0%), and spontaneously disappeared in two cases (1.9%) after four and 10 postoperative months, respectively. In the remaining 100 patients (97.1%), no new DD or other sexual function disorders were reported after surgery. vNOTES procedures were successfully performed in all cases, with a mean operative time of 38.2 ± 19.6 min and a conversion rate to conventional laparoscopy of 0.9%. No significant complication was observed.

CONCLUSION

This study suggests a very limited risk of developing postoperative sexual dysfunction after vNOTES benign adnexal procedures.

Transvaginal versus transabdominal specimen extraction in minimally invasive surgery: a systematic review and meta-analysis

AIM

Natural orifice specimen extraction (NOSE) is an alternative to conventional transabdominal retrieval. We aimed to compare outcomes following transvaginal specimen extraction (TVSE) and transabdominal specimen extraction (TASE) in minimally invasive abdominal surgery.

METHODS

An electronic database search of PubMed, Embase and CENTRAL was performed from inception until March 2023. Comparative studies evaluating TVSE versus TASE in adult female patients were included. Studies involving transanal NOSE, endoluminal surgery, or TVSE with concomitant hysterectomy were excluded. Weighted mean differences (WMD) and odds ratio were estimated for continuous and dichotomous outcomes respectively. Primary outcomes were postoperative day 1 (POD1) pain and length of stay (LOS). Secondary outcomes were operative time, rescue analgesia, morbidity, and cosmesis. A review of sexual, oncological, and technical outcomes was performed.

RESULTS

Thirteen studies (2 randomised trials, 11 retrospective cohort studies), involving 1094 patients (TASE 583, TVSE 511), were included in the analysis. Seven studies involved colorectal disease and six assessed gynaecological conditions. TVSE resulted in significantly decreased POD1 pain (WMD 1.08, 95% CI: 0.49, 1.68) and shorter LOS (WMD 1.18 days, 95% CI: 0.14, 2.22), compared to TASE. Operative time was similar between both groups, with fewer patients requiring postoperative rescue analgesia with TVSE. Overall morbidity rates, as well as both wound-related and non-wound related complication rates were better with TVSE, while anastomotic morbidity rates were comparable. Cosmetic scores were higher with TVSE. TVSE did not result in worse sexual or oncological outcomes.

CONCLUSION

TVSE may be feasible and beneficial compared to TASE when performed by proficient laparoscopic operators, using appropriate selection criteria. Continued evaluation with prospective studies is warranted.

Assessment of women's sexual quality of life after benign adnexal surgery using vNOTES approach in comparison to conventional laparoscopy: protocol for a randomised controlled trial

INTRODUCTION

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy without conversion. The results in terms of efficacy and safety are promising. However, we note a lack of medical literature and no specific randomised controlled trial assessing women's sexual function after vNOTES for benign adnexal surgery. The aim of this RCT is to confirm the non-inferiority of the vNOTES approach for benign adnexal pathology compared with CAL on women's sexual function. Secondary outcomes will evaluate vNOTES's efficiency, morbidity and postoperative complications compared with CAL for benign adnexal surgery. The relationship between adnexal mass morcellation and the quality of the histological analysis will also be evaluated as secondary outcome.

METHODS AND ANALYSIS

Women aged 18-70 years undergoing a benign adnexal surgery at the Geneva University Hospitals will be eligible and randomised with a 1:1 ratio to the CAL arm or the vNOTES arm, if inclusion criteria are met. Participants will complete the Female Sexual Function Index, the Couple Satisfaction Index-16 and a self-reported questionnaire on dyspareunia within 4 weeks prior to randomisation and at 3+6 months after surgery. General and clinical data will be collected when the patient is enrolled in the study, during hospitalisation and at 1 month postoperative to assess secondary outcomes.An absence of impairment on sexual function will be confirmed with a stability or an improvement of the evaluated scores in each group at 3 and 6 months postoperative compared with the preoperative scores. We expect to have no statistically significant difference in sexuality questionnaires scores between the two groups.

ETHICS AND DISSEMINATION

Protocol of this study was validated by the Cantonal Research Ethics Commission of Geneva, Switzerland, on 9 August 2022. We aim to publish the study's results in peer-reviewed journals within 3 years.

TRIAL REGISTRATION NUMBER

NCT05761275.

Laparoscopic Versus Open Partial Nephrectomy: A Systemic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes

Purpose

To summarize and analyze the current evidence about surgical, oncological, and functional outcomes between laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Materials and Methods

Through a systematical search of multiple scientific databases in March 2020, we performed a systematic review and cumulative meta-analysis. Meanwhile, we assessed the quality of the relevant evidence according to the framework in the Cochrane Handbook for Systematic Reviews of Interventions.

Results

A total of 26 studies with 8095 patients were included. There was no statistical difference between the LPN and OPN in the terms of operation time (p=0.13), intraoperative complications (p=0.94), recurrence (p=0.56), cancer-specific survival (p=0.72), disease-free survival (p=0.72), and variations of estimated glomerular filtration rate (p=0.31). The LPN group had significantly less estimated blood loss (P<0.00001), lower blood transfusion (p=0.04), shorter length of hospital stay (p<0.00001), lower total (p=0.03) and postoperative complications (p=0.02), higher positive surgical margin (p=0.005), higher overall survival (p<0.00001), and less increased serum creatinine (p=0.002). The subgroup analysis showed that no clinically meaningful differences were found for T1a tumors in terms of operation time (p=0.11) and positive surgical margin (p=0.23). In addition, the subgroup analysis also suggested that less estimated blood loss (p<0.0001) and shorter length of hospital stay (p<0.00001) were associated with the LPN group for T1a tumors.

Conclusions

This meta-analysis revealed that the LPN is a feasible and safe alternative to the OPN with comparable surgical, oncologic, and functional outcomes. However, the results should be applied prudently in the clinic because of the low quality of evidence. Further quality studies are needed to evaluate the effectiveness LPN and its postoperative quality of life compared with OPN.

Hysterectomy and salphingoopherectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery(NOTES): Turkish surgeons' initial experience

BACKGROUND

The aim of this study was to evaluate the feasibility, safety, and early postoperative outcomes of hysterectomies and salpingo-oophorectomies using transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

MATERIALS AND METHODS

The women undergoing vNOTES hysterectomies and salpingo-oophorectomies at a tertiary referral medical center between April 2016 and April 2017 were retrospectively analyzed. In all of the vNOTES procedures, a handmade glove port system comprised of a glove-wound retractor NOTES port was used.

RESULTS

Thirteen patients underwent gynecological procedures with benign indications via vNOTES. Of the 13 operations, 6 of the patients had salpingo-oophorectomies and 7 had hysterectomies, and all of the surgeries were performed by the same surgeon (Dr. Ahmet Kale). No conversion to a conventional laparoscopy or even a laparotomy was needed in any of the procedures. The mean operation time was 73.14 min in the hysterectomy patients and 40.8 min in the salpingo-oophorectomy patients. The mean drop in the hemoglobin (Hb) level was 1.4 g/dl in the hysterectomy patients and 1.6 g/dl in the salpingo-oophorectomy patients. For these patients undergoing vNOTES, the mean postoperative visual analog scale (VAS) pain score at 6 h was 4.38 and at 24 h it was 0.62. There were no intraoperative complications in any of the cases. The mean length of the hospital stay was 1.8 days in the hysterectomy patients and 1.5 days in the salpingo-oophorectomy patients.

CONCLUSION

The vNOTES procedure overcomes the surgical and technical difficulties of conventional vaginal surgery by incorporating the advantages of endoscopic surgery. Moreover, vNOTES uses inexpensive, reusable, handmade conventional laparoscopic instruments and avoids those problems related to abdominal wall incisions and trocar-related complications. Overall, this procedure results in high patient satisfaction, cosmetic advantages, and decreased postoperative pain.