Qualitative and quantitative analysis of women's perceptions of transvaginal surgery

Transvaginal Laparoscopic Appendectomy: A Systematic Review

Appendectomy remains the gold standard for treating appendicitis, but advancements in laparoscopic techniques have shifted the paradigm. Natural orifice transluminal endoscopic surgery (NOTES) and transvaginal appendectomy (TVA) offer a potentially less invasive alternative to traditional laparoscopic appendectomy (LA). This article systematically reviews the procedures, perceptions, and complications of TVA to assess its viability as a surgical option. Between January 1, 2003, and November 1, 2023, 4832 case reports, case series, and experimental and observational peer-reviewed publications were examined and filtered using the keyword "Transvaginal Laparoscopic Appendectomy." The publications were screened using PRISMA guidelines, and 20 studies were included for analysis and review. Survey results showed that women's acceptance of TVA was 43%, citing reduced invasiveness as a major reason for positive reception. TVA procedures exhibited consistency, with variations in appendectomy methods, appendix removal, and posterior fornix incision closure. Positive outcomes included shorter operation times, reduced postoperative pain, and minimal scarring. Complications were uncommon but included bladder puncture, urinary tract infections, and intra-abdominal abscesses. Indications primarily focused on surgical safety, reduced scarring, and postoperative benefits. Sexual function post-TVA exhibited no significant differences in most cases, with a recovery period of two to four weeks. This systematic review suggests that TVA is a promising alternative to traditional LA, offering potential advantages in terms of postoperative complications. While the existing literature indicates positive outcomes, further research with larger sample sizes and long-term follow-ups is needed to validate the efficacy and safety of TVA and assess how the procedure impacts the reproductive function of patients.

Comparison of Surgical Outcomes of Hysterectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) versus Single-Port Access (SPA) Surgery

Single-port access (SPA) laparoscopic surgery and vaginal natural orifice transluminal endoscopic surgery (vNOTES) have many advantages. The objective of the present study is to compare patient characteristics, operative details, and postoperative outcomes between the two surgical methods. Patients who were planned to undergo vNOTES or SPA laparoscopic surgery between April 2020 and June 2021 were prospectively enrolled. The surgical method was determined by a single surgeon after imaging results evaluation and a physical exam. Those who had favorable pelvic conditions without any evidence of adhesion were scheduled for vNOTES. A total of 33 patients underwent a vNOTES hysterectomy while 40 patients received a SPA laparoscopic hysterectomy. All surgeries were performed by one surgeon. The proportion of the patients who had a history of vaginal delivery was significantly higher in the vNOTES group. The operative time for port installation was significantly longer in the vNOTES group, but the total operative time was shorter compared to the SPA group. The postoperative pain scores 12 h after the operations were also significantly lower in the vNOTES group. Other surgical outcomes were comparable between the two groups. The present study demonstrated that the early operative outcomes of vNOTES hysterectomy were comparable to those of SPA hysterectomy. It also highlights the importance of adequate patient selection when determining surgical methods based on imaging results and physical examinations.

Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention

Objective

To examine narrative feedback to understand surgical team perceptions about surgical safety checklists (SSCs) and their impact on the safety of surgical practice.

Design

We reviewed free-text comments from surveys administered before and after SSC implementation between 2011 and 2013. We categorized feedback thematically and as positive, negative or neutral.

Setting

South Carolina hospitals participating in a statewide collaborative on checklist implementation.

Participants

Surgical teams from 11 hospitals offering free-text comments in both pre-and post-implementation surveys.

Intervention

Implementation of the World Health Organization SSC.

Main Outcome Measure

Differences in comments made before and after implementation and by provider role; types of complications averted through checklist use.

Results

Before SSC implementation, the proportion of positive comments among provider roles differed significantly (P = 0.04), with more clinicians offering negative comments (87.9%, (29/33)) compared to other surgical team members (58.3% (7/12) to 60.9% (14/23)), after SSC implementation, these proportions did not significantly differ (clinicians 77.8% (14/18)), other surgical team members (50% (2/4) to 76.9% (20/26)) (P = 0.52). Distribution of negative comments differed significantly before and after implementation (P = 0.01); for example, there were more negative comments made about checklist buy-in after implementation (51.3 % (20/39)) compared to before implementation (24.5% (13/53)). Surgical team members most frequently reported that checklist use averted complications involving antibiotic administration, equipment and side/site of surgery.

Conclusions

Narrative feedback suggested that SSC implementation can facilitate patient safety by averting complications; however, buy-in is a persistent challenge. Presenting information on the impact of the SSC on lives saved, teamwork and complications averted, adapting the SSC to fit the local context, demonstrating leadership support and engaging champions to promote checklist use and address concerns could improve checklist adoption and efficacy.

Women’s Perception of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Objective. Over the past 8 years, natural orifice transluminal endoscopic surgery (NOTES) has developed from preclinical to routine clinical practice. However, there are still concerns regarding the transvaginal approach. In our survey, we were interested in females with a professional medical background, thus having at least a basic medical understanding, which might discriminate between objective and subjective concerns. Material and Methods. A questionnaire with 14 items was distributed among 1895 female physicians and nursing and administration staff of the University Medical Center Hamburg-Eppendorf. In addition, a qualitative literature review was performed. Data analysis was carried out using statistical package R version 2.15.0. Results. The questionnaire was answered anonymously by 553 employees (29%). Fifty-seven percent were nurses, 18.6% belonged to administration, and 17% were physicians. A total of 63.1% of our respondents would choose the transvaginal NOTES technique for an assumed ovariectomy, while only 30.4% would choose this access for cholecystectomy. Doubts regarding transvaginal NOTES were related to sexual dysfunction (44.8%), its experimental nature (43.8%), future pregnancies (36.8%), and ethical reasons (30.3%). The literature review showed that women’s perception of the transvaginal access is documented very heterogeneously and therefore difficult to compare. Conclusions. Despite the good reported results of NOTES and the medical background of the surveyed female employees, our study and the literature review clearly shows that there are  fears regarding the transvaginal access, which might be a result of limited information. More accurate explanation of the available methods by the attending surgeon can lead to a better choice of the patient’s preferred method.

Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis

AIM: To compare the results of transvaginal cholecystectomy (TVC) and conventional laparoscopic cholecystectomy (CLC) for gallbladder disease.

METHODS: We performed a literature search of PubMed, EMBASE, Ovid, Web of Science, Cochrane Library, Google Scholar, MetaRegister of Controlled Trials, Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC. Data were extracted by two authors. Mean difference (MD), standardized mean difference (SMD), odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models. Statistical heterogeneity was evaluated with the χ² test. The fixed-effects model was used in the absence of statistically significant heterogeneity. The random-effects model was chosen when heterogeneity was found.

RESULTS: There were 730 patients in nine controlled clinical trials. No significant difference was found regarding demographic characteristics (P > 0.5), including anesthetic risk score, age, body mass index, and abdominal surgical history between the TVC and CLC groups. Both groups had similar mortality, morbidity, and return to work after surgery. Patients in the TVC group had a lower pain score on postoperative day 1 (SMD: -0.957, 95%CI: -1.488 to -0.426, P < 0.001), needed less postoperative analgesic medication (SMD: -0.574, 95%CI: -0.807 to -0.341, P < 0.001) and stayed for a shorter time in hospital (MD: -1.004 d, 95%CI: -1.779 to 0.228, P = 0.011), but had longer operative time (MD: 17.307 min, 95%CI: 6.789 to 27.826, P = 0.001). TVC had no significant influence on postoperative sexual function and quality of life. Better cosmetic results and satisfaction were achieved in the TVC group.

CONCLUSION: TVC is safe and effective for gallbladder disease. However, vaginal injury might occur, and further trials are needed to compare TVC with CLC.

Patient perceptions about laparoscopy at Komfo Anokye Teaching Hospital, Ghana

INTRODUCTION

Laparoscopy has become the gold standard for many surgical cases in the developed world. It however, remains a rarity in developing countries for several reasons, a major one being cost. This study aimed to determine the knowledge and attitude of patients attending Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana toward laparoscopic surgery and their willingness to pay for it.

METHODS

A cross-sectional survey was conducted among patients attending specialist clinics at KATH.

RESULTS

1070 patients participated. Mean age was 40±15 years. 54% were city-dwellers. 14% had salary-paying jobs. None had undergone prior laparoscopic surgery. 3% had knowledge of laparoscopy. 95% preferred laparoscopy to open surgery mainly because of faster recovery and less post-op pain. Age >45 years (AOR = 0.53, p = 0.03) and higher education (AOR = 2.00, p = 0.04) were significant predictors of patient choice. Among those preferring laparoscopy, 78% were willing to pay more than the baseline cost of open surgery for laparoscopy. A history of previous abdominal surgery (AOR = 0.67, p = 0.02), having a salaried job compared with being unemployed (AOR = 2.36, p < 0.01) and living in the city compared with the village (AOR = 1.78, p = 0.04) were significant predictors of patients' willingness to pay more for laparoscopy.

CONCLUSION

Knowledge about laparoscopy and its benefits are severely lacking among patients at KATH. Once educated about its benefits, most people prefer laparoscopy even if they needed to pay more for it even in resource-limited countries like Ghana.

Randomized trial on the physiologic impact of NOTES

BACKGROUND

Our previous work revealed significantly less acidosis in swine undergoing natural orifice translumenal endoscopic surgery (NOTES) using endoscopic air insufflation than swine undergoing standard laparoscopy. We wanted to evaluate the differential effects of CO2 versus intra-abdominal pressure as source for this finding. In addition, we investigated the endocrine stress response between swine undergoing NOTES peritoneoscopy with CO2 insufflation and animals undergoing standard diagnostic laparoscopy with CO2.

MATERIALS AND METHODS

Twenty-eight (28) female 50-kg domestic pigs were randomly assigned to one of four groups using a permuted block randomization table: Group 1: NOTES using CO2 insufflation, Group 2: NOTES using air insufflation, Group 3: laparoscopy max pressure 12 mmHg and Group 4: laparoscopy with max pressure 7 mmHg. Invasive monitoring lines were placed. Pneumoperitoneum was established by the respective method and maintained for 90 min, visualizing liver, spleen and colon. Arterial blood gas was obtained at baseline and four additional time points. Serum TNF-α for POD (postoperative day) 1 and cumulative urine adrenaline for the procedure were determined by ELISA. ANOVA and t test were used for statistical comparison. The study was Institutional Animal Care and Use Committees approved.

RESULTS

All experiments were completed as outlined. Blood pH showed a significant difference between groups. Serum TNF-α revealed higher levels for NOTES CO2 on POD 1 than standard laparoscopy (p = 0.03).

CONCLUSION

NOTES animals with CO2 insufflation initially experienced similar pH compared to standard laparoscopy but recovered to levels seen in low-pressure laparoscopy and NOTES with air. NOTES with CO2 appears to elicit a stronger stress response in this study than standard or low-pressure laparoscopy or NOTES with air.

Consumer demand for surgical innovation: a systematic review of public perception of NOTES

BACKGROUND

The full scope of benefits offered by NOTES over traditional laparoscopy, if any, is not yet fully clear. Perceived patient demand for truly "scarless surgery" is often referenced one of the driving factors in the continued development of this relatively new technique. The true scale of patient preference and demand for NOTES as a surgical technique is unknown. This review aims to summarise currently available literature on the topic of patient perceptions of NOTES to guide future development of the technique.

METHODS

A comprehensive search of PubMed and Web of Science electronic databases was performed on 1st Jan 2014. To be considered for inclusion, articles were required to assess and report the perception of NOTES in a sample of laypersons (patients or general public). The primary endpoint assessed was acceptance or preference rates expressed by patients for NOTES procedures. Reasons given for preference or rejection of NOTES were recorded, as well as preferred access routes and any predicting factors of NOTES acceptance.

RESULTS

Initial search returned 1,334 results, resulting in 15 articles included in final data synthesis. These polled a total of 4,420 subjects. Acceptance of NOTES ranged between 41 and 84 %. Compared to a laparoscopic approach, preference rates for NOTES ranged from 0 to 78 %. Reasons for preferring NOTES were largely centred on potentially reduced recovery time, complications (particularly with reference to hernias) and postoperative pain. Improved cosmesis also played a role, but was secondary to the above issues. Overall, study quality was poor.

CONCLUSIONS

This review suggests significant public interest in NOTES and scarless surgery in general. Further research and consideration of differences in public perceptions across regions, countries and cultures are required.

Natural orifice transluminal endoscopic surgery for intra-abdominal emergency conditions

BACKGROUND

Patient benefits from natural orifice transluminal endoscopic surgery (NOTES) are of interest in acute-care surgery. This review provides an overview of the historical development of NOTES procedures, and addresses their current uses and limitations for intra-abdominal emergency conditions.

METHODS

A PubMed search was carried out for articles describing NOTES approaches for appendicectomy, percutaneous gastrostomy, hollow viscus perforation and pancreatic necrosectomy. Pertinent articles were reviewed and data on available outcomes synthesized.

RESULTS

Emergency conditions in surgery tax the patient's cardiovascular and respiratory systems, and fluid and electrolyte balance. The operative intervention itself leads to an inflammatory response and blood loss, thus adding to the physiological stress. NOTES provides a minimally invasive alternative access to the peritoneal cavity, avoiding abdominal wall incisions. A clear advantage to the patient is evident with the implementation of an endoscopic approach to deal with inadvertently displaced percutaneous endoscopic gastrostomy tubes and perforated gastroduodenal ulcer. The NOTES approach appears less invasive for patients with infected pancreatic necrosis, in whom it allows surgical debridement and avoidance of open necrosectomy. Transvaginal appendicectomy is the second most frequently performed NOTES procedure after cholecystectomy. The NOTES concept has provided a change in perspective for intramural and transmural endoscopic approaches to iatrogenic perforations during endoscopy.

CONCLUSION

NOTES approaches have been implemented in clinical practice over the past decade. Selected techniques offer reduced invasiveness for patients with intra-abdominal emergencies, and may improve outcomes. Steady future development and adoption of NOTES are likely to follow as technology improves and surgeons become comfortable with the approaches.