Robotic natural orifice transluminal endoscopic surgery (NOTES) hysterectomy as a scarless and gasless surgery

Gasless vNOTES vs. traditional vNOTES for benign gynecological disease: a randomized controlled clinical trial

BACKGROUND

Gasless transvaginal natural orifice transluminal endoscopic surgery (G-vNOTES) can avoid complications related to pneumoperitoneum, but there is limited research on G-vNOTES. Here, we aimed to compare the hemodynamic profiles and outcomes of G-vNOTES with traditional vNOTES (T-vNOTES) in the treatment of patients with benign gynecologic disease.

METHODS

A total of 120 patients with benign gynecologic disease were randomly assigned to G-vNOTES (n = 60) or traditional vNOTES (n = 60). The primary outcome was vital sign at different time points. Secondary outcomes included conversion rate, surgical time, anesthesia time, the usage of anesthetics, estimated intraoperative blood loss, visual analogue scale (VAS) score for abdominal and shoulder pain and postoperative nausea and vomiting (PONV) at 2 and 24 h, intraoperative and postoperative complications, time to first anal exhaust, eating, and getting out of bed after surgery, and length of postoperative hospital stay. Multi-level model analysis was used for intraoperative hemodynamic indicators.

RESULTS

There was no significant difference between the two groups at the baseline level. The results of the multilevel model indicate that there is no difference in intraoperative hemodynamic performance between the G-vNOTE group and the T-vNOTES group. The conversion rate in the G-vNOTES group was higher than that in the T-vNOTES group (16.95% vs. 5.26%, p = 0.046). No significant differences were observed in other areas.

CONCLUSIONS

This study did not find advantages of gasless vNOTES in intraoperative hemodynamic fluctuations. The surgical conversion rate of the G-vNOTES group is higher than that of the T-vNOTES group, which may be related to poor surgical field exposure in the G-vNOTES group, making it more suitable for experienced and confident surgeons.

The Feasibility and Safety of Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery (RA-vNOTES) for Gynecologic Disease: 298-Case Series

Objectives: To explore the feasibility and surgical outcomes of robot-assisted vaginal natural orifice transluminal endoscopic surgery (RA-vNOTES) for women suffering from gynecologic disease. Methods: We performed an observational study reporting and analyzing the perioperative outcomes of 298 patients with gynecologic disease who underwent RA-vNOTES in a single institution from June 2019 to August 2024. Results: A total of 298 patients with a median age of 41 years and median body mass index of 29 kg/m2 underwent RA-vNOTES. The primary indications for surgery were endometriosis (43.62%), chronic pelvic pain (11.07%), abnormal uterine bleeding (20.81%), and uterine leiomyomata (14.77%). A total of 286 of 298 (95.97%) patients had a hysterectomy. The median total operating time was 138 min, with a port placement time of 5 min, dock time of 3 min, and robot console time of 63 min. The median estimated blood loss was 50 milliliters. Endometriosis resection of all stages was performed in 192 of 298 (64.43%) patients. Three cases (1.01%) were converted to laparoscopic surgery. One case was converted to robot-assisted single incision plus one port laparoscopic surgery (SILS plus one) and two cases were converted to robot-assisted multi-port surgery. The total complication rate was 17.45% (52 cases), of which 2.1% (6 cases) were intraoperative complications and 15.44% (46 cases) were postoperative complications. Conclusions: Our findings indicate that RA-vNOTES is a feasible and less invasive option for various gynecologic procedures, including complex endometriosis excision and sacrocolpopexy.

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

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

Background

The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines.

Methods

This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field.

Results

The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials.

Conclusions

vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).

Gasless transvaginal natural orifice transluminal endoscopic surgery for hysterectomy and salpingectomy on a robot platform with flexible devices in a porcine model

In this report, we described a new technique of gasless V-NOTES for hysterectomy and salpingectomy on a robotic platform with flexible devices in a porcine model. As a result, the gynecological procedures were successfully completed. The total operative time was 110 min, while the docking time was 10 min. The estimated blood loss was estimated to be 10 mL with no intraoperative complications. It revealed that gasless V-NOTES for hysterectomy and salpingectomy on a robotic platform with flexible devices appeared to be feasible and safe in the porcine model and has the potential for clinical use in human beings.

The comparison of gasless and traditional robot-assisted transvaginal natural orifice transluminal endoscopic surgery in hysterectomy

Study objective

To describe the surgical technique and compare the operative outcomes of gasless and traditional robot-assisted transvaginal natural orifice transluminal endoscopic surgery (GR-vNOTES vs. TR-vNOTES) in hysterectomy.

Methods

The patients undergoing hysterectomy via GR-vNOTES or TR-vNOTES between February 2020 and January 2022 in our hospital were included. Clinical data regarding patient demographics, operative time, blood loss, complications, and postoperative hospital stays were collected and analyzed.

Results

Five cases underwent hysterectomy via GR-vNOTES, and nine cases via TR-vNOTES. The baseline demographics and operative outcomes were not significantly different in GR-vNOTES and TR-vNOTES groups. There was no conversion to multiport robotic laparoscopy, conventional laparoscopy or laparotomy. No complications were seen in both groups, except two cases had fever postoperatively in the TR-vNOTES group. For those with early stage cervical/endometrial cancer, no recurrence or metastasis was observed in the follow-up of six months.

Conclusion

Both GR-vNOTES and TR-vNOTES were feasible and safe for hysterectomy. GR-vNOTES was a promising alternative to TR-vNOTES in hysterectomy.

A prospective study of specimen eversion to lateral rectum and valgus resection for low rectal cancer

Purpose

To investigate the safety and efficacy of a reverse puncture device (RPD) and specimen eversion of the rectum for resection in total laparoscopic proctectomy.

Methods

In a prospective study from August 2019 to March 2021, 40 patients underwent a procedure with an RPD and specimen eversion of the rectum for total laparoscopic low rectal cancer resection, that is natural orifice specimen extraction surgery (NOSES), were included in the NOSES group. Forty patients in the control group underwent conventional laparoscopic radical resection for low rectal cancer and were included in the LAP group. Intraoperative- and postoperative-related indicators, recovery and inflammatory factors, quality of life (QOL) and mental health were compared.

Results

All operations were successfully completed. Compared with the LAP group, the NOSES group showed better short-term outcomes, such as time to eating, postoperative pain, and especially postoperative incision-related complications. At the same time, postoperative inflammatory factor levels, psychological trauma, life-related anxiety and depression scores, and QOL were better in the NOSES group than in the LAP group.

Conclusions

The application of an RPD and specimen eversion of the rectum for total laparoscopic low rectal cancer resection is a technically feasible and safe approach with a short-term curative effect.

Evaluation of the learning curve and safety outcomes in robotic assisted vaginal natural orifice transluminal endoscopic hysterectomy: A case series of 84 patients

BACKGROUND

To explore the learning curve and safety outcomes of robotic assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) for hysterectomy in benign gynaecological diseases.

METHODS

A retrospective chart review of all patients undergoing R-vNOTES hysterectomy for benign gynaecological disease from 2019 to 2021.

SETTING

An academic tertiary care university hospital in Houston, TX, USA.

RESULTS

84 patients were identified that met the study requirements. The mean hysterectomy time was 77.27 ± 2.89 min. The median additional operation time was 63 (8-206) min. There were two conversions to robotic assisted single incision laparoscopy. Thirteen (15.48%) patients had an associated complication. Analysis of the learning curve suggests plateauing of hysterectomy time at approximately 10 cases and time for robot docking and port placement after 10-20 cases.

CONCLUSION

R-vNOTES is a safe and effective route for hysterectomy. For a surgeon with experience in laparoscopic single site surgery and abdominal robotic surgery, they need to perform 10 cases of R-vNOTES hysterectomy and 10-20 cases in port placement and robotic docking to achieve proficiency.

Robotic Natural Orifice Transluminal Endoscopic Surgery Hysterectomy and Salpingo-Oophorectomy in a Porcine Model

Purpose. The emergence of robotic-assisted surgical techniques has gained significant indications in terms of reduced trauma, shortened recovery, and higher patients' satisfaction. However, limitations by present surgical robotic systems used in natural orifice transluminal endoscopic surgery (NOTES) gynecology still exists, such as arm collisions, countertraction, instrument dexterity, and, in particular, space confinement due to the narrow pelvic anatomy. The current study evaluated the use of a miniaturized single-site surgical robotic system and its feasibility in performing robotic NOTES gynecological procedures using a live porcine animal model. Methods. Using a transrectal approach, the fully internalized robotic arms were deployed in a reverse configuration to access the lower pelvic cavity of the animals to perform NOTES gynecological procedures. Results. Robotic-assisted transrectal gynecological procedures were successfully performed using the new robotic system. A hemi-hysterectomy with unilateral salpingo-oophorectomy was completed in the first animal and a total hysterectomy with bilateral salpingo-oophorectomy in the second animal with an average docking time of 22.5 minutes and console time of 63 minutes and 58 minutes, respectively. The overall blood loss for each procedure was estimated to be <20 mL per animal with no intraoperative complications. Conclusions. The reverse configuration of the miniaturized surgical robotic system has demonstrated its capability to provide a potential solution to maintain clear visualization of the surgical field, optimal triangulation, and dexterity robotic NOTES gynecological procedures within the deep confined space of the pelvic cavity.