Natural orifice transluminal endoscopic surgery (NOTES) salpingectomy for ectopic pregnancy: a first series demonstrating how a new surgical technique can be applied in a low-resource setting

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Benign Gynaecology: A Systematic Review of Adnexal, Myomectomy and Prolapse Procedures

OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is utilised for gynecological procedures globally, however evidence to support its application aside from hysterectomy is lacking. A systematic review to determine feasibility and safety profile of vNOTES for benign gynaecology was conducted.

DATA SOURCES

A literature search of MEDLINE, EMBASE, CINAHL, SCOPUS, and CENTRAL was conducted, including all types of studies reporting vNOTES for gynecological indications. After excluding cases with concurrent hysterectomy, the review focuses on procedures for benign indications and oncological procedures are reported separately. Patient characteristics and perioperative outcomes were reported, with pooled analysis for sufficiently powered categories.

METHODS OF STUDY SELECTION

Fifty-four articles were analyzed, including 7 comparative studies (n = 439) and 1 RCT (n = 34), reporting 2469 cases of vNOTES, including adnexal (tubal and/or ovarian) (43 articles, n = 2261), myomectomy (10 articles, n = 136) and prolapse repair (6 articles, n = 72) in predominantly premenopausal women with BMI <30 kg/m2 on pooled analysis.

TABULATION, INTEGRATION AND RESULTS

The overall conversion rate was low (1.38%, n = 34) with procedure specific conversion rates of 0.45 to 6.8% for adnexal procedures, 1.47% for myomectomy and none reported for prolapse repair. Overall complication rates were low (3.44%, n = 85) with no associated mortality. Five (0.20%) adhesion-related rectal injuries at colpotomy were noted, all repaired intraoperatively without long-term sequelae.

CONCLUSION

vNOTES appears feasible based on limited evidence, for uterine-sparing gynecological indications, despite a notable rate of rectal injury at colpotomy. There is a negligible risk of rectal injury observed at conventional laparoscopy and robotically assisted surgery, but similar rate of entry-related gastrointestinal injury. This may be due to the learning-curve or suboptimal case selection, necessitating careful training, assessment, and appropriate patient selection. Surgeons should continue registering prospective vNOTES cases via iNOTESs, to evaluate emerging perioperative trends with global uptake of this novel technique.

A Case Control Study of vNOTES Versus Conventional Laparoscopic Salpingectomy for Ectopic Pregnancy

STUDY OBJECTIVE

While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic (CL) salpingectomy for the surgical management of ectopic pregnancy.

DESIGN

Case-control study.

SETTING

A London University hospital.

PATIENTS

Women with ectopic pregnancy unsuitable for medical management who underwent surgical management.

INTERVENTION

Twenty-five cases of vNOTES vs 25 CL salpingectomy.

MEASUREMENTS AND MAIN RESULTS

The mean patient age (29.7 ± 53 vs 31.4 ± 6.7 days), parity (1.2 ± 1.1 vs 1.6 ± 2.1), body mass index (26.7 ± 5.3 vs 27.2 ± 5.4 kg/m3), gestation age (8.44 ± 2.1 vs 7.3 ± 1.7 weeks) and β human chorionic gonadotrophin (βhCG) levels (3725.4 ± 3674.8 vs 4376.5 ± 6493.4 IU/liter) were comparable (p >.05, t test) between patients having vNOTES vs CL salpingectomy. While estimated blood loss was similar (218.2 ± 491.7 vs 173.5 ± 138.7 mL) (p >.001), vNOTES patients had a statistically shorter duration of surgery (35.8 ± 14.4 vs 75.8 ± 19.7 mins) (p <.001, t test) and length of stay (median: 11.5 vs 19.7 hours) (U = 72, p <.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%), and the median visual analog score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0) (U = 75, p <.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8 ± 4.3 vs 17.1 ± 8.2 days) (p <.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia.

CONCLUSION

Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain, and more rapid recovery, which help mitigate higher costs incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomized studies are needed.

Vaginal hysterectomy versus vaginal assisted NOTES hysterectomy (VANH): a protocol for a randomised controlled trial

Introduction

Natural Orifice Transluminal Endoscopic Surgery is a minimal invasive technique using natural body orifices like the vagina. Benefits of a vaginal assisted NOTES hysterectomy (VANH) are no visible scars, less blood loss, shorter surgery time and it allows more women to undergo a hysterectomy in a day-care setting compared with the total laparoscopic hysterectomy. Trials comparing vaginal hysterectomy (VH) and VANH are lacking. The aim of this study is to compare hysterectomy by VANH versus VH for same-day discharge (SDD), complications, surgical outcomes, postoperative recovery, quality of life, costs and cost-effectiveness.

Methods and analysis

The study is a single-blinded, multicentre, randomised controlled trial. Eligible women with benign indication for hysterectomy will be randomly allocated to the VH (control) group or the VANH (intervention) group. The primary outcome is SDD. We calculated a sample size of 124 women assuming 27% SDD difference with an alpha of 0.05 and power of 0.8. A total of 83 patients will be included in the VANH-group and 41 patients in the VH-group, using an enrolment ratio of 2:1. Secondary outcomes are; surgery-related complications, surgical outcomes, postoperative recovery, quality of life, costs and cost-effectiveness.

Ethics and dissemination

The study was approved on 27 May 2021 by the Ethics Committee of the Zuyderland Medical Centre Heerlen. The first patient was randomised on 8 July 2021. The last participant randomised should be treated before 31 December 2022. The results will be presented in peer-reviewed journals and at scientific meetings within 4 years after starting recruitment.

Trial registration number

NCT04886791.

Transvaginal natural orifice transluminal endoscopic surgery for ectopic pregnancy

AIMS

This study aims to describe our transvaginal natural orifice transluminal endoscopic surgery (vNOTES) technique for ectopic pregnancy that can be performed using conventional laparoscopic equipment with the addition of a self-constructed pessary port and to evaluate the safety, feasibility, and outcomes of the technique.

METHODS

This is a retrospective study evaluating outcomes of patients who underwent vNOTES for ectopic pregnancy (n = 21) between August 2019 and April 2021.

RESULTS

Twenty-one patients underwent vNOTES as intended without any intraoperative complications. Three patients (14.3%) were nulliparous, 16 patients (76.2%) had no history of vaginal delivery, and 13 patients (61.9%) had a history of at least one cesarean delivery. Eight patients (38.1%) had a history of previous abdominal surgery other than cesarean section. The mean duration of surgery was 43.4 ± 12.6 min. The mean visual analog scale scores for pain were 2.45 ± 1.13 at 2 h after surgery, 0.45 ± 0.83 at 12 h after surgery, and 0.18 ± 0.36 at 24 h after surgery. The median duration of postoperative hospital stay was 1 day (range, 1-2). There were no postoperative complications within 30 days after surgery.

CONCLUSIONS

vNOTES can be performed in an existing laparoscopy setup with the addition of a self-constructed pessary port. vNOTES is a safe and effective surgical treatment option for ectopic pregnancy, even in patients who have not had a vaginal delivery and have had multiple abdominal surgeries.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video)

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) adnexectomy for benign pathology compared with laparoscopic excision (NOTABLE): a protocol for a randomised controlled trial

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) uses natural orifices to access the cavities of the human body to perform surgical interventions. NOTES limits the magnitude of surgical trauma and potentially reduces postoperative pain. Our group published a protocol on a randomised study comparing transvaginal NOTES (vNOTES) versus laparoscopy for hysterectomy (HALON). We simultaneously designed a similar randomised controlled trial (RCT) comparing vNOTES with laparoscopy for adnexectomy. To the best of our knowledge, this is the first RCT comparing vNOTES with laparoscopy for adnexal surgery.

METHODS AND ANALYSIS

The methodology of the Notes Adnexectomy for Benign Indication versus Laparoscopic Excision (NOTABLE) study is similar to that of the HALON trial. Women aged 18-70 years with an indication for benign adnexal surgery will be eligible. We will use stratification according to adnexal size. Entrants will be randomised to the laparoscopic treatment (control) or vNOTES (intervention). Participants will be evaluated on days 0-7 and at 3 and 6 months. The primary outcome will be the proportion of women successfully treated by removing an adnexa by the allocated technique without conversion. We will collect the following data (secondary outcomes): proportion of women hospitalised on the day of surgery, postoperative pain scores measured two times per day from day 1 to 7, total dosage of pain killers used from day 1 to 7, hospital readmission during the first 6 weeks, dyspareunia and sexual well-being at baseline, 3 and 6 months using a validated questionnaire (Short Sexual Functioning Scale), health-related quality of life at baseline, 3 and 6 months after surgery using a validated questionnaire (EQ-5D-3L), duration of surgical intervention, infection or other surgical complications and direct costs up to 6 weeks following surgery. For the primary outcome measure, a one-sided 95% CI of the difference in the proportions of women with a successful removal of the uterus by the randomised technique will be estimated. Non-inferiority will be concluded when 15% lies above the upper limit of this 95% CI.

ETHICS AND DISSEMINATION

The study was approved on 1 December 2015 by the EthicsCommitteeof the Imelda Hospital (registration no: 689), Bonheiden, Belgium. We aim to present the final results of the NOTABLE trial in peer-reviewed journals and at scientific meetings within 4 years after the start of the recruitment.

TRIAL REGISTRATION NUMBER

NCT02630329.