Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES)

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.

Comparison of Pelvic Organ Prolapse and Sexual Function After Vaginal Natural Orifice Transluminal Endoscopic Surgery and Conventional Laparoscopic Hysterectomy

Aim: In our study, we aimed to comprehensively evaluate the surgical parameters of patients who underwent total laparoscopic hysterectomy (TLH) and vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy and their effects on the development of pelvic organ prolapse (POP) and sexual function one year later. Materials and Methods: This retrospective and comparative study involved a review of medical records for 42 patients who underwent total laparoscopic hysterectomy (TLH) for benign conditions and 42 patients who underwent hysterectomy using vaginal natural orifice transluminal endoscopic surgery (vNOTES) at our clinic between January 2023 and January 2024. Evaluations of preoperative and postoperative pelvic organ prolapse and sexual function were conducted, and the anatomical and functional outcomes of both surgical methods were compared. Results: In this study, there was no statistically significant difference between the groups in terms of age (p < 0.299), BMI (p < 0.819), parity (p < 0.615), surgical indications and menopausal status (p < 0.535) (p > 0.05). The vNOTES method was found to be significantly shorter than TLH in terms of surgical time (vNOTES: 58 min, TLH: 80 min, p < 0.001). However, there was no significant difference between the two methods in terms of preoperative and postoperative hematocrit values, hospital stay and FSFI scores (p > 0.05). Among the POP-Q parameters, a significant difference was observed only in the Aa parameter in favor of the vNOTES method (p < 0.003). Conclusions: In our study, the vNOTES method provided a shorter surgical time and better anterior vaginal support compared to TLH, but both methods offered similar results in terms of sexual function. More comprehensive studies are needed to clarify the long-term effects.

Proctored single surgeon learning curve for vaginal natural orifice transluminal endoscopic surgery (NOTES) hysterectomy

OBJECTIVE

We studied the learning curve of vaginally assisted NOTES hysterectomy (VANH) for individual surgical steps and competence scores.

DESIGN

Single centre, prospective cohort study in a Belgian teaching hospital.

MEASUREMENTS AND MAIN RESULTS

In a cohort of 57 women undergoing VANH we analysed 29 procedures performed completely or partly by the novice and 35 procedures performed completely or partly by the expert. Primary outcome was operation time dedicated to the endoscopic steps, unique to vNOTES. Operation time was determined by post hoc analysis of surgical videos. Standardised values of the operation time were expressed as a moving average. Adequate operation time, i.e. an operation time within 2 standard deviations of the average operation time of the expert, was after 16 cases. Secondary outcomes were operation time per step and competence scores based on Objective Structured Assessment of Technical Skills (OSATS). These measurements were used to determine critical steps in the learning process, which are not captured by reporting total operation time alone. Adequate operating times for critical steps (anterior colpotomy and right uterine artery), were obtained after 16 cases. Conversely, some vaginal and endoscopic steps on the right-hand side took longer. Competence was obtained after 18 cases.

CONCLUSION

We present the results of a proctored learning curve of a novice in vaginally assisted NOTES hysterectomy, expressed as operation time for different steps compared to an expert and with competence scores. For the primary outcome, the endoscopic operation time, adequate operation time was achieved after 16 cases. Regarding secondary outcomes, analysis per step showed that several vaginal steps and the endoscopic steps on the patient's right-hand side required a longer learning period. Competence score expressed as a CUSUM chart suggest a learning curve of 18 cases. Identifying critical steps can be used to adapt training novices. Adding competence scores rather than focusing on operation time alone provides valuable insights in the learning process of a new technique by trained surgeons.

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.

Adoption of vaginally assisted natural orifice transluminal endoscopic surgery for hysterectomy: A single tertiary experience

BACKGROUND

Vaginal hysterectomy (VH) rate is declining despite being considered as the optimal minimally invasive option for hysterectomy with reduced operative time and length of stay compared with laparoscopic hysterectomy (LH). Vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy (VANH) combines the advantages of both vaginal and endoscopic approach to surgery.

AIMS

To report feasibility and early experience of a single surgeon adopting VANH at a tertiary Australian hospital.

MATERIALS AND METHODS

Prospective review of the first 20 VANH cases with complete data set collected retrospectively including patient demographics, indication for surgery and perioperative outcomes.

RESULTS

The median age of the first 20 participants was 51.5 years (47-57 years of age) and the median body mass index was 33.5 kg/m2 (27.8-38.3 kg/m2). The predominant indication was complex hyperplasia with atypia (12/20, 60%). The median parity was two (1-3) where four patients were nulliparous. The median blood loss was 125 mL (100-200 mL) with an operative time of 149 min (138-198 min) and median weight of the specimen of 181.5 g (66.5-219 g). The mean length of stay was 1.4 days (1-2 days). Five cases had conversion to laparoscopy and the majority (80%) occurred within the first ten cases.

CONCLUSIONS

VANH is feasible but there is a learning curve to achieve competence in this technique, which requires adequate training in the early stages of adoption with careful case selection. Until further robust data is available to determine the clinical benefit and safety profile of VANH, patients should be carefully counselled and the decision on mode of hysterectomy be individualised.

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.

Feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) panhysterectomy: a polycentric retrospective study

OBJECTIVES

To investigate the feasibility and safety of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) panhysterectomy.

METHODS

A retrospective analysis was conducted on the data of 75 patients who underwent panhysterectomy for hysteromyoma in the Department of Obstetrics and Gynecology of Tongxiang Maternal and Child Health Hospital; Department of Gynecology, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University and Department of Gynecology, The First Affiliated Hospital of USTC from June 2019 to June 2020. According to the operation mode, the patients were divided into two groups: the traditional multi-port laparoscopic surgery (MPLS) group (n = 45) and the Transvaginal Natural Orifice Transluminal Endoscopic Surgery (V-NOTES) group (n = 30). The operation duration, intraoperative blood loss, postoperative exsufflation time, postoperative activity time, hospital stay, treatment cost, 6 h activities of daily living (ADL) score after the operation, cosmetic score, visual analog score, and complications were observed in the two groups.

RESULTS

Perioperative period related indicators: Compared with the MPLS group, the total treatment cost and cosmetic score of the V-NOTES group were significantly better than those of the MPLS group, but the operation duration was longer, and the HB decreased more significantly (P < 0.05). However, there was no significant difference in intraoperative blood loss, postoperative exsufflation time, postoperative activity time, 6 h ADL score after the operation, and hospital stay between the two groups (P > 0.05). Postoperative pain: The VAS score 1 h, 6 h, 12 h, and 24 h after the operation was lower in the V-NOTES group than in the MPLS group (P < 0.05). Postoperative complications: The complication rate of the V-NOTES group was significantly lower than that of the MPLS group (P < 0.05).

CONCLUSIONS

In treating panhysterectomy patients, both V-NOTES and MPLS can achieve satisfactory efficacy and prognosis, and both have advantages and disadvantages. Specifically, the V-NOTES surgery has significant advantages such as a lower treatment cost, lower incidence of postoperative complications, less pain, and more beautiful wounds.

Early surgical outcomes of 550 consecutive patients treated for benign gynecological conditions by transvaginal natural orifice transluminal endoscopic surgery

INTRODUCTION

Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years.

MATERIAL AND METHODS

To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024.

RESULTS

Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy.

CONCLUSIONS

The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Urogynecological Surgery: A Systematic Review

Background: Minimally invasive surgery could improve cosmetic outcomes and reduce the risks of surgical injury with less postoperative pain and a quicker patient's discharge. Recently, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been introduced in urogynecology with exciting results. Evidence Acquisition: After PROSPERO registration (n°CRD42023406815), we performed a comprehensive literature search on Pubmed, Embase, and Cochrane CENTRAL, including peer-reviewed studies evaluating transvaginal natural orifice transluminal endoscopic surgery. No limits on time or type of study were applied. Evidence synthesis: Overall, 12 manuscripts were included in the analysis. Seven studies evaluated uterosacral ligament suspension, four studies evaluated sacral colpopexy, three evaluated sacrospinous ligament suspension, and one study evaluated lateral suspension. Overall success rates were high (>90%); however, definitions of success were heterogeneous. In terms of complication, most of the studies reported low-grade complications (Clavien-Dindo I and II); only two patients needed mesh removal because of mesh exposure. The risk of bias of the trials was rated in the medium to high-risk category. Conclusions: The present review highlights important initial results for vNOTES. Future randomized clinical trials are needed to better define its role in the management of urogynecological procedures.

Comparison of Prone With Lithotomy Position in Removal of Posterior Myoma in Transvaginal Natural Orifice Endoscopic Surgery: A Prospective Cohort Study

OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is considered to have the advantages of completely scarless, less postoperative pain, earlier flatus, and faster postoperative recovery. However, posterior myoma are relatively difficult to operate through vNOTES in the conventional lithotomy position. Thus, we innovated the application of prone position in the removal of posterior myoma in vNOTES. The aim of this study is the comparison of myomectomy outcomes of patient for single posterior myoma in prone and lithotomy position.

DESIGN

A single-center, prospective study.

SETTING

A university teaching hospital.

PATIENTS

A total of 81 patients with posterior myoma who underwent myomectomy in vNOTES from January 2021 to December 2022.

INTERVENTIONS

The patients underwent myomectomy in vNOTES in prone or lithotomy position.

MEASUREMENTS AND MAIN RESULTS

Among the patients who underwent vNOTES myomectomy, 29 (35.8%) were in the lithotomy position group, and 52 (64.2%) in the prone position group. Of note, 4 (4.9%) patients underwent a conversion to LESS during the operation-3 in the lithotomy and 1 in the prone position group. And a patient in the lithotomy position group underwent resurgery for hemostasis due to postoperative pelvic bleeding. Compared with the lithotomy position, prone position significantly shortens the operation time (12.3, 95% CI: 6.811, 17.761. p = .009) without increasing the complications and postoperative discomfort of patients.

CONCLUSION

Compared to the lithotomy position, the prone position provides greater convenience for operation and exhibits a lower rate of surgical conversion during the removal of single posterior myomas via vNOTES. Further, for patients selecting vNOTES, surgeons need to conduct sufficient preoperative evaluation, timely hemostasis during surgery, and timely surgical conversion if necessary to ensure patient safety.

Ovarian tissue biopsy for cryopreservation by vaginal natural orifice transluminal endoscopic surgery: a new approach for a minimal invasive ovarian biopsy

OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging surgical procedure that combines the advantages of the vaginal approach with laparoscopic vision and instrumentation. Shorter hospitalization and lesser postoperative pain associated with vNOTES may be explained by the advantages of this innovative surgical approach (e.g., absence of abdominal incisions, shorter operative time, and lower insufflation pressure). Ovarian tissue cryopreservation allows to preserve reproductive and endocrine functions in young women with oncological disease at risk of premature ovarian insufficiency (POI) caused by gonadotoxic treatments. Ovarian tissue biopsy for cryopreservation consists of a large biopsy of 1 or both ovaries that is usually performed by laparoscopy. Then, the removed ovarian tissue is cryopreserved for the future transplant after cancer remission. The volume of ovarian biopsy ranges from 50% of the ovary for women at moderate risk of POI to 70%-100% of it for those at high risk. The inclusion criteria for ovarian tissue cryopreservation are women aged <35 years who cannot delay start of oncological treatments for follicle cryopreservation, with a moderate or high risk of POI and good chance of 5-year survival. Ovarian tissue cryopreservation cannot be performed if tumor treatments include uterine irradiation or for tumors at risk of ovarian metastases (as in the case of ovarian cancer, leukemia, neuroblastoma, or Burkitt lymphoma). Despite widespread adoption of vNOTES in gynecology, ovarian biopsy for cryopreservation has never been performed using this route.

DESIGN

Step-by-step explanation of the procedure with descriptive text and narrated video footage.

SETTING

Tertiary-level referral academic center.

PATIENT(S)

A 27-year-old patient recently diagnosed with low-grade follicular non-Hodgkin lymphoma was referred to our center for ovarian tissue cryopreservation before chemotherapy. The patient included in this study gave informed consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites. Because of the nature of the study, institutional review board approval was not required.

INTERVENTION(S)

Access to the peritoneal cavity was created by a 3-cm posterior colpotomy. The peritoneum was then opened using cold scissors and temporarily fixed to the posterior vaginal wall. The GelPOINT Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA), with 1 10-mm and 2 5-mm trocars, was used as the vNOTES port. The inner Alexis ring of the GelPOINT was inserted through the colpotomy into the pouch of Douglas. A hysterometer was placed into the uterine cavity to keep the uterus anteverted during the surgery. A pneumoperitoneum was created to a pressure of 8 mm Hg, and the operating table was tilted to a 20° Trendelenburg position. A 10-mm rigid 30° camera was inserted in the inferior and larger trocar, and both ovaries were visualized. Seventy percent of the left ovary was removed with cold scissors to minimize trauma on the surgical specimen. After removal of the GelPOINT cap, ovarian biopsy was immediately picked up by the biologist of our fertility center. The ovary was coagulated with a bipolar instrument. The hysterometer was then replaced by a uterine manipulator to perform tubal patency test, and blue dye passage through both salpinges was observed. Finally, the Alexis retractor and stich on the posterior peritoneum were removed, and the vagina was sutured using interrupted stiches. The total operative time was 25 minutes.

MAIN OUTCOMES MEASURE(S)

Ovarian tissue biopsy for cryopreservation by vNOTES.

RESULT(S)

No intraoperative and postoperative complications were reported, and the patient was discharged after 24 hours from surgery.

CONCLUSION(S)

Vaginal natural orifice transluminal endoscopic surgery may be a feasible alternative approach to laparoscopy for ovarian tissue cryopreservation: it allows an easy access to the ovaries and removal of different tissue volumes. Patients undergoing ovarian cryopreservation may benefit from the vNOTES approach because a rapid postoperative recovery is crucial to start chemotherapy in a short time. As for other vNOTES procedures, accurate selection of patients seems to be crucial for a successful ovarian tissue cryopreservation. We believe that the inclusion and exclusion criteria reported for other gynecologic procedures performed through vNOTES may also be valid for ovarian tissue cryopreservation by vNOTES. Women at high risk of pelvic adhesions (e.g., coexistent endometriosis, previous pelvic surgery, or inflammatory pelvic disease), those with an increased body mass index or enlarged uterus, and those with cervical, vaginal, or uterine cancer cannot be considered for this approach because all these factors are associated with failure of vNOTES. On the other hand, women with no history of surgery, endometriosis, and large myomas may benefit from the vNOTES approach, and these women represent most of patients who undergo ovarian tissue cryopreservation. Further and larger studies are needed to assess the efficacy and safety of this new approach.

Learning curve analysis of transvaginal natural orifice transluminal endoscopic surgery in treating ovarian cysts: a retrospective cohort study

BACKGROUND

Transvaginal Natural Orifice Transluminal Endoscopy (vNOTES) is regarded as a challenging surgical technique to learn but is promising in reducing perioperative pain and significantly improves the cosmetic outcomes. Previous studies on the learning curve analysis of vNOTES mainly focuses on the hysterectomy approach, while the vNOTES ovarian cystectomy's learning curve was merely reported though more frequently performed than vNOTES hysterectomy. Therefore, this study seeks to analyze the learning curve of three surgeons with varying levels of experience in performing endoscopic surgery and vaginal surgeries for the treatment of ovarian cysts using vNOTES.

METHODS

A total of 127 patients with ovarian cysts of a variety of pathological types were treated by ovarian vNOTES performed by three surgeons of different levels of endoscopic and transvaginal surgical experience. Each surgeon's learning curve was plotted using the Cumulative Sum method and divided into three or four phases of technique learning at the turning point of the learning curve. The sociodemographic and clinical features of patients in each phase were then compared and factors potentially associated with operation time were also screened.

RESULTS

The learning curve was presented in four phases. The operation time (OT) was significantly shorter in phases II (53.66 ± 16.55 min) and IV (54.39 ± 23.45 min) as compared with phases I (68.74 ± 15.85) and III (75.93 ± 30.55) (p < 0.001). More cases of serve pelvic adhesion and endometrioma were assigned in the later phases. The OT of endometriotic cysts had much longer than that of non-endometriotic cysts(62.57 ± 18.64 min vs. 49.88 ± 14.26 min, p = 0.15) The presence of pelvic adhesion [adjusted odds ratio (OR) 7.149 (0.506, 13.792), p = 0.035] and bilateral cyst [adjusted OR 16.996 (2.155, 31.837), p = 0.025], max diameter of cyst[adjusted OR 2.799 (0.174, 5.425), p = 0.037], and individual surgeon [adjusted OR -6.118 (-11.814, -0.423), p = 0.035] were significantly associated with OT.

CONCLUSION

There learning curve of ovarian vNOTES has four phases. ovarian vNOTES could be mastered after performing seven, nine, and 16 cases by surgeons #1, 2 and 3 respectively, in gynecologic endoscopic surgeries.

TRIAL REGISTRATION

ChiCTR2200059282 (Registered on April 28th, 2022).

vNOTES retroperitoneal sentinel lymph node dissection for endometrial cancer staging: First multicenter, prospective case series

INTRODUCTION

The current standard treatment for endometrial cancer is a laparoscopic hysterectomy with adnexectomies and bilateral sentinel node resection. A retroperitoneal vNOTES sentinel node resection has several theoretical potential advantages. These include being less invasive, leaving no visible scars, operating without Trendelenburg, and therefore offering the anesthetic advantage of easier ventilation in obese patients and following the natural lymph node trajectory from caudally to cranially and therefore a lower risk of missing the sentinel node. The aim of this study is to determine the feasibility of a retroperitoneal vNOTES approach to sentinel lymph node dissection for staging of endometrial cancer.

MATERIAL AND METHODS

A prospective multicenter case series was performed in four hospitals. A total of 64 women with early-stage endometrial carcinoma suitable for surgical staging with sentinel lymph node removal were operated via a transvaginal retroperitoneal vNOTES approach. The paravesical space was entered through a vaginal incision after injecting the cervix with indocyanine green. A vNOTES port was placed into this space and insufflation of the retroperitoneum was performed. Sentinel lymph nodes were identified bilaterally using near-infrared light followed by endoscopic removal of these nodes.

RESULTS

A total of 64 women with early-stage endometrial cancer underwent sentinel lymph node removal by retroperitoneal vNOTES technique. All patients also underwent subsequent vNOTES hysterectomy and bilateral salpingo-oophorectomy. The median age was 69.5 years, median total operative time was 126 min and the median estimated blood loss was 80 mL. In 97% of the cases bilateral sentinel nodes could be identified. A total of 60 patients had negative sentinel nodes, three had isolated tumor cells and one had macroscopically positive sentinel nodes. No complications with sequel occurred.

CONCLUSIONS

This prospective multicenter case series demonstrates the feasibility of the vNOTES approach for identifying and removing sentinel lymph nodes in women with endometrial carcinoma successfully and safely. vNOTES allows sole transvaginal access with exposure of the entire retroperitoneal space, following the natural lymph trajectory caudally to cranially, and without the need for a Trendelenburg position.

Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men

BACKGROUND AND AIM

Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62).

RESULTS

TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001).

CONCLUSIONS

For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.

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).

Pathological Insights on Polypropylene Mesh Complications From Laparoscopic Sacrocolpopexy: A Case Series

Background The use of polypropylene mesh in laparoscopic sacrocolpopexy (LSC) is a common treatment for pelvic organ prolapse (POP). Despite its widespread application, postoperative complications such as mesh pain and infection sometimes necessitate the removal of the mesh. However, it remains unclear in which cases mesh removal is warranted. Our research focused on the pathological changes at the sacral fixation point of the mesh. We sought to evaluate the pathological alterations of the sacral mesh removed through an innovative approach of transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Methods This retrospective study included nine patients who underwent mesh removal surgery at the Yokosuka Urogynecology and Urology Clinic in 2023. Extraction surgery was performed using vNOTES with the GelPoint Access Platform (Applied Medical JAPAN HEADQUARTERS, Tokyo, Japan). Non-ablative Erbium YAG and Neodymium YAG lasers (RenovaLase, SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia) were utilized for persistent stress urinary incontinence, fecal incontinence, vaginal erosion, and bleeding after surgery. Patients were categorized based on mesh fixation conditions, including unintended mesh overlap (Group I), excessive traction (Group II), and signs of mesh aging (Group III). This categorization helped to understand the distinct pathological outcomes associated with each condition. Results Pathological findings from the mesh removed via vNOTES varied significantly across the groups. In Group I, characteristic large vacuole formation and accumulation of atypical giant cells were observed, attributed to mesh overlap. Group II presented with vacuole formation, fiber degradation, and tissue destruction as a result of excessive mesh traction. In Group III, the aging of the mesh was marked by cracks in the surrounding tissues and granuloma formation. These detailed observations provide crucial insights into the underlying causes of mesh-related pain and other complications, highlighting the complexity of bodily responses to mesh implants. Conclusion This study demonstrated the effectiveness of vNOTES for polypropylene mesh removal in patients with post-LSC complications, resulting in significant pain reduction. Pathological analysis revealed that mesh-related issues stem from the surgical techniques, mesh properties, and long-term bodily reactions. These findings provide valuable insights for improving mesh design and POP treatment strategies. Despite the technical challenges, vNOTES is recommended for mesh removal in patients with pain. Additionally, the combination of UEL, VEL, targeted laser irradiation, AEL, and Nd:YAG laser treatments showed promising results in managing post-mesh removal complications such as stress urinary incontinence, vaginal erosion, bleeding, and fecal incontinence, offering hope for improved patient outcomes.

Clinical relevance of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecology

This study reviews the progress and recent advances in vaginal natural orifice transluminal endoscopic surgery (vNOTES) as a minimally invasive gynecologic procedure. The proposed advantages of vaginal natural orifice transluminal surgery include enhanced cosmesis due to a scarless procedure, better exposure compared with the pure vaginal approach, tolerable pain scores, fewer perioperative complications, and a shorter hospital stay. Recent advances in surgical instrumentation and technology have improved the feasibility of vNOTES as an innovative treatment option for gynecological conditions. However, technical challenges and training issues must be overcome before its widespread use. As a promising surgical innovation, further randomized comparative studies are required to clarify the safety and effectiveness of vNOTES in gynecology.

Impact of Uterine Weight and Shape on vNOTES Hysterectomy: Analysis of 238 Consecutive Cases

STUDY OBJECTIVE

To compare the perioperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies for different uterine weights and shapes.

DESIGN

Observational study.

SETTING

Swiss teaching hospital.

PATIENTS

Women who underwent vNOTES hysterectomy for benign conditions between May 2020 and July 2023 (N = 238). Patients were divided into 4 subgroups depending on uterus weight and shape. Uteri weighting <280 g were classified as type 0. Uteri weighting ≥280 g were categorized as type 1 (no vascular pedicle displacement), type 2 (cranial displacement of adnexal vascular pedicles), and type 3 (displacement of uterine arteries).

INTERVENTIONS

All women underwent vNOTES hysterectomies. We compared perioperative outcomes for the 4 subgroups.

MEASUREMENT AND MAIN RESULTS

We classified 168 patients (70.6%) as uterus type 0, 33 patients (13.9%) as type 1, 24 patients (10.1%) as type 2, and 13 patients (5.4%) as type 3. Mean uterine weight was 135.8 ± 59.5 g in type 0, 398.0 ± 167.3 g in type 1, 603.5 ± 217.9 g in type 2, and 661.7 ± 281.6 g in type 3. Operative time in type 0 (65.1 ± 30.9 minutes) and type 1 (65.1 ± 24.0 minutes) was shorter than in type 2 (102.3 ± 60.0 minutes) and type 3 (115.2 ± 40.3 minutes). Blood losses were more significant in type 2 (158.5 ± 212.0 mL) and type 3 (158.5 ± 110.7 mL) than in type 0 (85.6 ± 113.5 mL). No difference in the rate of total complications among groups was observed (8.3%, 3.0%, 12.5%, and 15.4% in types 0, 1, 2, and 3, respectively).

CONCLUSION

The displacement of the vascular pedicles seems associated with longer operative time and more blood loss and could represent a marker for technical difficulty in vNOTES hysterectomy. However, it does not influence the perioperative complication rate.

Analysis and suggestions on the complications in 2000 cases of transvaginal natural orifice transluminal endoscopic surgery: Can it be a conventional surgery?

OBJECTIVE

To reflect on the complications of transvaginal natural orifice transluminal endoscopic surgery (vNOTES), identify the corresponding risk factors, and provide caution to surgeons when performing this novel surgery.

METHODS

A retrospective study was carried out among 2000 patients in our hospital who underwent vNOTES between May 2019 and May 2022. Perioperative complications were stratified in chronological order and divided into those developed while establishing the vNOTES approach, during surgery, postoperatively, and 1 month after discharge. The complications were classified based on the Modified Clavien-Dindo classifications. The causes of each type III/IV complication were analyzed.

RESULTS

Of the 2000 patients, 88 (4.4%) experienced complications, which is not higher than that reported in laparoendoscopic surgery in previous studies. Grade I, II, III, IV, and V complications developed in 19 (0.95%), 57 (2.85%), 11 (0.55%), 1 (0.05%), and 0 (0%) patients, respectively. Complications were developed while establishing the approach platform, during the surgery, postoperatively, and within 1 month after discharge in 5 (0.25%), 30 (1.50%), 50 (2.50%), and 3 (0.15%) patients, respectively. Eight patients (0.4%) underwent conversion, including five cases of rectal injury repair.

CONCLUSION

The summarized suggestions were divided into three levels. Considering the security and effectiveness of vNOTES, it can be routinely used in various gynecologic operations. However, surgeons should focus on preoperative evaluation, strictly conduct preoperative disinfection, conform to prompt conversion during surgery, call for the presence of experienced doctors, and have routine use of antibiotics to prevent postoperative infections.

TRIAL REGISTRATION

ChiCTR2100053483.

vNOTES hysterectomy using the lateral window technique in case of a ventrofixed uterus following previous cesarean sections: A video article

vNOTES uses the vagina as the surgical channel for endoscopy and achieves improved cosmesis compared to conventional laparoscopy as there are no abdominal incisions. Ventrofixation of the uterus to the abdominal wall following previous cesarean sections further adds to the surgeon's concern of bladder injury. In such cases, a modification of the technique is proposed: introducing the vNOTES port first, before the opening of the vesico-uterine peritoneal folds, thus carried out under endoscopic view. Medial anterior vesico-uterine adhesions are identified and circumscribed by creating a lateral window in the broad ligament on both sides. This allows the cutting of adhesions under endoscopic view to minimize the risk of bladder injuries. The aim of this technical note is to present this modification of the surgical technique for vNOTES hysterectomy in case of ventrofixed uterus.

Feasibility and safety of vNOTES for gynecological procedures in obese patients

INTRODUCTION

This study aimed to determine the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to treat benign and malign gynecological conditions in obese patients.

MATERIAL AND METHODS

We analyzed data from 79 obese patients with a body mass index (BMI) > 30 Kg/m2 operated by vNOTES for gynecological conditions between May 2020 and April 2023. The primary outcome was the feasibility of performing the surgery as initially planned. Data were presented for subgroups of patients with obesity class I (BMI 30.1 - 34.9 Kg/m2), class II (BMI 35.0 - 39.9 Kg/m2), and class III (BMI ≥ 40.0 Kg/m2).

RESULTS

Patients presented obesity class I in 39 cases (49.4 %), class II in 27 cases (34.2 %), and class III in 13 cases (16.4 %). Fifty-two patients (65.8 %) underwent vNOTES hysterectomy, 26 patients (32.9 %) underwent procedures limited to the adnexa, and 1 patient (1.3 %) underwent myomectomy. The conversion rate was 0 %, 11.1 %, and 7.7 % in obesity class I, II, and III, respectively. Intraoperative bladder injury was observed in 1 case (1.3 %) and rectal serosal tear in 2 cases (2.5 %). Postoperatively, we observed 3 cases (3.8 %) of wound infection, 2 cases (2.5 %) of cystitis, and 1 case (1.3 %) of deep vein thrombosis.

DISCUSSION

This study demonstrated the feasibility and safety of performing gynecological vNOTES procedures in obese patients. However, obesity could be associated with longer and more complex interventions, especially in obesity class II and III patients.

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecological emergencies

Objective

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging minimally invasive approach increasingly applied to perform many gynecological procedures. Despite a still limited level of evidence, compared to conventional laparoscopy, vNOTES seems to be associated with reduced blood loss, shorter operative time, less postoperative pain, shorter hospitalization time, better cosmetic results and decreased postoperative morbidity. Although growing evidence supports the effectiveness of vNOTES for elective adnexal surgeries, there is still limited knowledge regarding its feasibility and safety in emergency settings. In the present study, we report our experience performing vNOTES in gynecological emergency cases.

Study design

We prospectively collected and analyzed data from patients who underwent vNOTES for gynecological emergencies between November 2021 and June 2023. Demographic and perioperative characteristics were collected and analyzed.

Results

Seventeen patients were included. Interventions were realized for suspicion of ectopic pregnancy in 7 cases (41.2%), for suspicion of adnexal torsion in 7 cases (41.2%), for post-hysterectomy hemoperitoneum in 2 cases (11.8%), and for uncontrollable uterine bleeding in 1 case (5.9%). Emergency procedures included unilateral salpingectomy (35.3%), ovarian cystectomy (23.5%), ovarian cystotomy (17.6%), adnexal detorsion (11.8%), hemoperitoneum drainage (11.8%), hysterectomy (5.9%), and appendectomy (5.9%). The overall median operative time was 38 [18-72] minutes. The median estimated intraoperative blood loss was 30 [5-150] mL, and no intraoperative complications occurred. Conversion to conventional laparoscopy or laparotomy was never needed. Patients stayed hospitalized for a median time of 30 [4-144] hours after the intervention. The median visual analog scale value for postoperative pain evaluation was 2 [0-5] at 12, 24, and 48 postoperative hours. No complications associated with the procedure occurred.

Conclusions

This study demonstrated the feasibility of performing vNOTES procedures for managing gynecological emergencies such as tubal ectopic pregnancy, adnexal torsion, painful ovarian lesions, post-hysterectomy hemoperitoneum, and uncontrollable uterine bleeding. Associated with data reported in the available literature, our results suggest potential benefits in treating gynecological emergencies by vNOTES over conventional laparoscopy. However, stronger evidence from larger studies is needed to confirm it.

Comparative analysis of transvaginal natural orifice transluminal endoscopic surgery versus laparoendoscopic single-site sacrocolpopexy for pelvic organ prolapse: A propensity score matching study

Purpose

To compare the safety, feasibility, and effectiveness of transvaginal natural orifice transluminal endoscopic sacrocolpopexy (vNOTES-SC) and laparoendoscopic single-site sacrocolpopexy (LESS-SC) for pelvic organ prolapse (POP).

Method

Ninety-four patients with POP who underwent vNOTES-SC or LESS-SC from October 2016 to November 2018 were included. The propensity score matching method was used for 1:1 matching between the two surgery groups. After matching, the general perioperative indicators, surgical complications, and the subjective and objective therapeutic effects of the two groups 3 years post-surgery were analyzed.

Results

After matching, 36 patients in each group were included, exhibiting balanced and comparable baseline data and an average follow-up of 48.6 ± 7.44 months. The operation time and postoperative hospitalization days were significantly reduced in the vNOTES-SC group (P < 0.05). However, perioperative complication incidence was not significantly different between the two groups (P > 0.05). Additionally, no significant differences were detected in de novo stress urinary incontinence (16.7% vs. 13.9%), de novo overactive bladder (de novo OAB, 8.3% vs. 0.0%), urination disorder (2.8% vs. 0.0%), defecation disorder (0.0% vs. 2.8%), lumbosacral pain (0.0% vs. 2.8%), or mesh complication (2.8% vs. 5.6%) incidences between the vNOTES-SC and LESS-SC groups (P > 0.05). Prolapse recurrence was not reported in either group. The quantitative description of pelvic organ position (POP-Q), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and Patient Global Impression of Improvement scale (PGI-I) scores showed improvement after the operation, but no significant differences were observed between the two groups (P > 0.05).

Conclusion

The 3-year follow-up revealed that vNOTES-SC and LESS-SC had similar complications and efficacy rates. Compared with LESS-SC, vNOTES-SC resulted in shorter operation time and fewer postoperative hospitalization days (corresponding to the enhanced recovery after surgery [ERAS] concept), along with better cosmetic results without a scar. Therefore, our study findings suggest that clinicians should choose the surgery method based on the specific situation, and we recommend choosing vNOTES-SC when both surgeries are suitable.

Omentectomy for oncological surgical staging by transvaginal natural orifice transluminal endoscopic surgery (vNOTES): a preliminary study

Objective

This study aimed to determine the feasibility of performing omentectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for surgical staging of ovarian and high-risk endometrial malignancies.

Methods

This descriptive study was realized in a non-university hospital in Switzerland. Eighteen patients with suspicious adnexal masses or high-risk endometrial cancer underwent surgical staging comprising infracolic omentectomy by vNOTES between May 2020 and April 2023.

Results

Patients underwent oncological surgical staging for suspicious adnexal masses in 14 cases (77.8%) and high-risk endometrial cancer in 4 cases (22.2%). vNOTES omentectomies were performed in all patients without complications. Associated procedures included salpingo-oophorectomy (94.4%), hysterectomy (55.6%), peritoneal biopsies (33.3%), pelvic sentinel lymph node biopsies (22.2%), and appendectomy (5.6%). The median time to perform omentectomies was 9 (4-13) min. All oncological staging were completed by vNOTES. No significant intraoperative complications occurred. We observed 1 case (5.6%) of postoperative fever probably associated with vaginal cuff infection (Clavien-Dindo grade II).

Conclusions

This study demonstrated the feasibility of performing vNOTES oncological staging requiring complex extrapelvic procedures such as infracolic omentectomy, supporting its potential role for managing gynecological malignancies such as ovarian and high-risk endometrial cancers. However, before expanding this approach outside study settings, strong evidence of its feasibility, practical benefits, and long-term oncological outcomes are needed.

Transvaginal natural orifice endoscopic surgery for ovarian cystectomy: a more suitable surgical approach for the day-care procedure

Introduction

Although previous studies have shown that vaginal natural orifice transluminal endoscopic surgery (vNOTES) has the advantages of causing less pain, faster recovery, and better concealment of surgical incisions, which aligns with the concept of the day-care procedure, this approach poses a greater risk of damaging adjacent organs (i. e., rectum and bladder) due to its anatomical specificity. Moreover, the day-care procedure may lead to relatively less preoperative evaluation and postoperative care. Hence, it is necessary to explore the safety and effectiveness of vNOTES for ovarian cystectomy in the day-care procedure, to provide a theoretical basis for the wider development of vNOTES surgery.

Materials and methods

This retrospective study included 131 patients at our hospital who underwent ovarian cystectomy from September 2021 to October 2022. Based on the surgical approach, patients were classified into transumbilical laparoendoscopic single-site surgery (LESS) and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and 1-month postoperatively.

Results

Vaginal natural orifice transluminal endoscopic surgery has less postoperative exhaust time, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use, with higher surgical conversion incidence. Multiple linear regression analysis showed that the surgical conversion, chocolate cyst, bilateral cyst, and pelvic adhesion increased the operation duration by ~43 (95% CI: 10.309, 68.152, p < 0.001), 15 (95% CI: 6.342, 45.961, p = 0.036), 10 (95% CI: 3.07, 40.166, p = 0.019), and 8 (95% CI: 4.555, 26.779, p = 0.035) min, respectively. Interestingly, vNOTES decreased the operation duration by ~8.5 min (95% CI: -18.313, -2.699, p = 0.033).

Conclusion

Vaginal natural orifice transluminal endoscopic surgery was equally safe and effective for ovarian cystectomy compared to LESS. vNOTES aligned with the concept of the day-care procedure due to its reduced postoperative pain, shorter exhaust time, and absence of scarring. However, surgeons should conduct a comprehensive preoperative evaluation and exclude patients suspected to have severe pelvic adhesions.

Implementing the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) "first" strategy in benign gynecological surgeries

PURPOSE

The use of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as the first choice of surgical route for patients scheduled to undergo conventional laparoscopy is still being debated. We aimed to evaluate and compare the outcomes of the "vNOTES first" strategy in benign gynecological cases.

METHODS

All benign gynecological surgeries were initiated using vNOTES during the study period, regardless of the difficulty. Surgical outcomes, short-term patient satisfaction and sexual pain were compared between hysterectomies, adnexal and diagnostic procedures. Visual Analog Score (VAS), Patients Global Impressions of Improvements scale (PGI-I) and Female Sexual Function Index (FSFI) were used to assess the postoperative pain, satisfaction and sexual pain, respectively.

RESULTS

A total of 105 vNOTES procedures were performed during the study period: 63 (60.58%) adnexal procedures, 36 (34.62%) hysterectomies, 5 (4.81%) diagnostic procedures and one (0.96%) myomectomy. The median 24th hour VAS scores for adnexal, hysterectomy, and diagnostic procedures were 1.29 ± 1.41, 2.06 ± 2.08, and 2.6 ± 2.41, respectively. The satisfaction rate was 96.19% at the 1st postoperative week and 97.14% at the first month. There was either no change or a slight improvement in the patients' total score on the FSFI/pain domain before and after surgery. There were two conversions (1.9%) from vNOTES to laparoscopy and laparotomy, and two (5.56%) bladder injuries in hysterectomy cases.

CONCLUSION

Implementing the vNOTES technique as an initial approach for all benign gynecological surgeries seems feasible, safe and satisfactory, even in those with a non-prolapsed or enlarged uterus and those that have previously undergone abdominal surgery. The pain scores were found to be low and patients stated a high satisfaction with no or better change in their sexual life.

Vaginal Natural Orifice Transluminal Endoscopic Surgery in a Second-trimester Pregnant Woman with an Ovarian Teratoma

We present the first case of a pregnant woman with teratoma, who underwent vaginal natural orifice transluminal endoscopic surgery (vNOTES). Mature ovarian cystic teratomas compromise 20%-30% of all ovarian tumors. The best surgical management is still unclear, especially during pregnancy. A 21-year-old pregnant woman (gravida 1, para 0) at 14 weeks and 3 days of gestational age was admitted with an intermittent mild sharp and dull pain in her right lower abdomen when walking or moving lower limbs. Pelvic ultrasonography revealed a 5.9 cm × 5.4 cm heterogeneous mass that was suspected as a teratoma in the right adnexa. Initially, laparoendoscopic single-site ovarian cystectomy (OC) was arranged. However, the ovarian tumor was impeded by the enlarged uterus. The OC procedure was changed to vNOTES OC. The vNOTES OC was performed smoothly and the pathology confirmed the mass to be a teratoma. After the operation, she recovered well and was discharged 2 days after the operation without any complication. In conclusion, the application of vNOTES in the second-trimester pregnancy might be considered safe and effective. The vNOTES can be performed safely in selected patients and by an experienced surgeon.

Perioperative outcomes of and predictors for conversion from transvaginal natural orifice transluminal endoscopic tubal surgeries: A retrospective cohort study of 619 patients

OBJECTIVE

To assess the perioperative outcomes of vNOTES tubal surgeries and to identify predictors of surgical conversion.

METHODS

A single-center retrospective cohort study was performed on 619 patients who underwent vNOTES tubal surgeries in our institute from December 2018 to October 2021. Patients were categorized into "converted" or "non-converted" groups based on whether conversion occurred. t-test and χ² test were performed on demographic and clinicopathologic data to compare their perioperative outcomes. Logistic regression was built to identify predictors for surgical conversions.

RESULTS

The conversion and complication rates of the vNOTES tubal surgeries in the present study were 3.07% and 4.85%, respectively. The "converted group" has a significantly higher percentage of patients with severe pelvic adhesions (9/19 [47.4%]) and pelvic endometriosis (2/19 [10.5%]), which significantly predicates surgical conversion. The "converted group" also had a longer duration of surgery (140.94 ± 88.73 min, P = 0.002) and an increased proportion of "converted from vNOTES" patients experienced more than 50 ml of intraoperative blood loss (7/19 [36.9%]). Four patients had intraoperative rectal injuries, and no Clavien-Dindo III-V postoperative complications occurred.

CONCLUSION

vNOTES tubal surgeries are safe due to low conversion and complication rates. Severe pelvic adhesion and endometriosis are predictors for surgical conversions.

Applications of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologic surgery

PURPOSE OF REVIEW

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging approach used across surgical disciplines. This review seeks to assess the growing body of literature on experiences and outcomes using vaginal NOTES (vNOTES) in gynecologic surgery.

RECENT FINDINGS

Many limitations of vaginal surgery including lack of descensus or restricted vaginal space can be overcome with vNOTES whereas avoiding risks of abdominal incisions in traditional laparoscopy. vNOTES may have superior outcomes in pain, length of stay, and satisfaction for multiple gynecologic indications however additional data is needed to assess cost-effectiveness and long-term outcomes. Surgeons implementing this technique should have adequate experience with both traditional vaginal and laparoscopic approaches. The current body of high-quality studies is heavily influenced by single site, single surgeon studies and as such may not be fully applicable to all practices incorporating this novel technique, and adequate training should precede implementation of Vnotes.

SUMMARY

Vaginal surgery is considered the least invasive approach, however, may not be appropriate in all cases. vNOTES presents a novel approach that combines the access and visualization afforded by endoscopy whereas avoiding the risks associated with transabdominal entry and can be considered as a feasible option in gynecologic surgery.

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.

Standardised step by step approach to adnexectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) combines the advantages of vaginal surgery with those of laparoscopic surgery. Feasibility of vNOTES for other indications such as hysterectomy, ovarian cystectomy and myomectomy has been established. In this article, we describe a standardised step by step process to perform adnexal surgery by vNOTES.

vNOTES Hysterectomy, Adnexectomy and Uterosacral Ligament Suspension: A Walk-through Guide

OBJECTIVE

To provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy and vault suspension, using two access platform methods.

DESIGN

Narrated surgical video based on two cases of vNOTES for abnormal uterine bleeding and endometrial intra-epithelial neoplasia.

SETTING

A single tertiary-care academic centre.

INTERVENTIONS

Step-by-step walk-through is shown to demonstrate the successful completion of a hysterectomy, adnexectomy, and vault suspension. Use of a traditional glove platform and that of an advanced access system, the GelPOINT Access System® (Applied Medical, Rancho Santa Margarita, CA, USA), are illustrated. The surgical steps are summarized as: (1) colpotomy and abdominal entry; (2) transection of the uterosacral ligaments; (3) placement of an access platform; (4) upper abdominal survey; (5) transection of the uterine and cornual pedicles; (6) identification of the ureters; (7) bilateral salpingo-oophorectomy; (8) uterosacral ligament suspension; (9) cystoscopy; (10) vaginal vault closure and tying of the suspension sutures.

CONCLUSION

This video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy and uterosacral ligament suspension with two access techniques. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favourable recovery profile, making it an attractive surgical route in appropriate candidates.

Initial experience with vNOTES hysterectomy for benign conditions in a French university hospital

Background: Natural orifice transluminal endoscopic surgery by the vaginal route (vNOTES) is a new approach to performing hysterectomy. Clinical outcomes must be evaluated in centres that have started performing this technique. Objectives: To compare operative outcomes between vNOTES hysterectomy and laparoscopic hysterectomy during the introduction of the vNOTES approach in a teaching hospital. Material and Methods: A retrospective study was conducted from November 2019 to May 2021 at a French academic hospital in Marseille. The included patients underwent total hysterectomy for benign indications by vNOTES or conventional laparoscopy. Main Outcome Measures: Operative time, uterus weight, intraoperative complications, and postoperative complications according to the Clavien-Dindo classification. Results: Eighty-six patients underwent hysterectomy according to the selected criteria: 36 procedures were performed by vNOTES and 50 by laparoscopy. The mean operative time was shorter in the vNOTES group than in the laparoscopy group [116 min versus 149 min; p=0.003]. The mean uterus weight was not different between the vNOTES group and the laparoscopy group (238g versus 281g; p=0.572). Laparo-conversion occurred in one case in the vNOTES group (2.7%) and three cases in the laparoscopy group (3.4%). One Grade III postoperative complication occurred in the laparoscopy group, and no severe complication occurred in the vNOTES group. Conclusion: Operative outcomes of the vNOTES hysterectomy were favourable and support good feasibility without additional morbidity compared to laparoscopy. What is new? During the introduction period of the vNOTES hysterectomy technique in a teaching hospital, reassuring operative outcomes and a low rate of complications were observed.

Standardized 10-step approach for successfully performing a hysterectomy via vaginal natural orifice transluminal endoscopic surgery

Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES.

Sentinel Node Biopsy for Endometrial Cancer by Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Preliminary Study

Objective

The primary objective was to determine the intraoperative and postoperative surgical complications of sentinel lymph node biopsy (SLNB) by retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES). The secondary objective was to assess the feasibility of this surgical technique.

Methods

This was a descriptive study realized in a non-university hospital in Switzerland. Seven patients with endometrial cancer or endometrial complex atypical hyperplasia underwent surgical staging with SLNB by retroperitoneal vNOTES using an indocyanine green-based near-infrared fluorescence imaging technique (October 2021-February 2022).

Results

The median operative time was 113 (81-211) minutes. The median estimated blood loss was 20 (20-400) mL. The overall bilateral detection rate was 100% (7/7). Upon histopathological examination, 5 patients presented an endometrial adenocarcinoma, and we found endometrial complex atypical hyperplasia in 2 cases. We successfully completed all procedures without significant intraoperative complications, but 1 case required conversion to conventional laparoscopy. The median postoperative stay was 2 (2-4) days, and we observed no postoperative complications during this period. We observed 1 case of postoperative deep vein thrombosis and an asymptomatic vaginal vault hematoma in the same patient.

Conclusions

Our preliminary study suggests that retroperitoneal vNOTES could be a feasible, safe, and valuable approach to perform SLNB in endometrial cancer. However, strong evidence of its feasibility, the effective benefits, and the long-term oncological outcomes is needed before expanding the use of vNOTES in endometrial cancer outside study settings.

Is transvaginal natural orifice transluminal endoscopic surgery (vNOTES) indicated in patients with previous extensive pelvic surgeries? A case report

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been increasingly applied to perform multiple gynecologic procedures. However, evidence is lacking on whether this surgical approach is feasible for patients with prior extensive abdominopelvic surgeries.

We report a case of prophylactic bilateral salpingo-oophorectomy (BSO) performed in a 51-year-old patient with previous laparotomic radical hysterectomy and pelvic lymphadenectomy for cervical cancer. The patient underwent rectovaginal examination and evaluation of the transvaginal sonographic sliding sign as preoperative screening to exclude the obliteration of the pouch of Douglas. The abdominal cavity was accessed by cautious endoscopic access to the pouch of Douglas. The BSO was realized in accordance with risk-reducing surgery guidelines. No intraoperative or postoperative complications were observed.

We suggest that selecting patients carefully prior to operation and adapting intraoperative techniques could be a safe method for conducting vNOTES interventions in patients with extensive abdominopelvic adhesions.

•

vNOTES has been increasingly applied to perform multiple gynecologic procedures.

•

There is a lack of evidence for its feasibility for patients who have previously had extensive surgery.

•

Careful preoperative evaluations and intraoperative adaptations are needed.

•

Extensive pelvic adhesiolysis by vNOTES appears feasible.

•

We report a vNOTES intervention in a patient with previous extensive surgery.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Surgical Staging of Early-Stage Ovarian Cancers: A Report of Two Cases

Surgical staging is essential in the management of ovarian cancers. This staging has traditionally been performed by laparotomy, but minimally invasive techniques are increasingly employed. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a promising technique in the field of gynecological oncology. We report 2 cases of vNOTES surgical staging for suspicious ovarian tumors. We operated on 2 patients aged of 81 and 62 years for low-grade serous ovarian carcinoma and ovarian cystadenofibroma, respectively. We performed surgical staging with a pure vNOTES technique for the first patient and used a hybrid approach for the second. No intraoperative or postoperative complications were observed. We suggest that vNOTES is a feasible and effective approach to surgically manage early-stage ovarian cancers.

Comparison of vNOTES technique with conventional laparoscopy in gynecological emergency cases

BACKGROUND

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a minimally invasive approach. This study aimed to evaluate the feasibility and surgical outcomes of the vNOTES method and compare it with conventional laparoscopy (CL) in gynecological emergency cases.

MATERIAL AND METHODS

A retrospective study was conducted to compare vNOTES with CL regarding pre-/intra-/postoperative outcomes. The women who were operated on for emergency indications such as ectopic pregnancy, ovarian torsion, ovarian cyst rupture and acute abdominal pain were evaluated. Patients' age, gravidity, parity, medical/surgical history, height, weight, blood pressure, heart rate, pre-/postoperative hemoglobin and hematocrit levels, the quantity of aspirated hemoperitoneum, visual analog scale (VAS) pain scores six and 12 h postoperatively, duration of surgery and hospital stay were recorded.

RESULTS

The study was conducted with 90 women. Sixty of them underwent CL, while 30 women had vNOTES. The vNOTES group had a significantly shorter duration of surgery -28.5 min (15-48 min) vs. 77 min (29-155 min), respectively, p < .001), shorter hospital stay - 32 h (11-125 h) vs. 38 h (12-201 h), respectively, p = .007), lower VAS scores after 6 h - 5 (4-7) vs. 6 (2-8), respectively, p < .001), and after 12 h - 2 (1-3) vs. 2 (1-5), respectively, p < .001) and a lower dose of postoperative analgesic administration - 2 (2-3) vs. 3 (1-5), respectively, p < .001) than the CL group.

CONCLUSION

vNOTES surgeries can be considered an alternative technique to CL by providing shorter surgery duration, lower postoperative pain scores, shorter hospital stays and better cosmetic outcomes.

Vaginal NOTES approach for risk-reducing salpingo-oophorectomy in BRCA mutation carriers: A video demonstration

Risk-reducing bilateral salpingo-oophorectomy (BSO) is an important option to prevent the development of ovarian and fallopian tube cancers in women with a BRCA1/2 mutation. Conventional laparoscopy is the current preferred technique since it is associated with less morbidity compared to laparotomy. Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a new minimally invasive technique that allows access to the peritoneal cavity through the vagina without skin incisions. The vNOTES technique for risk-reducing BSO is presented herein. This article includes a narrated, step-by-step video demonstration of the entire procedure. Risk-reducing BSO using the vNOTES approach is a feasible technique that appears to be simple, safe, and reproducible. This technique has the potential to improve patients' surgical experience and provide good long-term functional and cosmetics outcomes. This technique needs to be further evaluated and compared to the conventional laparoscopic approach.