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

Too big to bag? - Technique for bagging very large adnexal masses via vNOTES

The technique to perform adnexectomy for adnexal masses has shifted over the last decades, from open surgery towards minimally invasive approaches. At the same time caution is warranted to prevent perioperative intra-abdominal spilling of cyst content which can be a challenge especially for very large masses. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) combines a vaginal approach with endoscopic overview in performing gynaecological surgery without abdominal scarring. The aim of the video is to demonstrate a vNOTES technique for safely bagging very large adnexal masses.

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.

Repeated transvaginal natural orifice transluminal endoscopic surgery: An initial Chinese experience

AIMS

To investigate the perioperative outcomes and sexual function of patients undergoing repeated transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

METHODS

We retrieved the records of patients who underwent vNOTES twice at our institute between April 2019 and December 2022 and analyzed their baseline information and perioperative complications, and compared the pre- and postoperative sexual function of both vNOTES.

RESULTS

Patients' mean age and body mass index were 29.00 ± 3.59 and 30.4 ± 4.00 years and 21.89 ± 3.69 and 22.76 ± 3.88 kg/m2 , respectively, when receiving the first and second vNOTES. Ectopic pregnancy was the most frequent indication for vNOTES, with 7 cases in the first vNOTES and 11 cases in repeated vNOTES. The interval between the two vNOTESs ranged from 9 days to 38 months. The operation duration (63.33 ± 13.71 vs. 67.33 ± 22.51 min, p = 0.723), intraoperative estimated blood loss (32.00 ± 20.42 vs. 30.00 ± 9.26 mL, p = 0.429), and duration of postoperative hospital stay (2.20 ± 0.56 vs. 2.40 ± 0.51 days, p = 0.082) of both vNOTESs were comparable. No significant differences were found in any of the domains in the comparison of pre-first and post-first vNOTES, pre-second and post-second vNOTES, and pre-first and post-second vNOTES female sexual function index. None of the patients delivered after the second vNOTES.

CONCLUSION

Repeated vNOTES is safe and feasible. No significant change in the patients' sexual function was found in our cohort after the first and second vNOTES.

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.

Transvaginal natural orifice endoscopic surgery for myomectomy: Can it be a conventional surgery?

INTRODUCTION

As a new minimally invasive surgery, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been proved to be suitable for the treatment of a variety of gynecological benign diseases. However, compared with other minimally invasive surgeries that have been widely used, such as conventional multiport laparoscopy and transumbilical laparoendoscopic single-site surgery (LESS), their advantages and disadvantages and how to choose are still unknown. The purpose of our study is to compare the advantages and disadvantages of the three minimally invasive surgeries in myomectomy and to provide theoretical basis for the wider development of vNOTES surgery.

MATERIAL AND METHODS

This retrospective study included 282 patients at our hospital who underwent laparoscopic myomectomy from May 2021 to March 2022. Based on the surgical approach, patients were classified into multiport, transumbilical LESS, and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and at 1 month postoperatively.

RESULTS

Among the three procedures, vNOTES had the shortest anal exhaust time but also the highest postoperative infection rate. Multiple linear regression analysis showed that the operative time increased by 3.5 min for each 1 cm increase in myoma, and intraoperative bleeding increased by approximately 12 ml. The average duration of single pores increased by 25 min compared to that of multiports, and the operative duration increased by 10.48 min for each degree of adhesion.

CONCLUSIONS

For gynecologists who have mastered vNOTES, this procedure has the same efficacy and safety as the two existing minimally invasive surgeries in myomectomy, but it shows obvious advantages in postoperative recovery.