Hysterectomy and ovarian cystectomy using natural orifice transluminal endoscopic surgery: An initial experience at Tzu Chi General Hospital

Comparing outcomes of ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery versus laparoendoscopic single-site surgery: A retrospective cohort study

BACKGROUND

We aimed to compare the outcomes of ovarian cystectomy (OC) performed by vaginal natural orifice transluminal endoscopic surgery (vNOTES) vs transumbilical laparoendoscopic single-site surgery (LESS).

METHODS

We retrospectively analyzed the data of patients in our hospital who underwent OC either by vNOTES or LESS between January 2015 and September 2021. Demographic data were collected. The primary outcome was the conversion rate. The secondary outcomes were the duration of surgery, length of hospital stay, estimated blood loss, maximum body temperature within 48 hours after operation, and duration of maximum body temperature (hours), among others. Statistical analysis was done using the SPSS software.

RESULTS

Exactly 284 patients were screened. The vNOTES and LESS groups consisted of 21 and 47 patients, respectively. There was no significant difference in the conversion rates between the two groups (0 vs 8.5% in vNOTES and LESS, respectively; p = 0.303). Compared with the vNOTES group, the LESS group had a larger cyst diameter (6.00 ± 2.32 vs 4.69 ± 1.29 cm; p = 0.004), more endometriotic cysts (42.6% vs 9.5%; p < 0.001), and more pelvic adhesions requiring adhesiolysis (57.4% vs 19.0%; p = 0.003). At baseline, there were no other differences between the groups. The secondary outcomes included a shorter duration of surgery (70.14 ± 27.30 vs 99.57 ± 36.26 minutes; p = 0.001) and lower estimated blood loss (64.29 ± 39.19 vs 163.43 ± 251.20 mL; p = 0.011) in the vNOTES group. Regression analysis showed the diameter of the ovarian cyst correlated with surgical time. The complication was comparable between the two groups.

CONCLUSION

Above all, the advantages of vNOTES include an absence of visible scars, shorter surgical duration, and less blood loss when compared with LESS. Further large-scale prospective trials should confirm the results of our study.

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.

Serosal injury to a distended stomach during open entry for laparoendoscopic single-site surgery

Complications related to open entry for laparoscopic procedures are relatively rare, and the incidence of closed entry-related complications is 0.4 per 1000 cases. We report a case of serosal injury to a distended stomach that was caused during open entry. A 37-year-old woman presented with a 1-year history of dysmenorrhea. Transvaginal ultrasonography revealed a uterine myoma and cesarean section (C/S) wound defect. Laparoscopic single-site myomectomy and repair of the C/S wound defect were planned. Open abdominal entry was achieved at the umbilicus, and the patient's stomach was distended and injured by the electric knife (30 watts). After identifying the injury, we inserted a nasogastric tube to deflate the stomach and repaired the gastric serosal injury. The laparoscopic myomectomy and C/S defect repair were subsequently performed without complications. The patient has remained free from complications during the 1-year follow-up. Gastric serosal injury during open entry is a rare complication. Insertion of a nasopharyngeal tube and routine percussion of the abdomen before entering the abdominal cavity are the most important steps to prevent this complication.

Applying the vaginal approach for benign ovarian cystectomy: current evidence and future applications

Vaginal ovarian cystectomy has not gained wide acceptance owing to the potential difficulty in entering the cul-de-sac. We review the current evidence on vaginal approaches to benign ovarian cysts. Outcome measures of interest included time to return to work, patient satisfaction, surgical complications and length of hospital stay. Ten studies were included in this review and involving 525 patients. Vaginal ovarian cystectomy is overall safe and feasible in appropriately selected cases with no evidence of intrapelvic adhesions or endometriosis. These findings will need to be validated in appropriately powered studies, before reliable conclusions can be drawn. Furthermore, we emphasize the importance of ultrasound both preoperatively for case selection optimization and intraoperatively, as a means of guidance during posterior culdotomy.

The management of benign ovarian cysts through the vagina (VOC) has not gained wide acceptance by gynecologists worldwide owing to the potential difficulty in accessing the pelvic organs through an incision at the top of the vagina that may cause injury to adjacent structures such as the rectum. This is a review of the literature on the effectiveness of VOC. Various techniques have been described. Overall, VOC is safe and effective in appropriately selected cases. Larger studies will need to be conducted to validate these results. We also emphasize the importance of ultrasound both preoperatively as a tool to select the right patients for VOC as well as during surgery as an adjunct to guide the surgeon.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy in a Woman with Uterine Adenomyosis and Multiple Severe Abdominal Adhesions

Natural orifice transluminal endoscopic surgery (NOTES) had been used for many gynecologic surgeries without pelvic adhesions. We report a 30-year-old female with multiple abdominal adhesions underwent NOTES hysterectomy successfully. A 30-year-old female (para 2, gravida 3, abortus 1) presented with menorrhagia and dysmenorrhea. She had multiple abdominal surgical histories. Computed tomography scan revealed multiple adhesions between the abdominal wall and small intestine. On pelvic ultrasonography, an enlarged uterus 8.3 cm × 3.5 cm with adenomyosis was visualized. Because of the extensive intra-abdominal adhesions, we decided to use a transvaginal NOTES approach to perform hysterectomy. We performed the surgery successfully without complication. Pathological examination confirmed adenomyosis of uterus. NOTES hysterectomy may be feasibly and safely performed in gynecologic patients with extensive abdominal adhesions.