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.

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.

No mess with mesh; vaginal natural orifice transluminal endoscopic surgery (vNOTES) autologous posterior rectus fascia mesh for vaginal urinary incontinence procedures.

Urinary incontinence affects 25-45 % of women with the gold standard surgical approach being placement of mid-urethral synthetic slings; tension-free vaginal tape (TVT) and trans-obturator tape (TOT). Due to the controversies regarding vaginal mesh the last decade, an increasing demand has evolved for incontinence treatment without vaginal synthetic mesh. The short term results of autologous rectus fascia sling for TOT surgery have shown similar success rates compared to those after the use of synthetic mesh, but the harvesting of the mesh is less minimally invasive and is associated with longer surgical time. vNOTES is a combination of a vaginal entrance to the abdomen and endoscopy via the vagina. The aim with the video is to show a new surgical technique with a fully vaginal, scarless vNOTES approach for harvesting the posterior rectus fascia for TVT and TOT procedures.

Comparison between fascia lata and rectus fascia in treatment of pelvic organ prolapse: a systematic review.

OBJECTIVES: The purpose of this systematic review is to present and compare results from studies that have been using autologous tissue for POP repair. METHODS: Systematic review was done according to the Cochrane Handbook for Systematic Reviews. We aimed to retrieve reports of published and ongoing studies on the efficacy and safety of autologous tissue in vaginal vault prolapse repair. The databases searched were MEDLINE (PubMed interface), Scopus, Cohrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov. RESULTS: The success rate varied among studies. In fascia-lata group success rate reports varied from 83 to a 100%, with a median follow-up from 12 to 52 months among studies. Rectus fascia reported success rates from 87 to a 100% with a follow-up of 12 months to longest of 98 months. CONCLUSION: Autologous tissues show satisfying outcomes in terms of safety and efficacy. Sacrocolpopexy procedure with fascia lata has better outcome in term of treatment of prolapse. Harvesting place on lateral side of buttock has more complications in comparison with rectus fascia but size of the graft can be wider in fascia-lata group.

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.

VaNoLaH trial: a study protocol-a multinational randomised controlled trial including two identical substudies comparing vaginal versus vNOTES (vaginal natural orifice transluminal surgery) hysterectomy or laparoscopic versus vNOTES hysterectomy.

INTRODUCTION: Hysterectomy is one of the most common surgeries performed in women. Minimally invasive methods are on the rise globally as they have been shown to decrease surgical morbidity compared with abdominal hysterectomy. Hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) is the latest innovation. It combines the vaginal approach and endoscopy via the vagina. Large pragmatic randomised controlled trials (RCTs) are lacking comparing outcomes after vNOTES, vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). METHODS: Multicentre pragmatic RCT aiming to recruit 1000 women aged 18-75 years undergoing hysterectomy for benign disease. The RCT includes two identical substudies (groups A and B). If VH is considered safe and feasible, the patient will be randomised within group A (VH vs vNOTES). If VH is not considered safe or feasible, patients will be randomised within group B (LH vs vNOTES). ANALYSIS: Primary outcome is the proportion of women leaving the hospital within 12 hours after surgery. Secondary outcomes are hospitalisation time, conversion rates, duration of the surgical procedure, intraoperative complications, postoperative complications and readmission. ETHICS AND DISSEMINATION: The Ethical Board Committee at Imelda Hospital, Bonheiden, Belgium, has approved the research protocol 230704 (principal investigator). Before including patients, all centres will require local or national ethical approval. The results of the study will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05971875.

Retrospective analysis between total laparoscopic and vNOTES hysterectomy in obese patients: single-center study.

INTRODUCTION: Hysterectomy is one of the most common major gynecological surgeries, and it is performed for benign and malignant reasons. Currently, five types of hysterectomies are described: vaginal (VH), abdominal (AH), laparoscopic (LH), robotic, and vNOTES (vaginal natural orifice transluminal endoscopic surgery). This paper compares these two types of surgery in obese patients by analyzing the surgeries performed by our team. MATERIALS AND METHODS: The research was conducted from January 2022 to December 2023 at the Department of Gynecology and Obstetrics of the General Hospital in Zadar. The study included female patients aged 18-75 years with a BMI > 30 kg/m2, regardless of parity, who were operated on for benign pathology. RESULTS: There were 24 patients included in total. One conversion was observed in the TLH group because of excessive bleeding. Median operative time (IQR) was significantly lower in the vNOTES group (p < 0.05) than in the TLH group 35 (10.9) vs 125 (74.0) min. CONCLUSION: The results concerning the duration of surgery, conversion rate, and postoperative bleeding and complications show that vNOTES hysterectomies seem to be feasible for obese patients. Further studies are needed to confirm these observations.

vNOTES surgical staging for endometrial carcinoma in overweight patients: a case series.

OBJECTIVES: The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and obese patients with endometrial cancer. MATERIALS AND METHODS: Four patients had undergone pelvic lymphadenectomy with a sentinel lymph node. Three patients were overweight, and one was obese with a BMI of 34.6 kg/m2. By using NMR mode sentinel lymph node was visualized, excised and marked separately for pathohistological analysis from the rest of the visualized lymph nodes that were then consecutively excised. RESULTS: The mean number of overall excised lymph nodes was 12.5, and the mean number on the right side was 5.75 and 6.25 on the left side. There were no metastases verified in the pathohistological evaluation. CONCLUSION: vNOTES retroperitoneal isolation of sentinel lymph nodes is good alternative and has its benefits, especially in overweight and obese patients with satisfying low intra- and postoperative complications.

vNOTES Radical Hysterectomy: A New Approach to Cervical Cancer.

OBJECTIVE: To demonstrate how a radical hysterectomy with sentinel node resection for cervical cancer can be performed via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). DESIGN: Demonstration of the technique in 10 steps. making use of narrated original video footage SETTING: The surgical treatment of cervical cancer is traditionally performed via one of the following techniques: Wertheim radical hysterectomy via laparotomy, Schauta radical hysterectomy vaginally, laparoscopic radical hysterectomy or robotic radical hysterectomy. The results of the LACC trial showed that minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open radical hysterectomy among women with early-stage cervical Cancer [1]. For endometrial cancer, a vNOTES retroperitoneal approach to sentinel node resection was first published in 2019 [2]. Based on the experience with this approach and with Schauta-Stoeckel radical hysterectomy for cervical cancer [3], a new approach was developed to perform a radical hysterectomy via vNOTES whereby most of the procedure is performed retroperitoneally [4]. This video article demonstrates in 10 steps how a radical hysterectomy via vNOTES is performed. INTERVENTIONS: Radical hysterectomy via vNOTES demonstrated making use of original video footage of a 57-year-old woman operated on for cervical adenocarcinoma 7 weeks after a LEEP cone. The steps of the procedure are: 1. Vaginal cuff creation, 2. Development of lateral retroperitoneal space and sentinel node resection, 3. Uterine artery and vein transection, 4. Hypogastric nerve dissection, 5. Development of central retroperitoneal space and rectum dissection, 6. Posterior colpotomy, 7. Parametrium dissection, 8. Bladder pillar dissection, 9. Anterior colpotomy, 10. Salpingo-oophorectomy or salpingectomy. 3 Patients were so far treated by this new technique that allowed for good hemostatic control. CONCLUSION: vNOTES enables a potentially less invasive approach to radical hysterectomy performed largely retroperitoneally and completely transvaginally, leaving no visible scars. The endoscopic approach offers excellent visualization of the retroperitoneal and parametrial anatomy. This is a new approach that requires further validation and should only be performed in a research setting, taking into account the current reservations about endoscopic surgery for cervical cancer resulting from the LACC trial. VIDEO ABSTRACT.

vNOTES retroperitoneal transient uterine artery occlusion: a new approach to control bleeding during a high-risk evacuation of products of conception.

OBJECTIVE: To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery. DESIGN: Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval. SETTING: Teaching hospital. PATIENT(S): A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines. INTERVENTION(S): A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy. CONCLUSION(S): Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.

vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience.

PURPOSE: To analyze our experience with vNOTES gynecologic procedures in women with morbid and super morbid obesity to determine feasibility and compare outcomes with standard minimally invasive techniques. METHODS: Gynecologic procedures performed by three surgeons on women with a body mass index (BMI) ≥ 40 kg/m2 from 2017 to 2023. A subset of women with a BMI ≥ 50 kg/m2 was also analyzed. RESULTS: 103 women with a BMI ≥ 40 kg/m2 were identified (Class IV), 19 of whom had a BMI ≥ 50 kg/m2 (Class V). For the entire population the mean BMI was 45.7 kg/m2 (40-62). 29 women were nulliparous and 23 had at least one prior cesarean delivery. 51 had no prior abdominal surgery. The procedures performed were hysterectomy and removal of adnexae in 77 patients, hysterectomy alone in six, adnexal surgery alone in nine, and hysterectomy with adnexectomy and lymph nodes in five. Two surgeries were converted to laparoscopy and five to laparotomy. Average surgical time was 87 min (30-232). Average blood loss was 82 mL (10-400). Mean uterine weight was 206 g (29-2890). 53 procedures were performed as outpatient, 44 had overnight observation, four had a length of stay of 2 days, one each for 4 days and 5 days. The laparoscopies occurred in one patient with an obliterated cul-de-sac and in one patient for lymph node removal. The laparotomies occurred for adnexal adhesions in one, bleeding in two, a cystotomy in one requiring urology consultation, and an obliterated cul-de-sac One patient developed a postoperative vaginal cuff hematoma not requiring intervention. CONCLUSION: vNOTES gynecologic procedures are feasible in this high-risk population and may result in shorter recovery times and fewer complications than standard laparoscopy or transvaginal surgery. What does this study add to the clinical work: VNOTES approach is feasible in morbidly obese women and may have distinct advantages over conventional laparoscopic, vaginal or open techniques.

Old meets new: vNOTES retroperitoneal promontory fixation in conjunction with the uterus preserving Manchester procedure✰,✰✰.

INTRODUCTION AND HYPOTHESIS: The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.

Posterior rectus fascia prolapse (PREFAP) repair: a new native tissue approach to pelvic organ prolapse via vaginal natural orifice transluminal endoscopic surgery.

INTRODUCTION: Pelvic organ prolapse (POP) is a common condition in women. During lifetime, up to 40% of all women will develop (POP). MATERIALS AND METHODS: Between June and December 2021, five patients were successfully treated via vNOTES Posterior Rectus Fascia Prolapse ( PREFAP) repair. No intra-operative complications or conversions occurred. CONCLUSION: In this study we demonstrated a new technique for prolapse repair, harvesting the autologous posterior rectus fascia sheath via vaginal natural orifice transluminal endoscopic surgery (vNOTES) as an alternative for a synthetic mesh.

A novel approach using vaginal natural orifice transluminal endoscopic surgery to repair a symptomatic uterine isthmocele.

OBJECTIVE: To describe the first case of using a vaginal natural orifice transluminal endoscopic surgery approach to repair a uterine isthmocele. DESIGN: Stepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital Institutional Review Board approval. SETTING: Hospital. PATIENT(S): A 30-year-old (gravida 2, para 2) patient presented with symptoms of intermenstrual bleeding and secondary subfertility following 2 uncomplicated cesarean section deliveries (elective for breech and repeat). The patient had a transvaginal ultrasound (US) demonstrating an isthmocele with a defect of 8.1 × 7.0 mm with a myometrial thickness of 2 mm over the defect and proceeded to undergo surgery because of persistent symptoms. INTERVENTION(S): An anterior vaginal incision is made on the cervix from the 3 o'clock to 9 o'clock position after local anesthetic and adrenaline infiltration of the tissue. The vaginal epithelium was carefully dissected cephalad, although an attempt was made to maintain the uterovesical space and fold. A small (7 cm) V-path gel port was inserted into this uterovesical space and the gel port was affixed with a port connected to an insufflation stabilization bag to minimize the pressure fluctuations within the confines of a small operative space and help maintain visualization throughout. Under endoscopic view, the site of the isthmocele was identified using an endoscopic US probe and confirmed on 2 dimensional imaging. A monopolar hook with an inbuilt aspirator and suction function was used to incise over the isthmocele with a grasper used to dissect into this space. A Hegar dilator was used to delineate the cervical canal. Once the isthmocele was excised, the defect was reinforced and obliterated with a barbed suture whereas the Hegar dilator was in place to prevent inadvertent canal occlusion during suturing. Continuous suturing took place from the cephalad to the caudal directions in 2 layers. Once hemostasis was confirmed, the gel port was removed, and the vaginal epithelium was closed with interrupted sutures using a braided absorbable suture. The perioperative course and care were uneventful with the Foley catheter being removed 3 hours after surgery. The patient was discharged within 24 hours. A follow-up organized 6 weeks after surgery demonstrated obliteration and repair of the previously detected uterine isthmocele on the pelvic US scan. The patient also reported a resolution of symptoms at this postoperative visit. MAIN OUTCOME MEASURE(S): N/A. RESULT(S): N/A. CONCLUSION(S): Uterine-conserving surgical approaches to an isthmocele have been described, including vaginal, hysteroscopic, and laparoscopic (with and without robotic assistance) approches and laparotomy, with no single approach deemed to be superior to the others. The existing evidence is limited by the lack of uniformity in the definition and diagnosis of uterine isthmocele, consistency in indication for surgery, and small case numbers in published surgical series. Vaginal natural orifice transluminal endoscopic surgery provides a novel approach to this type of surgery, which may be potentially less invasive as the procedure is conducted outside the peritoneal cavity and combines the best vaginal approach to the surgical site with endoscopic magnification and capacity for microscopic dissection. This approach should be considered new and only in a clinically appropriate and carefully counseled patient.