Vaginal assisted NOTES hysterectomy in The Netherlands; A prospective cohort study.

Objectives: Vaginal assisted Natural Orifice Transluminal Endoscopic Surgery (NOTES) combines the benefits of vaginal and endoscopic surgery. This study presents the results of the first vaginal assisted NOTES hysterectomies (VANH) in The Netherlands. Study design: A prospective cohort study was performed in two non-academic teaching hospitals in The Netherlands. Data was collected from patients who underwent a VANH for benign indications between August 2019 and April 2023. Baseline characteristics and data of intra- and postoperative surgical outcomes were recorded and analysed. The VANHs were performed by four experienced vaginal and endoscopic gynaecological surgeons. Results: A total of 200 patients underwent a VANH. Indications were dysfunctional menstrual bleeding (61 %; n = 122), abnormal cervical cytology (15.5 %; n = 31), abdominal pain (11.5 %; n = 23), post ablation/sterilization pain syndrome (3.5 %; n = 7), uterine fibroids (5.0 %; n = 10), atypical endometrial hyperplasia (2.5 %; n = 5) and Lynch or BRCA gene mutation carriers (1.0 %, n = 2). The mean surgical time was 61.4 min ( ± 22.8 min) with a mean blood loss of 88 mL ( ± 89 mL) and a mean uterine weight of 150 g ( ± 112 g). In 2.0 % (n = 4) of the cases a conversion was necessary. Same day discharge (SDD) was feasible in 80.2 % (n = 105) of the patients planned in day-care. In 2.0 % (n = 4) an intra-operative complication and in 9.0 % (n = 18) a post-operative complication occurred. Conclusion: This study shows vNOTES to be a safe and feasible surgical technique and can be safely implemented with appropriate patient selection and skilled surgeons. It highlights the importance of surgeon awareness of the challenges inherent in the initial stages of the implementation of a new surgical technique when performing their first vNOTES procedures. Additional randomized clinical trials are needed to show superiority of vNOTES compared to traditional surgery.

Comparison of laparoscopy and vNOTES in early-stage endometrial cancer.

AIM: To compare the demographic, clinical, surgical, histopathological, and oncological outcomes of vNOTES and conventional laparoscopy (CL)for early-stage endometrial cancer. METHODS: A retrospective study was carried out in the Gynecologic Clinic of a tertiary hospital from January 2019 to November 2020. Patient demographic characteristics, surgical outcomes, histopathological characteristics, visual analog scale (VAS) pain scores at postoperative 6th, 12th, and 24th, intra- and postoperative complications, and follow-up results were noted. RESULTS: A total of 45 patients enrolled, of which 16 underwent CL and 29 were vNOTES. The operative time and decrease in hemoglobin levels were similar for both groups (p = 0.202, p = 0.699). Postoperative hospital stay did not differ between the vNOTES group and the CL group (p = 0.549). VAS pain scores at postoperative 6th, 12th, and 24th h were significantly lower in vNOTES group than in the CL group (p < 0.001). The requirement for additional opioid/narcotic analgesic was lower in the vNOTES group than in the CL group (p = 0.037). CONCLUSION: vNOTES may be a safe and feasible option in early-stage endometrial cancer, having less postoperative pain and less requirement of opioid/narcotic analgesic compared with laparoscopy.

Learning curve of ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery: a cumulative sum analysis.

Purpose: To identify the learning curve in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery. Methods: Data consist of consecutively ordered patients who underwent ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery between May 2020 and June 2023. The learning curve of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery was measured in terms of the operating time adjusted by multivariate linear regression. A cumulative sum analysis was performed to establish the learning curve. Patients' characteristics and surgical outcomes were compared based on the inflection points of this curve. Results: The learning curve was divided into two unique phases: phase 1 (1-26 patients), and phase 2 (27-40 patients). The expected operating time in phase 2 was shorter than in phase 1 (86.4 ± 11.2 min vs. 102.0 ± 22.7 min, p = 0.021). The time to first postoperative flatus was shorter in phase 2 compared with phase 1 (14.6 ± 6.5 h vs. 20.6 ± 6.3 h, respectively, p = 0.008). No significant differences were observed in terms of patient's age, BMI, tumor size, parity, bilateral ovarian tumor, pathological diagnoses, estimated blood loss, postoperative pain score, or perioperative complications between the two phases. Conclusion: Proficiency in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery was achieved after 26 surgeries based on cumulative sum analysis. These findings may provide insight for structured training programs of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery.

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) right hemicolectomy with intracorporeal anastomosis for cecal cancer.

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) for colorectal cancer utilizes transvaginal access for bowel mobilization, vascular pedicle ligation, oncological resection, and bowel anastomosis, along with subsequent transvaginal natural orifice specimen extraction (NOSE), reducing or eliminating the need for transabdominal access. In this report, we describe the technique of vNOTES right hemicolectomy for cecal cancer, with intracorporeal anastomosis and transvaginal NOSE, including a step-by-step operative video. The patient was a 59-year-old Chinese female (body mass index 32.0 kg/m2) with a cT3N0M0 3 cm cecal adenocarcinoma. Posterior colpotomy was created with insertion of a dual-ring wound protector. vNOTES D2 right hemicolectomy with a fully stapled intracorporeal anastomosis was performed via a homemade transvaginal glove port, using extra-long rigid instruments. A 10 mm, 30° rigid laparoscope was used for operative visualization through a transumbilical port, without additional percutaneous trocars. Operative difficulties pertained to suboptimal instrument reach, lack of triangulation, and frequent clashing within the restricted access space. Surgical duration was 300 min, with 50 ml of blood loss. There was minimal postoperative pain. Return of bowel function occurred on postoperative day 2, with discharge from hospital on postoperative day 3. The patient resumed normal daily activities and regular diet by 1-week post-surgery. Self-reported cosmetic satisfaction score was excellent. No operative complications were observed at 2 months' follow-up. vNOTES right hemicolectomy with intracorporeal anastomosis is safe and feasible in highly selected colon cancer patients. Operators should be proficient in conventional laparoscopic colectomy and transvaginal NOSE. More experience with the vNOTES technique is required to ascertain best practices.

Clinical efficacy and safety of transvaginal natural orifice transluminal endoscopic surgery for benign adnexal disease: a prospective trial.

BACKGROUND: There is a scarcity of prospective clinical research evidence regarding the utilization of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) as a treatment option for ovarian cysts. The objective of this study was to assess the feasibility and safety of employing vNOTES for the management of ovarian cysts. METHODS: Our study included women between the ages of 18 and 70 who intended to undergo surgical intervention for benign lesions. Stratified blocked randomization was employed to allocate participants into groups. The main objective was to assess whether the assigned group adhered to the recommended surgical technique for ovarian cystectomy or adnexectomy, without any deviation to alternative surgical methods. RESULTS: A total of 196 patients were included in the study, with all surgeries in each group being conducted according to the assigned procedures. Among them, the ovarian cystectomy layer included 58 cases in the vNOTES group and 58 cases in the conventional laparoscopy (CL) groups. The adnexectomy layer included 40 cases in the vNOTES group and 40 cases in the CL group. Utilizing a sensitivity analysis, the two-sided 95% lower confidence limit was determined to be 5.5% for the disparity in proportions between the vNOTES groups and CL groups. These lower limits fell below the predetermined non-inferiority margin of 10%. CONCLUSIONS: The study findings demonstrate that vNOTES was not inferior to CL in terms of adnexectomy or ovarian cystectomy. vNOTES can be considered a more minimally invasive surgical approach, as it results in reduced postoperative pain, faster recovery, and absence of visible incisions. Overall, vNOTES proves to be a safe, feasible, and less invasive treatment option. TRIAL REGISTRATION: This study retrospectively registered with the China Clinical Trial Registry with the registration number ChiCTR2100052223(22-10-2021).

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.

Which Is the Best Surgical Approach for Female-to-Male Sexual Reassignment? A Systematic Review of Hysterectomy and Salpingo-Oophorectomy Options from the Gynecological Perspective.

Background and Objectives: Transgender people are defined as individuals whose gender identity does not entirely match their sex assigned at birth. Gender surgery typically represents the conclusive and irreversible step in the therapeutic process, especially for the impact on the reproductive sphere. The increased awareness of gender dysphoria and the expanding array of medical and surgical options, including minimally invasive techniques, contribute to the gradual increase in the social impact of transgender surgery. There are several surgical techniques for "gender assignment", such as vaginal, laparotomic, laparoscopic, and robotic, and the novel approach of vaginal natural orifice transluminal endoscopic surgery to perform a hysterectomy and bilateral salpingo-oophorectomy (BSO). The purpose of this review is to assess the various surgical approaches (hysterectomy and salpingo-oophorectomy) for gender reassignment in order to determine the best option in clinical practice for the female-to-male population in terms of surgical outcomes such as operative time, surgical complication, hospital discharge, postoperative pain, and bleeding. Materials and Methods: This systematic review includes studies from 2007 to 2024. Special consideration was given to articles documenting the characteristics and management of female-to-male reassignment surgery. Finally, eight papers were included in this review. Results: The literature analysis considered surgical techniques ranging from traditional surgery to innovative methods like vaginal natural orifice transluminal endoscopic surgery and robotic-assisted laparoscopic hysterectomy. Vaginal natural orifice transluminal endoscopic surgery and the robotic approach offer potential benefits such as reduced postoperative pain and shorter hospital stays. While vaginal natural orifice transluminal endoscopic surgery may encounter challenges due to narrow access and smaller vaginal dimensions, robotic single-site hysterectomy may face instrument conflict. Conclusions: The conventional laparoscopic approach remains widely used, demonstrating safety and efficacy. Overall, this review underscores the evolving landscape of surgical techniques for gender affirmation and emphasizes the necessity for personalized approaches to meet the specific needs of transgender patients.

Health-related quality of life following hysterectomy by vNOTES versus conventional laparoscopy.

OBJECTIVE: To evaluate safety, efficacy, pre- and postoperative outcomes of vNOTES hysterectomy compared to conventional laparoscopic (CL) hysterectomy. MATERIAL AND METHODS: This prospective study was conducted on patients who underwent CL or vNOTES hysterectomy for benign gynecological indications between January and July 2021. Sociodemographic, clinical, and surgical data were collected. Health-related quality of life (HRQoL) outcomes were evaluated using the EQ-5D-5L questionnaire. RESULTS: A total of 228 patients (CL vs. vNOTES: 147 vs. 81) were included. No significant differences were observed between the two groups in terms of blood loss, uterine weight, complications, length of hospital stay, and readmission rate. Patients in the vNOTES group experienced significantly less postoperative pain and required less analgesia compared to those who underwent CL hysterectomy (p < 0.001). The CL group had a shorter operative time (p < 0.001). There was a significant difference between the two groups in the EQ-5D-5L pain/discomfort dimension (p = 0.047). CONCLUSION: This research showed that vNOTES has various advantages, such as less postoperative pain, reduced analgesic usage, and better HRQoL outcomes three months after surgery.

Transvaginal natural orifice transluminal endoscopic surgery (VNOTES) retroperitoneal sentinel lymph node BIOPSY compared with conventional laparoscopy in patients with endometrial cancer.

INTRODUCTION: To explore the possibility of treatment with VNOTES sentinel lymph node dissection concept in patients with endometrial cancer. METHODS: Patients who underwent VNOTES sentinel lymph node biopsy with the Comba modification were compared to patients who underwent conventional laparoscopic sentinel lymph node biopsy performed by the same surgical team. A total of 38 patients who underwent sentinel lymph node biopsy + total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (BSO) were compared with 19 patients who underwent VNOTES retroperitoneal sentinel lymph node biopsy + hysterectomy and BSO. Surgical steps were described. RESULTS: The average operation time, perioperative blood loss, the number of sentinel lymph nodes, presence of complications, and preoperative-postoperative hemoglobin-hematocrit differences, tumor stages, grades, largest tumor diameter, depths of invasion, and histological subtypes were similar in both the VNOTES and conventional laparoscopy groups. The postoperative pain scores were lower and the hospital stay was shorter in the VNOTES group than in the conventional laparoscopy group. No disease recurrence had been detected in either group at the time of writing. CONCLUSION: Compared to conventional laparoscopy, sentinel lymph node biopsy with the VNOTES technique provides similar surgical results and is more advantageous in terms of postoperative pain and hospital length of stay.

Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach.

(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described and developed by Jan Baekelandt. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is in Stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: Description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: We describe a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL Stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary for evolving through future IDEAL Stage 2b (multi-center studies) and Stage 3 (randomized controlled trials) studies.

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.

Systematic review and meta-analysis of vaginal natural orifice transluminal endoscopic surgery hysterectomy versus vaginal hysterectomy for benign indications.

Objective: As the second most common surgery performed on women in the United States, hysterectomy techniques are constantly examined for validity and superiority. The vaginal natural orifice transluminal endoscopic surgery (vNOTES) has increased in popularity since the first vNOTES hysterectomy was performed in 2012. We sought out to evaluate the safety and effectiveness of hysterectomy by vNOTES compared to conventional vaginal hysterectomy for various benign indications. Data sources: We searched Scopus, Medline, PubMed, ClinicalTrials.Gov, and the Cochrane Library. Our search included all studies from each respective database's inception until September 1, 2023. Study eligibility criteria: We included eligible studies that compare vNOTES hysterectomy versus conventional vaginal hysterectomy for various benign indications, and included at least one of our preselected outcomes. The main outcomes were estimated blood loss (mL), operation time (min), length of hospital stay (d), Visual Analogue Scale pain score at Day 1, intraoperative complications, and postoperative complications. Study appraisal and synthesis methods: We analyzed data of our continuous outcomes using RevMan 5.4.1. Continuous outcomes were analyzed using mean difference (MD) and 95% confidence intervals (CIs) under the inverse variance analysis method. We assessed the quality of the studies using the ROBINS-I assessment tool. Results: We found 4 eligible studies to include in our analysis. Surgeon declared estimated blood loss was found to be similar in both groups (MD=-44.70 [-99.97, 10.57]; P=.11). Also, the total length of hospital stay (in days) was found to be comparable in both groups (MD=-0.16 [-1.62, 1.30]; P=.83). We also found no other statistically significant difference between hysterectomy by vNOTES and vaginal hysterectomy in other studied outcomes, including the duration of the operation, the Visual Analogue Scale Pain score after 1 day, intraoperative complications, and postoperative complications. Conclusion: vNOTES seems to be associated with a nonsignificant lower surgeon declared estimated blood loss. We found no other significant differences in hospital stay, intraoperative, or postoperative outcomes. Further studies may clarify if other differences in safety or efficacy exist.

Discharge within 24 h, transvaginal natural orifice transluminal endoscopic surgery- more suitable for ambulatory surgery in gynecology procedures: a retrospective study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is an achievement in the field of minimally invasive surgery. However, the vantage point of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologicalprocedures remains unclear. The main purpose of this study was to compare vNOTES with laparo-endoscopic single-site surgery, and to determine which procedure is more suitable for ambulatory surgery in gynecologic procedures. METHODS: This retrospective observational study was conducted at the Department of Gynecology, Chengdu Women's and Children's Central Hospital. The 207 enrolled patients had accepted vNOTES and laparo-endoscopic single-site surgery in gynecology procedures from February 2021 to March 2022. Surgically relevant information regarding patients who underwent ambulatory surgery was collected, and 64 females underwent vNOTES. RESULTS: Multiple outcomes were analyzed in 207 patients. The Wilcoxon Rank-Sum test showed that there were statistically significant differences between the vNOTES and laparo-endoscopic single-site surgery groups in terms of postoperative pain score (0 vs. 1 scores, p = 0.026), duration of anesthesia (90 vs. 101 min, p = 0.025), surgery time (65 vs. 80 min, p = 0.015), estimated blood loss (20 vs. 40 mL, p < 0.001), and intestinal exhaustion time (12.20 vs. 17.14 h, p < 0.001). Treatment with vNOTES resulted in convenience, both with respect to time savings and hemorrhage volume in surgery and with respect to the quality of the prognosis. CONCLUSION: These comprehensive data reveal the capacity of vNOTES to increase surgical efficiency. vNOTES in gynecological procedures may demonstrate sufficient feasibility and provide a new medical strategy compared with laparo-endoscopic single-site surgery for ambulatory surgery in gynecological 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.

Vaginal Hysterectomy and Pelvic Organ Prolapse: History and Recent Developments.

INTRODUCTION AND HYPOTHESIS: Vaginal hysterectomy (VH) was described as far back as 120 CE. However, it was not till the mid-1900s when reconstructive procedures were introduced to mitigate the risk of, or treat, pelvic organ prolapse in relation to VH. Furthermore, routine hysterectomy, particularly VH, has long been advocated in prolapse surgery. However, this indication is now questionable. METHODS: Literature review to provide an overview of current evidence and experts' opinion regarding the relationship between VH and pelvic organ prolapse. The review presents a historical perspective on the role of VH in the management of pelvic organ prolapse, the current debate on the usefulness of the procedure in this context, a practical guide on operative techniques used during VH and the impact of recent surgical developments on its use. RESULTS: Vaginal hysterectomy is a well-established technique that is still superior to laparoscopic hysterectomy for benign gynecological disease, although more surgically challenging. However, it is possible that some contemporary techniques, such as vaginal natural orifice transluminal endoscopic surgery, may overcome some of these challenges, and hence increase the number of hysterectomies performed via the vaginal route. Although patients should be counselled about uterine-sparing reconstructive surgery, vaginal hysterectomy continues to be a major surgical procedure in reconstructive pelvic floor surgery. CONCLUSIONS: Therefore, it is prudent to continue to train residents in vaginal surgical skills to ensure that they continue to provide safe, cost-effective, and comprehensive patient care.

Transvaginally Adjustable Apical Suspension and Compartment-Specific Tensioning in Vaginal Natural-Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Cadaveric and Live Patient Experience.

Objective: This article provides a systematic approach to performing a vaginal natural-orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy (SCP) to create an anatomically aligned vaginal axis, an intraoperatively adjustable apical suspension, and variable compartment tensioning. Methods: The technique presented for vNOTES SCP focuses on: (1) retroperitoneal tunneling; (2) direct sacrum access below the S-1 level, using uterosacral-ligament guidance; (3) transvaginal tensioning of the mesh to ensure both adequate vaginal length and cuff elevation using the DZOH apical-suspension technique; (4) circumvention of intrapelvic laparoscopic suturing; and (5) near-total peritoneal coverage of the mesh arms. Results: This detailed description of a successful novel technique to perform vNOTES SCP was based on cadaveric experience as well as in live patients that is reproducible on living patients. Conclusions: This apical suspension technique for vNOTES SCP may be a viable, reproducible, safe, and efficient transvaginal alternative to the commonly practiced minimally invasive approaches that involve abdominal-port placements. (J GYNECOL SURG 40:116).

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).

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.

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.