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.

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.

New Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery Approach to Sentinel Node for Endometrial Cancer: A Demonstration Video.

STUDY OBJECTIVE: To assess whether sentinel node resection for endometrial cancer is feasible via retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and gives better exposure than transperitoneal vNOTES. DESIGN: This is a first small IDEAL (Idea Development Exploration Assessment Long-term follow up) stage 1 study to assess the feasibility of a new approach; the technique is explained step-by-step using videos (Video 1) and pictures. SETTING: The gynecologic oncology department of a nonuniversity teaching hospital in Belgium. PATIENTS: Since 2015, 15 patients were operated on via vNOTES for endometrial cancer [1]. INTERVENTIONS: Our initial experience showed that a transperitoneal approach via vNOTES [2] provided good access to the cranial pelvic retroperitoneum but not to the caudal pelvic retroperitoneum. Therefore, a new retroperitoneal vNOTES approach via a paracervical incision in the lateral vaginal fornix was developed. Via this incision, the obturator fossa is accessed, and a vNOTES port is placed for endoscopic dissection of the retroperitoneal space. This video article shows this new access route to the pelvic retroperitoneal space. MEASUREMENTS AND MAIN RESULTS: Our initial experience with vNOTES for endometrial cancer showed that transperitoneal access to the retroperitoneal space did not give optimal exposure to the caudal parts of the obturator space. The new retroperitoneal vNOTES approach shown in this video article gives better exposure to the entire retroperitoneal space including the caudal part of the obturator space; the sacral plexus; the external, internal, and common iliac arteries; and even the lower para-aortic region. CONCLUSION: It has been previously shown that vNOTES hysterectomy offers patient benefits over total laparoscopic hysterectomy [3]. The retroperitoneal vNOTES approach now also offers good transvaginal access to the entire retroperitoneal space for sentinel node resection. This is a new approach that requires further validation before vNOTES hysterectomy with retroperitoneal sentinel node resection can be used outside study settings for the treatment of endometrial cancer.