New approach to myomectomy: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as a less invasive approach to laparoscopic surgeries.

NOTES is considered a logical next step in the evolution of minimal invasive surgery, and the first NOTES procedure in humans is often considered to be a transgastric appendectomy performed in India in 2006 which was presented but not reported in manuscript form.

vNOTES is a natural orifice surgery performed through vaginal route. A look into history reveals that gynecologists have been performing colpotomies since years, adding their valuable experience towards NOTES surgeries and subsequent closure.

A recently published paper in January issue of Fertility and Sterility have demonstrated a new technique of performing myomectomy by this route and reports the technique and results of a small study involving 8 patients. Eight patients were treated transvaginally for intramural, subserosal, and pedunculated myomas.

The study was conducted at Gynecology department of a non-university teaching hospital in Belgium.

In case of the anterior myoma, anterior colpotomy was used to gain access to the peritoneal cavity, if the myoma was located posteriorly, a 2.5-cm posterior colpotomy was made under general anesthesia. The pouch of Douglas was opened and a vNOTES port was inserted transvaginally.

A pneumoperitoneum was created and the myoma was identified. With the use of conventional endoscopic instruments and a standard endoscope, all inserted through the vNOTES port, the uterine serosa was incised over the myoma and the myoma was resected. After achieving hemostasis, the uterine scar was sutured in two layers with the use of a standard absorbable suture or an autolocking suture.

 An adhesion-preventing barrier was applied over the uterine scar. The myoma was removed through the colpotomy in an endobag. The vNOTES port was removed and the colpotomy was sutured with the use of an absorbable suture.

The patients’ data collected included demographics, number of previous abdominal surgeries, myoma size, myoma weight, operating time, length of hospital stay, visual analog scale pain score, and serum hemoglobin drop.

All fibroids were successfully removed without any intraoperative or postoperative complications via vNOTES without converting to open or standard laparoscopic access. Patients were discharged within 24 hours, 2 of them went home in 12 hours.

In a developed setting, the surgical time can be reduced with the use of an autolocking suture and a commercially available vNOTES port, while in low resource setting it can be replaced by standard absorbable suture and a self-constructed gloveport, as clearly seen in the following video.

The authors concluded that vNOTES provides a new less invasive approach for the resection of myoma types 3–7 that are conventionally resected via laparotomy, laparoscopy, or transabdominal robotic surgery.

This was the first successful IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study which confirmed the feasibility of vNOTES myomectomy. This novel approach not only provides a better cosmetic result than conventional laparoscopy but also improves patient comfort.

Larger studies are warranted in future. 

A new approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

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Here is the video of stepwise explanation of the technique.