A novel route for tubal surgery: 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 the vaginal route. A look into history reveals that gynecologists have been performing colpotomies for years, adding their valuable experience towards NOTES surgeries and subsequent closure.

A recently published paper in July issue of Fertility and Sterility have demonstrated a new technique of performing tubal reanastomosis via the vaginal route. The step-by-step procedure is explained in the accompanying video, using the surgical case of a 42-year-old female G2P2 with a history of tubal ligation 11 years before, who requested a tubal reanastomosis.   

A three-dimensional sonohystogram at 8 weeks postop showed bilateral patency of both the fallopian tubes.

The current method of performing tubal reanastomosis involves a minimal invasive surgery with end-to-end anastomosis with a 60% to 90% success rate of post-operative intrauterine pregnancy.

A recent systematic review comparing laparotomy vs laparoscopy vs robotic mode of surgery showed that laparotomy had the worst outlook.

NOTES have the advantage of a fast recovery, no abdominal incision, and an extremely cosmetic outcome. With prophylactic antibiotic, the current rate of pelvic infection with NOTES is a 0%–3.1%.

In the hands of a skilled minimally invasive surgeon, vNOTES offers an alternate route for tubal surgery.

Here is a video showing the stepwise surgical procedure 

Abstract

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New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

New approach to myomectomy: Transvaginal natural orifice transluminal endoscopic surgery

New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

self constructed vNOTES glove port in low resource settings

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 less invasive approach to laparoscopic surgeries. 

NOTES is considered a logical next step in 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 forthcoming issue of Fertility and Sterility have demonstrated a new technique of performing ovarian cystectomy by this route and reports the technique and results of small study involving 14 patients.

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

All patients were placed in lithotomy position and under general anesthesia, a one-inch posterior colpotomy incision opened the pouch of Douglas.

vNOTES port was inserted through the incision, pneumoperitoneum was created by CO2, and the ovarian cyst was identified. Conventional endoscopic instruments and standard endoscope was used to dissect the cyst from the ovarian cortex by blunt and sharp dissection. Hemostasis achieved by bipolar forceps and cyst removed by bagging it in endobag through the colpotomy incision, which was closed by absorbable sutures.

All 14 patients underwent a successful fertility sparing cystectomy via the vNOTES procedure, without any complications or need for converting into open surgery.

The mean age of patients was 38 years, BMI= 24.7, cyst diameter = 45mm and mean parity = 2. The average surgical time was 37 minutes with only one patient having a history of previous pelvic surgery.

Nine patients were sent home within 12 hours and the rest within 30 hours of surgery.

The authors concluded, “Transvaginal natural orifice transluminal endoscopic surgery provides a new, less invasive approach for performing an ovarian cystectomy. This first IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study confirms the feasibility of vNOTES ovarian cystectomy although it remains a novel approach that requires further investigation. It can provide improved patient comfort and better cosmetic results.”

Earlier studies involving small sample sizes have also reported successful performance of hysterectomies and uterine adnexal surgeries by transvaginal NOTES.

Abstract

Here is the video demonstrating the actual procedure.