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| 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.
Here is the
video demonstrating the actual procedure.
