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Pavone M, Lecointre L, Seeliger B, Oliva R, Akladios C, Querleu D, Scambia G, Marescaux J, Forgione A. The vaginal route for minimally invasive surgery: a practical guide for general surgeons. MINIM INVASIV THER 2025; 34:78-87. [PMID: 38850263 DOI: 10.1080/13645706.2024.2359707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/21/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Vaginal approaches have become routine in the field of gynecologic surgery, whereas in general surgery vaginal wall transection is an infrequent practice typically reserved for extensive tumor resections. Approximately two decades ago, natural orifice transluminal endoscopic surgery (NOTES) revolutionized conventional boundaries by accessing the peritoneal cavity transorally, transrectally, or transvaginally, enabling general surgery without visible scars. Although transvaginal approaches have been successfully used for various abdominal procedures by general surgeons, a gap remains in comprehensive training to fully exploit the potential of this route. MATERIAL AND METHODS PubMed, Google Scholar, and Scopus databases were searched to retrieve relevant articles illustrating how general surgeons can adeptly manage vaginal approaches. RESULTS The article presents a practical framework for general surgeons to execute a complete vaginal approach, addressing the management of vaginal specimen extraction and vaginal cuff closure, even in the absence of an experienced gynecologist. CONCLUSION The evolution of abdominal surgery is moving towards less invasive techniques, emphasizing the importance of understanding the nuances and challenges associated with the vaginal route. This approach is linked to minimal oncological, sexual, and infective complications, and to the absence of pregnancy-related complications. Such knowledge becomes increasingly crucial, particularly with the renewed demand for transvaginal access in robot-assisted NOTES procedures.
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Affiliation(s)
- Matteo Pavone
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Lise Lecointre
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Department of Gynecologic Surgery, University Hospital of Strasbourg, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Barbara Seeliger
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
- Department of Digestive and Endocrine Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Riccardo Oliva
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Cherif Akladios
- Department of Gynecologic Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Denis Querleu
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Giovanni Scambia
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Jacques Marescaux
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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Feng D, Liu T, Li X, Peng J, Huang L, He L. Repeated transvaginal natural orifice transluminal endoscopic surgery: An initial Chinese experience. J Obstet Gynaecol Res 2023; 49:2501-2508. [PMID: 37522305 DOI: 10.1111/jog.15757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023]
Abstract
AIMS To investigate the perioperative outcomes and sexual function of patients undergoing repeated transvaginal natural orifice transluminal endoscopic surgery (vNOTES). METHODS We retrieved the records of patients who underwent vNOTES twice at our institute between April 2019 and December 2022 and analyzed their baseline information and perioperative complications, and compared the pre- and postoperative sexual function of both vNOTES. RESULTS Patients' mean age and body mass index were 29.00 ± 3.59 and 30.4 ± 4.00 years and 21.89 ± 3.69 and 22.76 ± 3.88 kg/m2 , respectively, when receiving the first and second vNOTES. Ectopic pregnancy was the most frequent indication for vNOTES, with 7 cases in the first vNOTES and 11 cases in repeated vNOTES. The interval between the two vNOTESs ranged from 9 days to 38 months. The operation duration (63.33 ± 13.71 vs. 67.33 ± 22.51 min, p = 0.723), intraoperative estimated blood loss (32.00 ± 20.42 vs. 30.00 ± 9.26 mL, p = 0.429), and duration of postoperative hospital stay (2.20 ± 0.56 vs. 2.40 ± 0.51 days, p = 0.082) of both vNOTESs were comparable. No significant differences were found in any of the domains in the comparison of pre-first and post-first vNOTES, pre-second and post-second vNOTES, and pre-first and post-second vNOTES female sexual function index. None of the patients delivered after the second vNOTES. CONCLUSION Repeated vNOTES is safe and feasible. No significant change in the patients' sexual function was found in our cohort after the first and second vNOTES.
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Affiliation(s)
- Dan Feng
- Department of Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Tianjiao Liu
- Department of Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xin Li
- Department of Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jieru Peng
- Medical Administrative Department, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lu Huang
- Department of Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li He
- Department of Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Li SL, Zhao E, Zhao L, Wang ZK, Li W. Transvaginal natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin. Gastrointest Endosc 2019; 89:872-877. [PMID: 30391254 DOI: 10.1016/j.gie.2018.09.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies, but few clinical studies have investigated transvaginal NOTES in the diagnosis of unexplained refractory ascites. We aimed to assess the feasibility, efficacy, and safety of transvaginal NOTES for the diagnosis of unexplained ascites in female patients. METHODS A prospective study was done involving 3 female patients with unexplained ascites. After general anesthesia and disinfection, a 1.0-cm incision was made in the posterior fornix of the vagina. A gastroscope was inserted into the abdominal cavity through the transvaginal incision and an artificial pneumoperitoneum was created; NOTES peritoneoscopy was performed to scrutinize the pathologic changes. Endoscopic biopsy specimens were obtained for pathologic examination. The transvaginal incision was closed by direct suturing. RESULTS Transvaginal NOTES for diagnostic peritoneoscopy was successfully performed in 3 patients. The mean operative time was 61 minutes. The estimated blood loss was 5 to 10 mL. The pathologic diagnoses were tuberculosis for all patients, and the symptoms and ascites disappeared after antituberculosis therapy. During the 4-year follow-up, no clinically significant adverse events occurred in any patient after NOTES. No patient experienced an annex inflammation, vaginitis, dyspareunia, or sexual dysfunction. All patients were comfortable and satisfied with the nonscarring surgical procedure. CONCLUSIONS Transvaginal NOTES for the diagnosis of unexplained ascites is feasible, effective, and safe. This method had no long-term effect on female sexual function and is particularly suitable for women who have special aesthetic requirements. (Clinical trial registration number: ChiCTR-TRC-10001053.).
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Affiliation(s)
- Shu-Ling Li
- Department of Gastroenterology and Hepatology, the General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Enfeng Zhao
- Department of Gastroenterology and Hepatology, the General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Li Zhao
- Department of Gastroenterology and Hepatology, Hainan Branch of the Chinese PLA General Hospital, Hainan, China
| | - Zi-Kai Wang
- Department of Gastroenterology and Hepatology, the General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, the General Hospital of the Chinese People's Liberation Army, Beijing, China
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Total Vaginal NOTES Hysterectomy: A New Approach to Hysterectomy. J Minim Invasive Gynecol 2015; 22:1088-94. [PMID: 26009278 DOI: 10.1016/j.jmig.2015.05.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/18/2015] [Accepted: 05/20/2015] [Indexed: 01/04/2023]
Abstract
The aim of this study was to demonstrate the feasibility of a total hysterectomy performed entirely by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Conventional, reusable laparoscopic instruments were used, inserted through an inexpensive, self-constructed single-port device. Ten total vaginal NOTES hysterectomies (TVNHs) were performed by a single surgeon. The self-constructed single-port device was made by assembling a surgical glove, a wound protector or modified laryngeal mask airway, 1 reusable 10-mm trocar, and 4 reusable 5-mm trocars. This gloveport was inserted into the vagina to create a pneumovagina. The conventional steps of a vaginal hysterectomy were followed, but performed endoscopically with standard reusable endoscopic instruments. The patient and perioperative data were analyzed. No conversion to standard laparoscopy or laparotomy was necessary in any of the 10 patients who underwent a TVNH. Mean operation time was 97 min (range: 60-120); mean drop in hemoglobin level was 1.5 g/dL (range: 0.5-2.4). There were no operative complications, and postoperative pain scores were very low. This first report on a small number of patients demonstrates that TVNH is possible. By incorporating the advantages of endoscopic surgery, TVNH broadens the indications for vaginal hysterectomy and helps overcome its limitations. At the same time, the NOTES approach avoids abdominal wall wounds and trocar-related complications. TVNH is feasible, even when performed with reusable, conventional laparoscopic instruments. This frugally innovative technique also enables surgeons to perform hysterectomies by vNOTES in low resource settings.
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Xu B, Xu B, Zheng WY, Ge HY, Wang LW, Song ZS, He B. Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis. World J Gastroenterol 2015; 21:5393-5406. [PMID: 25954114 PMCID: PMC4419081 DOI: 10.3748/wjg.v21.i17.5393] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/29/2014] [Accepted: 01/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the results of transvaginal cholecystectomy (TVC) and conventional laparoscopic cholecystectomy (CLC) for gallbladder disease.
METHODS: We performed a literature search of PubMed, EMBASE, Ovid, Web of Science, Cochrane Library, Google Scholar, MetaRegister of Controlled Trials, Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC. Data were extracted by two authors. Mean difference (MD), standardized mean difference (SMD), odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models. Statistical heterogeneity was evaluated with the χ2 test. The fixed-effects model was used in the absence of statistically significant heterogeneity. The random-effects model was chosen when heterogeneity was found.
RESULTS: There were 730 patients in nine controlled clinical trials. No significant difference was found regarding demographic characteristics (P > 0.5), including anesthetic risk score, age, body mass index, and abdominal surgical history between the TVC and CLC groups. Both groups had similar mortality, morbidity, and return to work after surgery. Patients in the TVC group had a lower pain score on postoperative day 1 (SMD: -0.957, 95%CI: -1.488 to -0.426, P < 0.001), needed less postoperative analgesic medication (SMD: -0.574, 95%CI: -0.807 to -0.341, P < 0.001) and stayed for a shorter time in hospital (MD: -1.004 d, 95%CI: -1.779 to 0.228, P = 0.011), but had longer operative time (MD: 17.307 min, 95%CI: 6.789 to 27.826, P = 0.001). TVC had no significant influence on postoperative sexual function and quality of life. Better cosmetic results and satisfaction were achieved in the TVC group.
CONCLUSION: TVC is safe and effective for gallbladder disease. However, vaginal injury might occur, and further trials are needed to compare TVC with CLC.
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Panait L, Wood SG, Bell RL, Duffy AJ, Roberts KE. Transvaginal natural orifice transluminal endoscopic surgery in the morbidly obese. Surg Endosc 2013; 27:2625-9. [PMID: 23355168 DOI: 10.1007/s00464-012-2775-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 12/12/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND The objective of this study is to assess the safety and efficacy of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) operations in morbidly obese patients. METHODS One hundred seven NOTES operations have been performed at our institution to date, of which 17 were completed in patients with body mass index (BMI) between 35 and 45 kg/m(2). These included 14 cholecystectomies, one appendectomy, and two ventral hernia repairs. The patients had average age of 36.2 years (range 19-62 years) and average BMI of 38.9 kg/m(2) (range 35.2-44.9 kg/m(2)). The mean number of previous abdominal operations was 1. The TV cholecystectomies were hybrid NOTES procedures, while TV appendectomy and ventral hernia repair were pure NOTES. All operations were completed with standard straight laparoscopic instruments. RESULTS The mean operative time was 60 min for cholecystectomy, 41 min for TV appendectomy, and 90 min for ventral hernia repair. No significant difference was encountered between the operative time for NOTES cholecystectomies in obese versus nonobese (60 vs. 61 min, p = 0.86). No conversions to traditional laparoscopy or open surgery were made, and no major complications were encountered. CONCLUSIONS NOTES is an attractive alternative to laparoscopy in female patients with morbid obesity. The procedures are safe and have short operative times, good postoperative outcomes, and improved cosmesis compared with laparoscopy.
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Affiliation(s)
- Lucian Panait
- Department of Surgery, Yale School of Medicine, 40 Temple St., Suite 7B, New Haven, CT 06510, USA
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