Histerectomía mediante acceso vNOTES. Reporte de caso / Hysterectomy across vNOTES procedure. A case report

Resumen ANTECEDENTES: La cirugía mediante vNOTES (Vaginal Natural Orifices Transluminal Endoscopic Surgery, por sus siglas en inglés), practicada por primera vez en el 2010, es una técnica quirúrgica emergente que elimina el traumatismo quirúrgico en la pared abdominal mediante orificios naturales del cuerpo para la ejecución de procedimientos quirúrgicos. Debido a la falta de reportes con vNOTES en México se comunica el caso de una paciente en quien se aplicó este acceso, con buenos resultados. CASO CLÍNICO: Paciente de 60 años, asintomática, referida para tratamiento definitivo de una lesión intraepitelial cervical, porque no aceptó el conservador. La histerectomía se efectuó mediante el acceso vNOTES, con una duración de 100 minutos, sin contratiempos ni complicaciones posoperatorias. A las 24 horas se dio de alta del hospital hemodinámicamente estable y asintomática, y sin complicaciones tardías. CONCLUSIÓN: La histerectomía mediante el acceso VNOTES fue exitosa, sin complicaciones y con adecuada evolución posquirúrgica. La evidencia actual demuestra que el acceso mediante vNOTES para la histerectomía es un procedimiento eficaz y seguro que combina las ventajas de la vía vaginal con la vía laparoscópica.

Abstract BACKGROUND: vNOTES surgery (Vaginal Natural Orifices Transluminal Endoscopic Surgery), first practiced in 2010, is an emerging surgical technique that eliminates surgical trauma to the abdominal wall by means of natural body orifices for the execution of surgical procedures. Due to the lack of reports with vNOTES in Mexico, we report the case of a patient in whom this access was applied, with good results. CLINICAL CASE: 60-year-old asymptomatic patient referred for definitive treatment of a cervical intraepithelial lesion, because she did not accept the conservative treatment. The hysterectomy was performed by vNOTES access, with a duration of 100 minutes, without setbacks or postoperative complications. At 24 hours she was discharged from the hospital hemodynamically stable and asymptomatic, and without late complications. CONCLUSION: Hysterectomy by VNOTES access was successful, without complications and with adequate postoperative evolution. Current evidence demonstrates that vNOTES access for hysterectomy is an effective and safe procedure that combines the advantages of the vaginal and laparoscopic routes.

La vagina como sitio de extracción y puerto laparoscópico en NOSE y NOTES / The vagina as an extraction site and laparoscopic port in NOSE and NOTES

El objetivo del presente estudio es evaluar nuestra experiencia inicial utilizando la vagina para el retiro de especímenes quirúrgicos o como puerto laparoscópico en intervenciones de cirugía a través de orificios naturales (NOTES). Métodos: Analizamos retrospectivamente los datos de pacientes femeninos, intervenidos en el Instituto Medico La Floresta, Caracas, Venezuela, desde Junio de 2009 a junio de 2015. Dichos pacientes fueron sometidas a intervenciones involucrando resecciones laparoscópicas de órganos sólidos como pancreatectomías distales, esplenectomías y miomectomías uterinas, utilizando la vagina como sitio de extracción. También incluimos pacientes sometidas a apendicectomía transvaginal híbrida NOTES y a colecistectomía transvaginal híbrida. Reportamos el procedimiento técnico, las complicaciones relacionadas con el acceso transvaginal y el seguimiento clínico. Resultados: Cuatro pacientes fueron sometidas a pancreatectomía distal con esplenectomía, siete a esplenectomía laparoscópica, cuatro casos fueron resecciones de masas anexiales y seis miomectomías uterinas. Tres pacientes fueron intervenidas para apendicectomía laparoscópica hibrida transvaginal y cuatro a colecistectomía hibrida trans-vaginal. En todos los casos el espécimen quirúrgico fue retirado a través de la vagina. Todas las pacientes reportaron manchado vaginal mínimo por un máximo de 14 días (media de 8), sangramiento escaso durante el coito por un máximo de 54 días (media de 32) y ninguna paciente reportó dispareunia u otras molestias relacionadas con el acceso vaginal a los seis meses. Conclusiones: El uso de la vagina como sitio de extracción para especímenes quirúrgicos es posible y seguro, incluso en casos de órganos sólidos o especímenes contaminado(AU)

The objective of this study is to evaluate our initial experience, using the vagina, for the removal of surgical specimens, or as a laparoscopic port in surgical interventions through natural orifices "NOTES" or (natural orifice translumenal endoscopic surgery). Methods: We retrospectively analyzed data from female patients operated at the La Floresta Medical Institute in Caracas, Venezuela, from June 2009 to June 2015, who underwent interventions involving laparoscopic resections of solid organs, such as distal pancreatectomies, splenectomies, and uterine myomectomies. Using the vagina as an extraction site. We also included patients undergoing hybrid NOTES trans-vaginal appendectomy and hybrid trans-vaginal cholecystectomy. We report the technical procedure, complications related to trans-vaginal access and clinical follow-up. Results: Four patients underwent distal pancreatectomy with splenectomy, seven underwent laparoscopic splenectomy, four cases were resections of adnexal masses and six were uterine myomectomies. Three patients underwent surgery for trans-vaginal hybrid laparoscopic appendectomy and four for trans-vaginal hybrid cholecystectomy. In all cases, the surgical specimen was removed through the vagina. All patients reported minimal vaginal blood spotting for a maximum of 14 days (average of 8), scarce bleeding during intercourse for a maximum of 54 days (average of 32), and no patient reported dyspareunia or other discomfort related to vaginal access after six months. Conclusions: The use of the vagina as an extraction site for surgical specimens is possible and safe, even in cases of solid organs or contaminated specimens(AU)

Clinical efficacy of vaginal repair for type Ⅱ cesarean scar pregnancy / 局解手术学杂志

Objective To explore the clinical efficacy of vaginal hysterectomy and uterine scar repair in the treatment of type Ⅱ cesare-an scar pregnancy. Methods A total of 157 patients with type Ⅱ cesarean scar pregnancy (CSP) admitted to our obstetrics and gynecology department of our hospital from July 2016 to July 2017 were selected as research subjects. They were divided into ultrasound curettage group (n =87) and vaginal repair group(n =70) according to different surgical methods. The surgical bleeding volume, operative time, hospital stay and human chorionic gonadotropin (β-HCG) level before and after operation,the time of blood β-HCG returning to normal level,hemoglobin (HB) level before and after operation,menstrual recovery time,stress response, inflammatory response and surgical complications were compared between the two groups. Results The intraoperative blood loss volume, operative time and hospital slay in ultrasound curettage group were lower than those in vaginal repair group,the difference was significant(P ＜0.05). The time of blood β-HCG returning to normal level in vaginal repair group after operation was shorter than that in ultrasound curettage group, the difference was significant (P ＜ 0. 05). There was no significant difference in the HB level between the two groups(P＞0.05). The menstrual recovery time in vaginal repair group was shorter than that in ultrasound curettage group,the difference was significant(P ＜0. 05). The levels of postoperative epinephrine (E) and Cortisol (Cor) in vaginal repair group after operation were lower than those in ultrasound curettage group, while the level of thyroid stimulating hormone (TSH) was higher than that in ultrasound curettage group,the difference was significant(P ＜0.05). The levels of IL-2, IL-6 and IL-8 in vaginal repair group after operation were lower than those in ultrasound curettage group while the level of C-reactive protein (CRP) was higher than that in ultrasound curettage group,the difference was significant(P ＜0.05). The incidence rate of postoperative complications in ultrasound curettage group was higher than that in vaginal repair group(P ＜0. 05). Conclusion Vaginal repair is more beneficial to shortern the time of blood β-HCG returning to normal level and menstrual recovery time, promote the inflammatory factor and hormone recovery to a normal level, and reduce the incidence of complication.

Malla para la reparación del prolapso vaginal apical y anterior: resultados subjetivos y complicaciones / Vaginal mesh for repair of apical and anterior vaginal prolapse: subjective outcomes and complications

Resumen Antecedentes: la aplicación de mallas con fijación al ligamento sacroespinoso para corregir el prolapso apical de órganos pélvicos tiene tasas de éxito objetivo de 92%, con 2-12% de eventos adversos. Objetivo: evaluar los resultados clínicos posteriores a la aplicación de la malla UpholdTM en pacientes con prolapso apical, con o sin útero. Materiales y métodos: estudio retrospectivo y descriptivo efectuado en pacientes atendidas en la Clínica de Urología Ginecológica del Instituto Nacionalo de Perinatología Isidro Espinosa de los Reyes entre los meses de noviembre de 2013 a marzo de 2017 con prolapso de órganos pélvicos de la cúpula a quienes se aplicaron mallas que se fijaron al ligamento sacroespinoso. A las pacientes con incontinencia urinaria de esfuerzo se les colocó una cinta mediouretral. Resultados: se estudiaron 22 pacientes de las que 72% (n = 16) tenían histerectomía previa. El estadio del prolapso de órganos pélvicos fue II en 18% (n = 4), III en 41% (n = 9) y IV en 41% (n = 9). El compartimento anterior se encontró afectado en 41% (n = 9) y en 59% (n = 13) el apical. El 54% (n = 12) de las pacientes tenía incontinencia urinaria de esfuerzo. A 9% (n = 2) de las pacientes solo se les colocó la malla UpholdTM, a 45% (n = 10) se les practicó una cirugía concomitante para corrección del prolapso de órganos pélvicos (colpoplastia posterior [n = 5], colpoperineoplastia [ n = 4] y 1 culdoplastia) y para incontinencia urinaria de esfuerzo a 68% (n = 15) se les colocó una cinta mediouretral. El 9% (n = 2) tuvieron lesión vesical, 40% (n = 9) retención urinaria, 4.5% (n = 1) exposición y 4.5% (n = 1) extrusión. El éxito subjetivo y objetivo fue de 100%. Conclusiones: la colocación de la malla Uphold con fines de corrección del prolapso apical tiene buenos resultados, con mínimos efectos adversos. El procedimiento antiincontinencia concomitante incrementa la retención urinaria.

Abstract Introduction: The use of mesh with fixation to sacoespinous ligament (SEL) for correction of pelvic organ prolapse has a success rate of 92% and adverse events are reported in 2-12%. The aim of this study was to evaluate the clinical results after the application of Uphold mesh in women with apical prolapse with or without uterus. Methods: A retrospective and descriptive study, 22 patients with E ≥ II voult pelvic organ prolapse who underwent vault fixation or hysteropexy to SEL and mediourethral tape (CMU) in those with stress urinary incontinence (SUI) from November-2013 to March-2017. Results: 72.7% (n = 16) had previous hysterectomy. The pelvic organ prolapse stage was grade II in 18% (n = 4), III in 41% (n = 9) and IV in 41% (n = 9), the anterior compartment was affected in 40.9% and 59% (n = 13) for apical. 54.5% (n = 12) had SUI. In 9% (n = 2) were placed exclusively Uphold, concomitant surgery was performed for correction of posterior compartment pelvic organ prolapse in 45% (n=10) and at 68% (n = 15) CMU was placed. 9% (n = 2) had bladder injury, 40% (n = 9) urinary retention of patients with CMU application, 4.5% (n = 1) exposure and 4.5% (n = 1) extrusion. Subjective and objective success was 100%. Conclusions: The placement of Uphold has successful results in the correction of apical prolapse. The concomitant anti-incontinence procedure increases the presence of urinary retention.

Analysis of the clinical effect of vaginal ovarian cystectomy on ovarian reserve / 天津医药

Objective To compare the clinical efficacy between the vaginal ovarian cystectomy and the laparoscopic ovarian cystectomy. Methods A total of 104 patients with ovarian cyst hospitalized in our hospital during June 2013-June 2016 were selected and divided into observation group (vaginal ovarian cystectomy, n=55) and control group (laparoscopic ovarian cystectomy, n=49). There were no significant differences in mean age, body mass index (BMI), abdominal surgical history, cyst diameter and cyst type between the two groups. The operation time, blood loss in operation, hospitalization expenses and average hospital stay were observed in the two groups. The ovarian reserve function before and after the operation was also observed. Results The operation time [(46.9±18.4 min)], hospitalization cost [(8165.3±951.8) yuan] and the average length of hospital stay (4.5 ± 1.9 days) were significantly less in the observation group than those of the control group [(62.3 ± 26.5) min], [(12543.9 ± 1464.4) yuan] and [(6.8 ± 2.3) days], (P<0.05). Before the operation, there were no significant differences in estradiol (E2), follicle stimulating hormone (FSH)/luteinizing (LH), FSH and antral follicle count (AFC) between the two groups. After the operation, the values of FSH/LH (1.4±0.4 vs. 1.8±0.6) and FSH [(9.2±2.9) U/L vs. (13.6±4.3) U/L] were significantly decreased in the observation group than those of the control group. The AFC (7.2±1.6 vs. 6.0±1.3) was significantly more in the observation group than that of the control group (P<0.05). Conclusion The vaginal ovarian cystectomy is of little damage to ovarian reserve function, which is suitable for women of child-bearing age and conforms to the requirement of"value medicine".

Analysis of the clinical effect of vaginal ovarian cystectomy on ovarian reserve / 天津医药

Objective To compare the clinical efficacy between the vaginal ovarian cystectomy and the laparoscopic ovarian cystectomy. Methods A total of 104 patients with ovarian cyst hospitalized in our hospital during June 2013-June 2016 were selected and divided into observation group (vaginal ovarian cystectomy, n=55) and control group (laparoscopic ovarian cystectomy, n=49). There were no significant differences in mean age, body mass index (BMI), abdominal surgical history, cyst diameter and cyst type between the two groups. The operation time, blood loss in operation, hospitalization expenses and average hospital stay were observed in the two groups. The ovarian reserve function before and after the operation was also observed. Results The operation time [(46.9±18.4 min)], hospitalization cost [(8165.3±951.8) yuan] and the average length of hospital stay (4.5 ± 1.9 days) were significantly less in the observation group than those of the control group [(62.3 ± 26.5) min], [(12543.9 ± 1464.4) yuan] and [(6.8 ± 2.3) days], (P<0.05). Before the operation, there were no significant differences in estradiol (E2), follicle stimulating hormone (FSH)/luteinizing (LH), FSH and antral follicle count (AFC) between the two groups. After the operation, the values of FSH/LH (1.4±0.4 vs. 1.8±0.6) and FSH [(9.2±2.9) U/L vs. (13.6±4.3) U/L] were significantly decreased in the observation group than those of the control group. The AFC (7.2±1.6 vs. 6.0±1.3) was significantly more in the observation group than that of the control group (P<0.05). Conclusion The vaginal ovarian cystectomy is of little damage to ovarian reserve function, which is suitable for women of child-bearing age and conforms to the requirement of"value medicine".

Esterilización tubaria transvaginal: Experiencia en el Hospital Universitario de Caracas

Objetivo: Evaluar las ventajas de la técnica de esterilización tubaria por vía vaginal en pacientes que acudieron al servicio de Ginecología del Hospital Universitario de Caracas y Ambulatorio del IVSS Patrocino Peñuela Ruíz, de enero a noviembre de 2014. Métodos: Investigación tipo ensayo clínico multicéntrico, en 49 mujeres no puérperas en edad fértil que solicitaron la esterilización quirúrgica. Se realizó la técnica de colpotomía posterior para localizar las trompas y realizar la esterilización. Resultados: La edad promedio fue de 32,5 años. El 80 % tenía de 1 a 3 partos. El 12,2 % tenía una cesárea previa y dos el 16, 3 %. El tiempo promedio de intervención fue de 22,8 minutos y de pérdida sanguínea de 32,5 cm³, sin necesidad de hemoderivados. Las complicaciones intraoperatorias se presentaron en 6 % de los casos, ameritando laparotomía 2 casos. Se pudo demostrar que las adherencias retrasan el tiempo quirúrgico. Según la escala visual análoga (EVA), 53,1 % de las pacientes a las seis horas no tenía dolor y a las 12 horas había disminuido notoriamente en el 85,7 %. Conclusión: La esterilización quirúrgica por colpotomía es beneficiosa porque el tiempo quirúrgico es corto, el sangrado escaso, el dolor leve y las complicaciones bajas.

Objective: To evaluate the advantages of tubal ligation by colpotomy incision in patients who assisted to the Gynecology Unit of University Hospital of Caracas and Patrocino Peñuela Ruíz Hospital form January to November 2014. Methods: Multicentric clinical assay, performed in 49 patients of reproductive age who demanded tubal ligation. Posterior colpotomy was performed to access the Fallopian tubes. Results: Mean age was 32,5 years. Eighty percent had 1 to 3 vaginal deliveries. One previous C section was reported in 12 %, and 2 in 16, 3 %. Mean surgery time was 22,8 minutes, and the mean blood loss 32,5 cc; blood transfusión was not required. Intraoperatory complications were present in 6 % of cases, 2 of them required laparotomy. The presence of adherences was related to longer surgical time. According to the Visual Analogue Scale (VAS), 53,1 % of the patients had no pain 6 hours after the surgery, and pain decreased significantly in 85. 7 % of the patients 12 hours after the procedure. Conclusion: Tubal ligation by colpotomy is highly recommended due to the short surgical time and low rate of complications, blood loss and pain.

Rectal prolapse repair via vaginal route / Reparo do prolapso retal via vaginal

Many elderly patients have concomitant anorectal, urological and gynecological symptoms involving multiple perineal structures, which require the surgeon to operate in different areas of his specialty in order to correct different dystopias in a single procedure. We describe a technique for total rectal prolapse correction offering low surgical risk for patients presenting with this pathology along with pelvic floor defects. We used a simple, minimally invasive technique, which showed complete success in the postoperative follow-up. The patients showed no peri- and post-operative complications and were discharged briefly after the procedure. Although it was a small sample, there was no case of rectal prolapse recurrence with the technique described. With the procedure described here, the treatment of rectal prolapse is possible with concomitant pelvic reconstruction in a single procedure, which is an interesting approach for elderly patients commonly affected by both diseases, as these patients often have other comorbidities that increase the perioperative risk. (AU)

Muitos pacientes idosos possuem concomitância de sintomas anorretais, urológicos e ginecológicos, envolvendo múltiplas estruturas perineais e obrigando o cirurgião a atuar em áreas diversas à sua especialidade para que possa corrigir diferentes distopias em um único procedimento. Descrevemos aqui uma técnica de correção de prolapso total de reto que oferece baixo risco cirúrgico a pacientes que se apresentam com tal patologia juntamente com defeitos do assoalho pélvico. Utilizamos uma técnica simples, minimamente invasiva e que demonstrou sucesso total no acompanhamento pós operatório. Os pacientes não apresentaram intercorrências peri- e pós- operatórias, e tiveram breve tempo de internação hospitalar após o procedimento. Embora em amostra pequena, não obtivemos nenhum caso de recorrência do prolapso retal com a técnica descrita. Com o procedimento aqui descrito, é possível o tratamento do prolapso retal concomitante à correção da distopia genital em um único procedimento sendo tal abordagem interessante na população idosa comumente afetada pelas duas patologias, uma vez que tais pacientes frequentemente apresentam outras comorbidades que aumentam o risco perioperatório. (AU)

Analysis on Operation Selection to Myomectomy of Child-bearing Period (Report of 200 Cases) / 浙江中医药大学学报

[Objective] To compare the clinical cure effects of different operations on myomectomy, and screen out best clinical treatment for hysteromyoma in child-bearing period. [Method] Trace back and analyse 200 cases of such patients, divide them into laparotomy group, laparoscope group, vaginal group and UAE group under different therapies, compare cure effect analysis. [Result] On operation time, operation bleeding and evacuation time, the UAE group ,vaginal and laparoscope groups were successively better than the laparotomy group; but on post-operation medication rate and average in-hospital days, the UAE group was successively less than laparoscope, vaginal and laparotomy groups. On complication rate,the laparoscope was successively less than UAE, vaginal and laparotomy groups.[Conclusion] 4 therapies have respective advantages, UAE and laparoscope myomectomy have little trauma, quick re-covery and reliable cure effect, however, laparotomy can't be completely replaced owing to its wide indications.

Reparación del cistocele por vía vaginal con malla subvesical sin tensión: técnica y resultados / Tension-free vaginal mesh repair for anterior vaginal wall prolapse: technique and outcomes

Objetivos: Determinar la eficacia y tolerancia de la interposición de una malla de polipropileno monofilamento colocada sin tensión por vía vaginal bajo la vejiga para la corrección quirúrgica del cistocele, evaluando sus resultados anatómicos postoperatorios, la mejoría en la calidad de vida y sus complicaciones a mediano plazo. Pacientes y Método: El ensayo incluyó a 28 mujeres consecutivas (edad promedio 64 años), portadoras de cistocele grado II o III según la clasificación POP-Q, quienes fueron intervenidas entre septiembre de 2004 y octubre de 2006. Después de una completa disección de la vejiga y plicatura de la fascia perivesical, se labraron 2 túneles laterales hasta perforar la fascia endopélvica a cada lado; luego se configuró la malla de polipropileno monofilamento (Ginemesh®), dimensionada con un cuerpo central y dos ramas laterales, posicionándola sin tensión ni fijación bajo la vejiga, introduciendo y abandonando sus extensiones laterales hacia el espacio paravesical. Del total de la serie, 8 pacientes tenían cistocele G II (29 por ciento) y 20 tenían prolapso G III (71 por ciento); 11 mujeres presentaban además IOE (39 por ciento). El promedio de duración de la cirugía fue de 30 minutos. Como evaluación del resultado anatómico se utilizó la clasificación POP-Q. Para evaluar la satisfacción personal objetiva se usó el cuestionario validado de calidad de vida (I-QOL) al 3º, 6º y 12º mes post cirugía. El promedio de seguimiento fue de 18 meses (10-36).Resultados: La cirugía fue realizada sin problemas en todas las pacientes. La tasa de complicaciones tempranas fue de 7 por ciento (una erosión vaginal y 1 hematoma severo). No se reportó infección de la malla. La tasa de éxito fue de un 93 por ciento. Al sexto mes, el índice de satisfacción en la calidad de vida fue de 89 por ciento, al 12º mes fue de 86 por ciento...

Objectives: To determine the efficacy and tolerance of the introduction of a vaginal tension-free monofilament polypropylene mesh placed under the bladder for the surgical correction of cystocele. Patients and Methods: The trial included 28 consecutive women mean age 64 years), with diagnosis of grade II - III cystocele based on POP-Q classification, who were operated between September2004 and October 2006. Surgical technique include a complete dissection of the bladder and fixation of perivesical fascia. Two laterals tunnels were developed to pierce the lateral side of the endopelvic fascia at either side. Then a designed monofilament polypropylene mesh (Ginemesh ®), was placed without any tension free the bladder, positioning their lateral extensions into paravesical space. We evaluated the postoperative anatomical results, improvement in the quality of life and mid-terms complications. Results: Of the total series, 8 patients had G II cystocele (29 percent) and 20 had G III prolapse (71 percent ), 11women had also SUI (39 percent). Mean operative time for surgery was 30 minutes. Anatomical results were objectively measured with POP-Q classification. Evaluate of personal satisfaction was done by application of a validated questionnaire of quality of life (I-QOL) that was full filled at 3, 6 and 12months post surgery. Mean follow-up of the series was 18 months (10-36). No operative complication occurred. Early complication rate was 7 percent (a vaginal erosion and severe bruising ). No infection was reported in the mesh. The success rate for the series was 93 percent. At the sixth month, the rate of satisfaction in the quality of life was has been 89 percent and 86 percent at 12 months...