Is single-port laparoscopy or vaginal natural orifice transluminal endoscopic surgery the better option for salpingo-oophorectomy?

AIM: To compare postoperative pain and recovery in patients undergoing oophorectomy with single-port laparoscopic surgery (SPLS) versus vaginal natural orifice transluminal endoscopic surgery (vNOTES). METHOD: Patients who underwent salpingo-oophorectomy with SPLS or vNOTES between 2016 and 2023 were analyzed retrospectively. Oophorectomy was performed based on the presence of an adnexal mass or breast cancer susceptibility gene mutation. RESULTS: Fifty-two patients underwent oophorectomy with SPLS and 35 underwent vNOTES. Although the mean mass size was slightly larger in the SPLS group than in the vNOTES group (8.0 ± 4.1 vs. 6.8 ± 3.3 cm), the difference was not significant. There was no difference in operating times between SPLS and vNOTES. The mean visual analog scale and faces pain scale scores 2 and 6 h postoperatively were lower in the vNOTES group. The mean quality of recovery-40 (QoR-40) score was higher in the vNOTES group (156 ± 14 vs. 148 ± 11; p = 0.009). This analysis identified vNOTES as an independent predictor of a high QoR-40 score. CONCLUSION: The vNOTES group experienced less pain during the early postoperative period than the SPLS group. Although the operating and removal times were similar, the port setup time was longer for the vNOTES group.

TWO-YEAR FOLLOW-UP ON SURGICAL OUTCOMES OF vNOTES HIGH UTEROSACRAL LIGAMENT SUSPENSION FOR THE PROPHYLAXIS AND TREATMENT OF PELVIC ORGAN PROLAPSE: A MULTICENTER PROSPECTIVE COHORT STUDY.

STUDY OBJECTIVE: We aimed to evaluate the medium-term outcomes of high uterosacral ligament suspension (HUSLS) with vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) in patients either suffering from pelvic organ prolapse (POP) or undergoing routine prophylaxis to prevent post-hysterectomy vaginal vault prolapse. DESIGN: Multicenter prospective cohort study SETTING: Three tertiary care hospitals PATIENTS: Patients who received vNOTES-HUSLS between January 1, 2021 and January 1, 2023, were included in the study. INTERVENTIONS: vNOTES-HUSLS MEASUREMENTS AND MAIN RESULTS: The data collected included surgery duration, intraoperative and postoperative complications, postoperative Visual Analog Scores (VAS), and Female Sexual Function Index (FSFI) pain subdomain scores. The changes in prolapse levels were measured using modified POP-Q scores, including the C, Ba, and Bp scores recorded prior to surgery and during the postoperative follow-up examination. Patient satisfaction was assessed using the Patient Global Impression of Improvement (PGI-I) questionnaire. The final analysis included 55 women. Of these, vNOTES-HUSLS was performed in 43 patients (78.2%) to treat apical prolapse, while the remaining 12 patients (21.8%) underwent prophylaxis following hysterectomy to prevent vaginal vault prolapse. The median follow-up period was 23.5 months, with a range of 12-37 months. Ba,C, and Bp points significantly improved in patients who underwent surgery for prolapse (p<0.001). There was no recurrence in the apical compartment following vNOTES-HUSLS for both performed prophylactic and treatment purposes after hysterectomy. Two (3.6%) patients were diagnosed with stage 3 anterior compartment prolapse. The overall vNOTES-HUSLS success rate was 96.4% at approximately two years follow-up. Bladder injury was detected as an intraoperative complication in one patient (1.8%). The overall satisfaction rate was 98.1% at the final follow-up. CONCLUSION: vNOTES-HUSLS was effective in the treatment and prophylaxis of apical prolapse, demonstrating high anatomical success rates. The procedure demonstrated a low complication rate, with intraoperative and postoperative complications each observed in 1.8%(n=1) of patients. SYNOPSIS: The Medium-Term Outcomes of vNOTES High Uterosacral Ligament Suspension.

Comparison of different types of single-port laparoscopic surgery in posterior uterine fibroid resection.

This study aims to objectively assess the effect of three surgical approaches for posterior uterine fibroid resection: transumbilical laparoendoscopic single-site surgery (LESS), vaginal natural orifice transluminal endoscopic surgery (vNOTES) in prone position (vNOTES-P), and vNOTES in the lithotomy position (vNOTES-L). A retrospective analysis was conducted on data pertaining to all patients who underwent vNOTES and LESS for single posterior fibroids at our institution from January 2023 to July 2023. Patients were categorized into three groups based on the surgical approach: vNOTES-P group (n = 30), vNOTES-L group (n = 17), and LESS group (n = 32). Comparative analysis was performed on the demographic characteristics and perioperative outcomes among the three groups of patients. All 79 patients underwent surgery without the need for conversion to laparotomy. There were no statistically significant differences among the LESS group, vNOTES-P group, and vNOTES-L group in terms of operative time, intraoperative blood loss, and perioperative complication rates. In the vNOTES-L group, two patients required conversion to LESS during surgery. Patients had faster return of bowel function (less time to flatus) in the vNOTES group compared to the LESS group (P < 0.05). However, three cases of postoperative infection occurred in the vNOTES group, while none were reported in the LESS group. Compared to LESS, vNOTES demonstrates significant advantages in alleviating postoperative pain, shortening time to passage of flatus, speeding recovery and enhancing cosmetic outcomes. Particularly, vNOTES-P for posterior uterine fibroid resection, as an emerging surgical approach, offers certain advantages in facilitating surgical maneuverability and reducing operative time, rendering it more suitable for posterior uterine fibroid resection.

Tissue Retrieval of Laparoscopically Excised Adnexal Specimens in Gynecologic Surgery: Posterior Culdotomy versus Abdominal Extraction.

OBJECTIVE: The objective of this study is to compare intraoperative and postoperative outcomes in women undergoing removal of adnexal structures by either posterior culdotomy or abdominal extraction. DESIGN: This is a retrospective cohort study conducted via medical record review. Demographic, clinical, and operative variables were abstracted from the medical records. Statistical analysis consisted of descriptive statistics, Fisher's exact tests, Wilcoxon rank sum tests, and multivariable logistic regression models. SETTING: Single academic tertiary care center between 2010 and 2022. PARTICIPANTS: A total of 718 patients were identified and included in our analysis who underwent minimally invasive ovarian cystectomy or oophorectomy. Patients were excluded if they underwent concomitant hysterectomy. INTERVENTIONS: Patients underwent minimally invasive oophorectomy or ovarian cystectomy, and specimens were extracted by either abdominal extraction (AE) or culdotomy extraction (CE). MEASUREMENTS AND MAIN RESULTS: Of the 718 patients who met inclusion criteria, 127 (17.7%) underwent CE, and 591 (82.3%) underwent abdominal extraction. The CE group had longer operative times (113 minutes vs 96 minutes, p <.001) and higher estimated blood loss (25 mL vs 10 mL, p <.001) compared to the abdominal extraction group. There were more malignancies in the CE than the abdominal extraction group (15.7% vs 8.1%, respectively, p <.001). After adjusting for potential confounders, those who underwent CE were more likely to have 2 or more clinic visits (OR 2.89; 95% confidence interval, 1.66-5.03; p <.001) and call or message the clinic (OR 2.08; 95% confidence interval, 1.35-3.20; p <.001). There were no incidences of cuff dehiscence, cuff cellulitis, or pelvic abscess in either group. CONCLUSION: Removal of adnexal specimens via abdominal port site or posterior culdotomy incision is a feasible option for specimen extraction and can be individualized based on patient and surgeon preference and patient factors. Those undergoing CE may require more preoperative counseling due to higher rate of postoperative messages seen in our cohort.

A case control study of vNOTES vs conventional laparoscopic salpingectomy for ectopic pregnancy.

STUDY OBJECTIVE: While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vNOTES is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic salpingectomy for the surgical management of ectopic pregnancy. DESIGN: Case control study SETTING: A London University hospital PATIENTS: Women with ectopic pregnancy unsuitable for medical management who underwent surgical management INTERVENTION: 25 cases of vNOTES vs 25 conventional laparoscopic salpingectomy MEASUREMENTS AND MAIN RESULTS: The mean patient age (29.7±53 vs 31.4±6.7 days), parity (1.2±1.1 vs 1.6±2.1), BMI (26.7±5.3 vs 27.2±5.4 kg/m3), gestation age (8.44±2.1 vs 7.3±1.7 weeks) and ßhCG levels (3725.4±3674.8 vs 4376.5±6493.4 IU/litre) were comparable (p>0.05, t test) between patients having vNOTES vs conventional laparoscopic salpingectomy. While estimated blood loss was similar (218.2±491.7 vs 173.5±138.7 mls)(p>0.001), vNOTES patients had statistically shorter duration of surgery (35.8±14.4 vs 75.8±19.7 mins)(p<0.001, t test) and length of stay (median: 11.5 vs 19.7 hours)(U=72, p<0.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%) and median Visual Analogue Score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0)(U=75, p<0.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8±4.3 vs 17.1±8.2 days)(p<0.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia. CONCLUSION: Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain and more rapid recovery, which help mitigate higher cost incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomised studies are needed.

Early surgical outcomes of 550 consecutive patients treated for benign gynecological conditions by transvaginal natural orifice transluminal endoscopic surgery.

INTRODUCTION: Evidence about intra- and postoperative complication rates related to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for benign gynecological conditions is still limited. We report and analyze data from a large cohort of patients operated in a single institution during 3.5 years. MATERIAL AND METHODS: To evaluate the safety and feasibility of vNOTES for benign gynecological indications, we performed a single-center observational study reporting and analyzing perioperative outcomes of 550 consecutive patients operated between 2020 and 2024. RESULTS: Of the 550 included patients, 365 (66.4%) underwent a vNOTES hysterectomy, 167 (30.4%) a procedure limited to the adnexa, and 18 (3.3%) other interventions, including myomectomy, pelvic adhesiolysis, post-hysterectomy pelvic hematoma drainage, pelvic organ prolapse repair, and appendectomy. The mean age was 49.4 ± 12.2 years, and the mean BMI was 26.2 ± 5.8 kg/m2. The total complication rate was 6.5% (36 cases), of which 2.7% (15 cases) were intraoperative complications and 4.0% (22 cases) were postoperative complications. Patients presented postoperative complications classified as Clavien-Dindo (CD) grade I in 4 cases (0.7%), grade II in 10 cases (1.8%), and grade III in 8 cases (1.5%). We observed no CD grade IV and V complications. Three patients (0.5%) were rehospitalized for postoperative complications management. The conversion rate was 1.6%, with nine cases of conversion to conventional laparoscopy and none to laparotomy. CONCLUSIONS: The application of vNOTES appears safe and feasible for most benign gynecological surgeries. Our study focused on surgical complications and demonstrated a profile similar to those reported in previous studies.

Progress, challenges, and future perspectives of robot-assisted natural orifice specimen extraction surgery for colorectal cancer: a review.

With the continuous advancements in precision medicine and the relentless pursuit of minimally invasive techniques, Natural Orifice Specimen Extraction Surgery (NOSES) has emerged. Compared to traditional surgical methods, NOSES better embodies the principles of minimally invasive surgery, making scar-free operations possible. In recent years, with the progress of science and technology, Robot-Assisted Laparoscopic Surgery has been widely applied in the treatment of colorectal cancer. Robotic surgical systems, with their clear surgical view and high operational precision, have shown significant advantages in the treatment process. To further improve the therapeutic outcomes for colorectal cancer patients, some scholars have attempted to combine robotic technology with NOSES. However, like traditional open surgery or laparoscopic surgery, the use of the robotic platform presents both advantages and limitations. Therefore, this study reviews the current research status, progress, and controversies regarding Robot-Assisted Laparoscopic Natural Orifice Specimen Extraction Surgery for colorectal cancer, aiming to provide clinicians with more options in the diagnosis and treatment of colorectal cancer.

Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) for benign ovarian cysts is safe and feasible in same-day discharge: a retrospective cohort study.

BACKGROUND: Advances in minimally invasive surgery and the development of Enhanced Recovery After Surgery (ERAS) have favored the spread of day-surgery programs. Even though Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) is accepted as an innovative treatment for benign ovarian cysts that is rapidly gaining recognition worldwide, the safety and feasibility of same-day surgery (SDS) have yet to be established. OBJECTIVE: This study aimed to evaluate the safety and feasibility of day surgery compared to inpatient surgery of patients undergoing vNOTES for benign ovarian cysts by determining perioperative outcomes. MATERIALS AND METHODS: The study consisted of 213 patients who underwent vNOTES for ovarian cystectomy at a single institution from January 2020 to November 2022. Based on the hospital stay, patients were classified into the same-day surgery group (SDSG) and the inpatient surgery group (ISG); after data processing and screening considering the balance of the two groups, SDSG has 83 samples(n = 83), and ISG has 113 samples(n = 113). The patient's demographic characteristics and follow-up data were collected during the perioperative period by doctors and nurses for medical tracking and analysis purposes and 1-month postoperatively by doctors in charge of their operation. Independent sample t-tests were performed to verify if there was any major difference between these two groups for continuous data like age, BMI, and cyst diameter, and Pearson's chi-squared tests were used to test whether there was a major difference between these two groups for categorical data like cyst count, abdominal surgery history and whether their cyst is bilateral ovarian cysts or not. The association between exhaust time and postoperative characteristics and the association between levels of pain and postoperative characteristics were further analyzed to unveil the confounding factors contributing to the same-day discharge method's quick recovery nature. RESULTS: Upon performing propensity score matching, 196 patients were finally enrolled in this study for the matched comparison, including 83(42.3%) patients in the SDSG and 113(57.7%) patients in the ISG. There was no statistical difference between the two groups in terms of duration of operation (85.0 ± 41.5 min vs. 80.5 ± 33.5 min), estimated blood loss (27.7 ± 28.0 ml vs. 36.3 ± 33.2 ml), preoperative hemoglobin levels (128.8 ± 13.2 g/L vs. 128.6 ± 14.0 g/L), postoperative hemoglobin difference at 24 h (16.5 ± 15.4 g/L vs. 19.3 ± 9.1 g/L), pelvic adhesions (42 (50.6%) vs. 47 (41.6%)), and postoperative complications (7(8.4%) vs. 4(3.5%)). The SDSG group showed less time of feeding/off-bed/exhaust/urination after surgery, shorter hospitalization duration, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use. Multiple linear regression analysis showed that advancing the time of postoperative off-bed activity and feeding reduced the postoperative exhaust time by 0.34 (95% CI: 0.185-0.496, 0.34 h, p < 0.001) and 0.299(95% CI: 0.158-0.443, 0.229 h, p = 0.036) hours. In addition, Ordinal logistic regression revealed a correlation between pain scores and bilaterality of cyst, increasing about 25.98 times the risk of pain levels when ovarian cysts are bilateral (OR: 26.98, 95% CI: 1.071-679.859, P = 0.045). CONCLUSION: In this pilot study, same-day discharge after vaginal natural orifice transvaginal endoscopic ovarian cystectomy is safe and feasible. The vNOTES for ovarian cystectomy combined with the same-day discharge shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and lower the use incidence of analgesic drugs.

Comparison of laparoscopy and vNOTES in early-stage endometrial cancer.

AIM: To compare the demographic, clinical, surgical, histopathological, and oncological outcomes of vNOTES and conventional laparoscopy (CL)for early-stage endometrial cancer. METHODS: A retrospective study was carried out in the Gynecologic Clinic of a tertiary hospital from January 2019 to November 2020. Patient demographic characteristics, surgical outcomes, histopathological characteristics, visual analog scale (VAS) pain scores at postoperative 6th, 12th, and 24th, intra- and postoperative complications, and follow-up results were noted. RESULTS: A total of 45 patients enrolled, of which 16 underwent CL and 29 were vNOTES. The operative time and decrease in hemoglobin levels were similar for both groups (p = 0.202, p = 0.699). Postoperative hospital stay did not differ between the vNOTES group and the CL group (p = 0.549). VAS pain scores at postoperative 6th, 12th, and 24th h were significantly lower in vNOTES group than in the CL group (p < 0.001). The requirement for additional opioid/narcotic analgesic was lower in the vNOTES group than in the CL group (p = 0.037). CONCLUSION: vNOTES may be a safe and feasible option in early-stage endometrial cancer, having less postoperative pain and less requirement of opioid/narcotic analgesic compared with laparoscopy.

Robotics in interventional endoscopy-evolution and the way forward.

The integration of robotics into gastrointestinal (GI) endoscopy represents a transformative advancement and bears the potential to bridge the gap between traditional limitations by offering unprecedented precision and control in diagnostic and therapeutic procedures. This review explores the historical progression, current applications and future potential of robotic platforms in GI endoscopy. Originally designed for surgical applications, robotic systems have expanded their reach into endoscopy, potentially enhancing procedural accuracy and reducing ergonomic strain on practitioners. Natural Orifice Transluminal Endoscopic Surgery (NOTES) emerged as a promising technique, leveraging natural orifices to perform minimally invasive surgeries. Despite its initial potential, several factors, including limitations of the available instrumentations and lack of reliable closure techniques, hindered its widespread adoption and progress. Conventional endoscopic tools often fall short in terms of triangulation, traction and degrees of freedom, necessitating the adoption of robotic interventions. Over recent decades, robotic endoscopy has significantly evolved, focusing on both diagnostic and complex therapeutic procedures such as endoscopic sub-mucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). Various robotic platforms demonstrate enhanced safety and efficiency in GI procedures. As the field progresses, the emphasis on clinical validation, advanced training and the exploration of new applications remains crucial. Continuous innovation in robotic technology and endoscopic techniques promises to overcome existing limitations, further revolutionizing the management of GI diseases and improving patient outcomes.

Myomectomy: Choosing the Surgical Approach - A Systematic Review.

Myomectomy has evolved from open laparotomy to laparoscopy, hysteroscopy, VNOTES and robotic myomectomy. The surgical approach in doing myomectomy depends on the type and location of the myoma and the surgeon's expertise. Minimally invasive surgery has been the preferred approach due to the benefit of shorter hospital stay, lesser postoperative pain, earlier recovery, minimal blood loss and the cosmetic appearance of the scar. The success of this procedure depends on the incision technique, enucleation, and blood loss prevention by using hemostatic techniques and suturing techniques. Performing myomectomy for a large uterine myoma is a laparoscopic challenge; however, with the use of Lee-Huang point (midpoint between umbilicus and xiphoid) as the primary insertion and camera port, one can easily navigate thru the abdominal cavity in case the uterus is huge obscuring the umbilical port. Laparoscopic Myomectomy can be safely and efficiently performed by experienced laparoscopic surgeons regardless of myoma size, number and location. Removal of large myoma specimen from the abdominal cavity through the laparoscope became a challenge after the use of power morcellator was abandoned. To overcome this problem, the large myoma is placed inside an Endo bag and its edges brought extracorporeally through the port site. The myoma is incised in a C-manner using a scalpel to reduce the size. Myoma can also be removed using in-bag power morcellation. Fertility preservation is the long-term aim of doing myomectomy instead of hysterectomy in the management of leiomyoma aside from alleviating symptoms of abnormal uterine bleeding, urinary frequency and abdominal pain.

vNOTES versus Laparoscopic Uterosacral Ligament Suspension for Apical Pelvic Organ Prolapse: Perioperative and Short-Term Outcomes.

INTRODUCTION AND HYPOTHESIS: Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) is a novel approach in gynecological surgery. This study was aimed at comparing perioperative and short-term postoperative outcomes of vNOTES versus laparoscopic approaches to uterosacral ligament suspension (USLS) for apical pelvic organ prolapse. METHODS: A retrospective cohort study included all women who underwent vNOTES versus laparoscopic USLS at two university-affiliated centers between 2017 and 2023. The relationships between variables were tested using Fisher's exact test or t test, including a sub-analysis comparing hysterectomy and hysteropexy outcomes within the groups. Logistic regression assessed the influence of baseline factors and operative factors on the primary and main secondary outcomes of interest. RESULTS: This study comprised 47 vNOTES and 54 laparoscopic USLS cases (including 11 and 15 hysteropexies respectively). Baseline demographics in the two groups were similar. There were no differences in operative outcomes and no instances of ureteral injury. The vNOTES technique allowed for the use of significantly more sutures per side (2.0 [2.0-4.0] vs 1.0 [1.0-1.0], p = 0.001). Postoperative complications within 6 weeks demonstrated no significant differences. Both groups exhibited comparable rates of baseline subjective POP symptoms (100% vs 96.2%, p = 1.00) which improved significantly at 6 weeks (4.3% vs 11.1%, p = 0.282). At 6 weeks, anatomical success was achieved by significantly more patients with vNOTES (93.5% vs 78.6%, p = 0.042). Baseline and 6-week POP symptoms in the hysterectomy and hysteropexy subgroups were similar. CONCLUSION: Both vNOTES and laparoscopic USLS demonstrated comparable subjective success rates at 6 weeks postoperatively. The vNOTES approach demonstrated improved anatomical success at 6 weeks, but the difference was not significant after adjusting for operative factors.

Simultaneous laparoscopic colectomy and liver metastasectomy with natural orifice specimen extraction: A proof-of-concept study.

Background, Natural orifice specimen extraction (NOSE) via the anus or vagina is an alternative to conventional transabdominal specimen extraction in laparoscopic colorectal cancer surgery. NOSE has been shown to be safe and effective, resulting in decreased postoperative pain, analgesia use, and improved recovery, without oncological compromise. We aimed to demonstrate the feasibility of NOSE for combined colectomy with liver metastasectomy. Methods, From July 2022 to April 2024, all cases of laparoscopic colorectal cancer resection and synchronous liver metastasectomy with NOSE were included in the study. Selection criteria included a maximum specimen diameter of less than 5 cm and patient body mass index of less than 35 kg/m2. Results, Over the 22-month duration, four consecutive patients (two males, two females) underwent combined resection with NOSE. Mean age and BMI were 74.8 (range 63-81) years and 20.9 (range 19.5-22.3) kg/m2 respectively. Patient A and D underwent anterior resection for sigmoid cancer, Patient B underwent D3 right hemicolectomy for cecal cancer, and Patient C underwent subtotal colectomy for synchronous cecal and descending colon cancer. All patients underwent liver metastasectomy at the same sitting. Patient A and D had transanal NOSE while Patients B and C underwent transvaginal NOSE. Mean operative time and blood loss was 416 (range 330-535) minutes and 338 (range 50-500) ml respectively. All patients recovered gastrointestinal function within the first two postoperative days. Infected seroma of the liver bed occurred in one patient requiring percutaneous drainage. The average maximum colon tumor diameter was 2.9 (range 1.3-4.0) cm. All resection margins were clear. Mean duration of follow-up was 7.5 (range 2-12) months. Conclusions, Simultaneous colectomy and liver metastasectomy with NOSE for colorectal cancer is feasible and safe in highly selected patients, resulting in good postoperative outcomes. This proof-of-concept analysis paves the way for larger studies to draw definitive conclusions.

Perioperative outcomes of transvaginal specimen extraction laparoscopic total gastrectomy and conventional laparoscopic-assisted total gastrectomy.

BACKGROUND: Natural orifice specimen extraction surgery (NOSES) has emerged as a promising alternative compared to conventional laparoscopic-assisted total gastrectomy (LATG) for treating gastric cancer (GC). However, evidence regarding the efficacy and safety of NOSES for GC surgery is limited. This study aimed to compare the safety and feasibility, in addition to postoperative complications of NOSES and LATG. AIM: To discuss the postoperative effects of two different surgical methods in patients with GC. METHODS: Dual circular staplers were used in Roux-en-Y digestive tract reconstruction for transvaginal specimen extraction LATG, and its outcomes were compared with LATG in a cohort of 51 GC patients with tumor size ≤ 5 cm. The study was conducted from May 2018 to September 2020, and patients were categorized into the NOSES group (n = 22) and LATG group (n = 29). Perioperative parameters were compared and analyzed, including patient and tumor characteristics, postoperative outcomes, and anastomosis-related complications, postoperative hospital stay, the length of abdominal incision, difference in tumor type, postoperative complications, and postoperative survival. RESULTS: Postoperative exhaust time, operation duration, mean postoperative hospital stay, length of abdominal incision, number of specific staplers used, and Brief Illness Perception Questionnaire score were significant in both groups (P < 0.01). In the NOSES group, the postoperative time to first flatus, mean postoperative hospital stay, and length of abdominal incision were significantly shorter than those in the LATG group. Patients in the NOSES group had faster postoperative recovery, and achieved abdominal minimally invasive incision that met aesthetic requirements. There were no significant differences in gender, age, tumor type, postoperative complications, and postoperative survival between the two groups. CONCLUSION: The application of dual circular staplers in Roux-en-Y digestive tract reconstruction combined with NOSES gastrectomy is safe and convenient. This approach offers better short-term outcomes compared to LATG, while long-term survival rates are comparable to those of conventional laparoscopic surgery.

Learning curve analysis of transvaginal natural orifice transluminal endoscopic surgery in treating ovarian cysts: a retrospective cohort study.

BACKGROUND: Transvaginal Natural Orifice Transluminal Endoscopy (vNOTES) is regarded as a challenging surgical technique to learn but is promising in reducing perioperative pain and significantly improves the cosmetic outcomes. Previous studies on the learning curve analysis of vNOTES mainly focuses on the hysterectomy approach, while the vNOTES ovarian cystectomy's learning curve was merely reported though more frequently performed than vNOTES hysterectomy. Therefore, this study seeks to analyze the learning curve of three surgeons with varying levels of experience in performing endoscopic surgery and vaginal surgeries for the treatment of ovarian cysts using vNOTES. METHODS: A total of 127 patients with ovarian cysts of a variety of pathological types were treated by ovarian vNOTES performed by three surgeons of different levels of endoscopic and transvaginal surgical experience. Each surgeon's learning curve was plotted using the Cumulative Sum method and divided into three or four phases of technique learning at the turning point of the learning curve. The sociodemographic and clinical features of patients in each phase were then compared and factors potentially associated with operation time were also screened. RESULTS: The learning curve was presented in four phases. The operation time (OT) was significantly shorter in phases II (53.66 ± 16.55 min) and IV (54.39 ± 23.45 min) as compared with phases I (68.74 ± 15.85) and III (75.93 ± 30.55) (p < 0.001). More cases of serve pelvic adhesion and endometrioma were assigned in the later phases. The OT of endometriotic cysts had much longer than that of non-endometriotic cysts(62.57 ± 18.64 min vs. 49.88 ± 14.26 min, p = 0.15) The presence of pelvic adhesion [adjusted odds ratio (OR) 7.149 (0.506, 13.792), p = 0.035] and bilateral cyst [adjusted OR 16.996 (2.155, 31.837), p = 0.025], max diameter of cyst[adjusted OR 2.799 (0.174, 5.425), p = 0.037], and individual surgeon [adjusted OR -6.118 (-11.814, -0.423), p = 0.035] were significantly associated with OT. CONCLUSION: There learning curve of ovarian vNOTES has four phases. ovarian vNOTES could be mastered after performing seven, nine, and 16 cases by surgeons #1, 2 and 3 respectively, in gynecologic endoscopic surgeries. TRIAL REGISTRATION: ChiCTR2200059282 (Registered on April 28th, 2022).

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery.

BACKGROUND: At present, laparoscopic cholecystectomy (LC) is the main surgical treatment for gallstones. But, after gallbladder removal, there are many complications. Therefore, it is hoped to remove stones while preserving the function of the gallbladder, and with the development of endoscopic technology, natural orifice transluminal endoscopic surgery came into being. AIM: To compare the quality of life, perioperative indicators, adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery (EGPS) in patients with gallstones. METHODS: Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected. We adopted propensity score matching (1:1) to compare EGPS and LC patients. RESULTS: A total of 662 cases were collected, of which 589 cases underwent LC, and 73 cases underwent EGPS. Propensity score matching was performed, and 40 patients were included in each of the groups. In the EGPS group, except the gastrointestinal defecation (P = 0.603), the total score, physical well-being, mental well-being, and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery (P < 0.05). In the LC group, except the mental well-being, the total score, physical well-being, gastrointestinal digestion, the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery (P < 0.05). When comparing between groups, gastrointestinal defecation had significantly difference (P = 0.002) between the two groups, there was no statistically significant difference in the total postoperative score and the other three subscales. In the surgery duration, hospital stay and cost, LC group were lower than EGPS group. The recurrence factors of gallstones after EGPS were analyzed: and recurrence was not correlated with gender, age, body mass index, number of stones, and preoperative score. CONCLUSION: Whether EGPS or LC, it can improve the patient's symptoms, and the EGPS has less impact on the patient's defecation. It needed to, prospective, multicenter, long-term follow-up, large-sample related studies to prove.

Adoption of vaginally assisted natural orifice transluminal endoscopic surgery for hysterectomy: A single tertiary experience.

BACKGROUND: Vaginal hysterectomy (VH) rate is declining despite being considered as the optimal minimally invasive option for hysterectomy with reduced operative time and length of stay compared with laparoscopic hysterectomy (LH). Vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy (VANH) combines the advantages of both vaginal and endoscopic approach to surgery. AIMS: To report feasibility and early experience of a single surgeon adopting VANH at a tertiary Australian hospital. MATERIALS AND METHODS: Prospective review of the first 20 VANH cases with complete data set collected retrospectively including patient demographics, indication for surgery and perioperative outcomes. RESULTS: The median age of the first 20 participants was 51.5 years (47-57 years of age) and the median body mass index was 33.5 kg/m2 (27.8-38.3 kg/m2). The predominant indication was complex hyperplasia with atypia (12/20, 60%). The median parity was two (1-3) where four patients were nulliparous. The median blood loss was 125 mL (100-200 mL) with an operative time of 149 min (138-198 min) and median weight of the specimen of 181.5 g (66.5-219 g). The mean length of stay was 1.4 days (1-2 days). Five cases had conversion to laparoscopy and the majority (80%) occurred within the first ten cases. CONCLUSIONS: VANH is feasible but there is a learning curve to achieve competence in this technique, which requires adequate training in the early stages of adoption with careful case selection. Until further robust data is available to determine the clinical benefit and safety profile of VANH, patients should be carefully counselled and the decision on mode of hysterectomy be individualised.

Sentinel Lymph Node Mapping by Retroperitoneal vNOTES for Uterus-Confined Malignancies: A Standardized 10-Step Approach.

(1) Background: Sentinel lymph node (SLN) mapping represents an accurate and feasible technique for the surgical staging of endometrial and cervical cancer. This is commonly performed by conventional laparoscopy or robotic-assisted laparoscopy, but in recent years, a new retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach has been described and developed by Jan Baekelandt. This technique provides easy visualization of lymphatic afferent vessels and pelvic lymph nodes, early SLN assessment, and a coherent mapping methodology following the lymphatic flow from caudal to cranial. However, only a few publications have reported it. Following the IDEAL (Idea Development Exploration Assessment Long-term follow-up) framework, research concerning this technique is in Stage 2a, with only small case series as evidence of its feasibility. Its standardized description appears necessary to provide the surgical homogeneity required to move further. (2) Methods: Description of a standardized approach for retroperitoneal pelvic SLN mapping by vNOTES. (3) Results: We describe a 10-step approach to successfully perform retroperitoneal vNOTES SLN mapping, including pre-, intra-, and postoperative management. (4) Conclusions: This IDEAL Stage 2a study could help other surgeons approach this new technique, and it proposes a common methodology necessary for evolving through future IDEAL Stage 2b (multi-center studies) and Stage 3 (randomized controlled trials) studies.

Comparison of transvaginal natural orifice transluminal endoscopic surgery versus conventional surgery for uterosacral ligament suspension in patients who had concomitant vaginal hysterectomy for subtotal uterine prolapse.

INTRODUCTION: The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) versus nonendoscopic USLS in patients with subtotal uterine prolapse who had a concomitant vaginal hysterectomy. METHODS: There were 51 patients who underwent vNOTES USLS, whereas the nonendoscopic conventional USLS group had 49 patients. The information about patient demographics, and perioperative data including the operative duration, blood loss, intraoperative and postoperative complications, and length of postoperative hospital stay were determined from the patients' files. Postoperative follow-up visits were scheduled at the first week and 1 month after surgery. RESULTS: The demographic variables including age, body mass index, menopausal status, and parity were comparable, and no significant differences were found. A total of 90.2% of the patients in the vNOTES group and 69.4% of the patients in the shull group were at menopause (p = .09). Operation time was significantly shorter in the shull group (p < .001), and the hospitalization period (p = .029) was significantly shorter in the vNOTES group. Ba, Bp, and D points and total vaginal length (TVL) were significantly behind the hymenal ring in patients who had vNOTES USLS procedure (p < .001). None of the patients who had intraoperative significant blood loss required transfusion. One patient in the vNOTES and two patients in the shull group had a postoperative cuff hematoma. CONCLUSION: vNOTES USLS has a good safety profile, higher percentage of adnexal surgeries with better improvement on POP-Q points Ba, Bp, D, and TVL compared with classic USLS in patients with subtotal uterine prolapse. Studies evaluating short- and long-term results of vNOTES versus conventional USLS are needed.

Transvaginal versus transabdominal specimen extraction in minimally invasive surgery: a systematic review and meta-analysis.

AIM: Natural orifice specimen extraction (NOSE) is an alternative to conventional transabdominal retrieval. We aimed to compare outcomes following transvaginal specimen extraction (TVSE) and transabdominal specimen extraction (TASE) in minimally invasive abdominal surgery. METHODS: An electronic database search of PubMed, Embase and CENTRAL was performed from inception until March 2023. Comparative studies evaluating TVSE versus TASE in adult female patients were included. Studies involving transanal NOSE, endoluminal surgery, or TVSE with concomitant hysterectomy were excluded. Weighted mean differences (WMD) and odds ratio were estimated for continuous and dichotomous outcomes respectively. Primary outcomes were postoperative day 1 (POD1) pain and length of stay (LOS). Secondary outcomes were operative time, rescue analgesia, morbidity, and cosmesis. A review of sexual, oncological, and technical outcomes was performed. RESULTS: Thirteen studies (2 randomised trials, 11 retrospective cohort studies), involving 1094 patients (TASE 583, TVSE 511), were included in the analysis. Seven studies involved colorectal disease and six assessed gynaecological conditions. TVSE resulted in significantly decreased POD1 pain (WMD 1.08, 95% CI: 0.49, 1.68) and shorter LOS (WMD 1.18 days, 95% CI: 0.14, 2.22), compared to TASE. Operative time was similar between both groups, with fewer patients requiring postoperative rescue analgesia with TVSE. Overall morbidity rates, as well as both wound-related and non-wound related complication rates were better with TVSE, while anastomotic morbidity rates were comparable. Cosmetic scores were higher with TVSE. TVSE did not result in worse sexual or oncological outcomes. CONCLUSION: TVSE may be feasible and beneficial compared to TASE when performed by proficient laparoscopic operators, using appropriate selection criteria. Continued evaluation with prospective studies is warranted.