Clinical Review

2019 Update on minimally invasive gynecologic surgery

OBG Manag. 2019 November;31(11):15-16, 18-20, 28-29

References

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Operative time, post-op stay shorter in NAOC-treated patients

Few studies have compared outcomes with vNOTES to those with traditional laparoscopy. In 2016, Wang and colleagues compared surgical outcomes between NOTES-assisted ovarian cystectomy (NAOC) and laparoscopic ovarian cystectomy (LOC) in a case-matched study that included 277 patients.²⁹ Although mean (SD) blood loss in patients who underwent LOC was significantly less compared with those who underwent NAOC (21.4 [14.7] mL vs 31.6 [24.1] mL; P = .028), absolute blood loss in both groups was deemed minimal. Additionally, mean (SD) operative time and postoperative stay were significantly less in patients undergoing NAOC compared with those having LOC (38.23 [10.19] minutes vs 53.82 [18.61] minutes; P≤.001; and 1.38 [0.55] days vs 1.82 [0.52] days; P≤.001; respectively).²⁹

How vNOTES hysterectomy stacked up against TLH

In 2018, Baekelandt and colleagues compared outcomes between vNOTES hysterectomy and total laparoscopic hysterectomy (TLH) in a noninferiority single-blinded trial of 70 women.⁸ Compared with TLH, vNOTES hysterectomy was associated with shorter operative time (41 vs 75 minutes; P<.001), shorter hospital stay (0.8 vs 1.3 days; P = .004), and lower postoperative analgesic requirement (8 vs 14 U; P = .006). Additionally, there were no differences between the 2 groups in postoperative infection rate, intraoperative complications, or hospital readmissions within 6 weeks.⁸

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Clearly, vNOTES is the next exciting development in minimally invasive surgery, improving patient outcomes and satisfaction with truly scarless surgery. Compared with traditional transvaginal surgery, vNOTES has the advantage of improved visualization with laparoendoscopic guidance, and it may be beneficial even for patients previously thought to have relative contraindications to successful completion of transvaginal surgery, such as nulliparity or a narrow introitus.

Approach for performing vNOTES procedures

At our institution, Baylor College of Medicine, the majority of gynecologic surgeries are performed via either transumbilical robot-assisted single-incision laparoscopy or vNOTES. Preoperative selection of appropriate candidates for vNOTES includes:

low suspicion for or prior diagnosis of endometriosis with obliteration of the posterior cul-de-sac
no surgical history suggestive of severe adhesive disease, and
adequate vaginal sidewall access and sufficient descent for instrumentation for entry into the peritoneal cavity.

In general, a key concept in vNOTES is "vaginal pull, laparoscopic push," which means that the surgeon must pull the cervix while performing vaginal entry and then push the uterus back in the peritoneal cavity to increase surgical space during laparoscopic surgery.

Continue to: Overview of vNOTES steps...