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Natural orifice transluminal endoscopic surgery (NOTES) is currently a very important topic for surgeons. This study aimed to describe the initial clinical experience of transvaginal NOTES for adnexal masses and investigate its feasibility and surgical outcome.
We performed transvaginal NOTES in seven patients with adnexal masses through a 2-cm incision in the posterior vaginal fornix. A transvaginal NOTES system comprising a wound protractor and a surgical glove with sheaths was used. Resection was performed according to the method of standard laparoscopic adnexal surgery. The adnexal mass was removed via the incision of the posterior vaginal fornix after complete resection.
Since June 2011, seven patients have undergone transvaginal NOTES for adnexal masses. All cases were completed successfully without conversion to standard laparoscopic approach. The median age of the patients was 48 years (range, 36–60) and the median body mass index was 23.6 (range, 20.4–25.3). The median tumor size was 6 cm (range, 3.7–6.7). The median operative time was 45 min (range, 40–80). The estimated blood loss was minimal (range, 5–300 mL). The median postoperative hospital stay was 2 days (range, 1–3). No postoperative complications were observed at follow-up. All the patients were very satisfied with the cosmetic result.
The findings show transvaginal NOTES with our method to be a feasible, safe and effective surgical technique that results in excellent cosmesis. It may be an alternative technique for the treatment of properly selected female patients with adnexal masses. More experience and instrumental improvement suitable for transvaginal NOTES are needed.
Natural orifice transluminal endoscopic surgery (NOTES) is a developing field of minimally invasive surgery. The NOTES approach conveys the concept of performing surgical operations within the abdominal or even the thoracic cavities using access achieved via a natural orifice (i.e. mouth, anus, urethra or vagina). In recent years, driven by the desire for less invasiveness, lower morbidity, more rapid convalescence and better cosmesis, surgeons have been devoted to investigating NOTES. NOTES has been attempted worldwide and enhanced tremendously in a short time. It provides numerous potential benefits in terms of postoperative pain, surgery site infections, convalescence, hospital stay, port-site hernia and cosmesis compared with conventional open and laparoscopic procedures. Since Marescaux et al. first performed transvaginal cholecystectomy for a 30-year-old woman, clinical application of NOTES is clearly still in its early development phase.
Natural orifice transluminal endoscopic surgery has numerous limitations, such as a longer operation time due to technical difficulties and a lack of proper equipment. In addition, in regard to closure of the perforation site within the natural orifice, an acceptable closure method is not yet present. The current status of NOTES development seems to select the transvaginal port as the most reliable for human application at this moment.
Transvaginal access has the longest history of use for intraperitoneal procedures, prior to the recent description of NOTES. In 1949, Bueno described a series of transvaginal appendectomies performed with open instruments (without an endoscope) at the time of hysterectomy. Since then, transvaginal access for intraperitoneal procedures in the form of culdoscopy has developed as an accepted, safe procedure in the gynecology community.[4-8] Indeed, transvaginal surgery may be superior to laparoscopic surgery in reducing abdominal wall pain and hernia formation.
Despite its merits, however, the transvaginal approach is still not commonly used. A relatively limited operative field makes the manipulation more difficult and surgeons are more likely to abandon this approach. By contrast, these limitations were easily overcome using laparoscopy. Although a few patients have undergone pure NOTES procedures (without any percutaneous or laparoscopic assistance), most NOTES procedures have been hybrid, using transabdominal assistance with one or more standard laparoscopic ports.
Transvaginal NOTES with our system for adnexal masses was introduced in June 2011. Herein, we describe our experience with transvaginal NOTES for adnexal masses and to evaluate its feasibility and surgical outcome.
Laparoscopic surgery for adnexal masses has been one of the standard laparoscopic procedures performed by Dr Yang since 1997, with the use of four ports. Subsequent to November 2010, embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for gynecological tumors was introduced by Dr Yang. Beginning June 2011, transvaginal NOTES for adnexal masses was performed by the same gynecology surgeon. Before the procedures, all patients were fully informed of the characteristics of transvaginal NOTES and the possibility of requiring conversion to an open procedure or conventional laparoscopic surgery. This study was approved by the Institutional Review Board of Eulji University Hospital.
All transvaginal NOTES procedures have been documented in our database: age, medical history, previous operations, indication, degree of inflammation, operation time, intra- and postoperative complications, amount of analgesic drugs used and patients hemoglobin levels measured on postoperative day 1. Postoperative visual analog scale (VAS) pain score and length of hospital stay were registered. Discharge was planned for the second postoperative day. All patients were examined for postoperative complications such as hematoma formation in the incision site and infection within 2 weeks after surgery in the outpatient department by the operating surgeon. After at least 3 months, patients were evaluated concerning cosmetic satisfaction, dyspareunia and any possible negative experiences. The mean follow-up duration was 8 months (range, 3–13).
We enrolled patients with benign adnexal mass documented using results from ultrasound examinations, who fulfilled inclusion criteria, including history of vaginal delivery, no history of pelvic inflammatory disease, no medical illness, no symptom as well as the size of mass of less than 10 cm. Exclusion criteria included endometriosis and pregnancy. Patients were excluded for inoperable medical conditions, and adnexal mass suspicious of malignancy on ultrasonography or tumor marker elevation. For all women presenting with adnexal masses, a pelvic examination was performed to confirm the absence of nodularity in the cul-de-sac. The presence of a fixed uterus or strong pelvic adhesions was evaluated and, if present, those patients were excluded. The presence of large uteri or myomas was considered a relative contraindication to transvaginal NOTES, and affected patients were excluded from the study.
Patient work-up (history taking including previous surgery, routine preoperative studies including complete blood count, chemistry, electrolyte, prothrombin time/adjusted partial thromboplastin time, electrocardiography, chest radiography, and tumor markers such as carbohydrate antigen 125) was done in all patients.
The patients were given general anesthesia and placed in lithotomy positions and then Trendelenburg positions. A Foley catheter was used to empty the urinary bladder and vaginal retractors were used to expose the operative field. The vaginal mucosa in the posterior vaginal fornix was opened by a 2-cm incision (Fig. 1a), and inserted the wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) into a wound opening transvaginally (Fig. 1b). The extravaginal portion of the wound protractor was rolled up with the wrist portion of a surgical glove (Fig. 1c,d). Three sheaths were inserted through cut edges of distal fingertips and tied with elastic bandage to prevent leakage of carbon dioxide. The supply line of carbon dioxide was also inserted through cut edges of distal fingertips. The last cut edges of distal fingertips functioned as gas outlet or site to extract the specimen. The transvaginal NOTES system, consisting of the wound protractor and a surgical glove, is shown in Figure 1(e). The multiple fingers of the glove functioned as a multiport for laparoscopic instruments, carbon dioxide supply line, gas outlet, site to extract the specimen and a camera (Fig. 1e). Next, carbon dioxide was insufflated to maintain intra-abdominal pressure at 10–12 mmHg, depending on age and condition of the patient. We used a 30°, 10-mm, rigid laparoscope during the study. Once the laparoscope and instruments were in place, the procedure was similar to the procedure performed in E-NOTES (Fig. 1f). The ovarian ligaments and fallopian tube were dissected using a unipolar and bipolar coagulation bovie or a 5–10-mm LigaSure (vessel sealing system, Covidien; Valleylab, Boulder, CO, USA).
All adnexal masses were extracted through the incision site of the posterior vaginal fornix without using laparoscopic endo-bag after complete resection. The adnexal mass was brought into the incision site of the posterior vaginal fornix by grasping the mass with a laparoscopic forceps. The contents of the adnexal mass were then aspirated with a needle or a laparoscopy suction catheter to reduce their volume and permit exteriorization. After all procedures were completed, the opening in the vaginal wall was closed using a 2–0 absorbable suture. For hemostasis, the vagina was packed with sterile paraffin gauze for 24 h.
Table 1 shows the patient characteristics and operative outcomes. Transvaginal NOTES for adnexal masses was successfully completed in seven of seven patients. No intraoperative complication and conversion to conventional laparoscopy occurred. No blood transfusions were required. The median age of the patients was 48 years (range, 36–60) and the median body mass index was 23.6 (range, 20.4–25.3). The median parity of the patients was two (range, 2–3), median number of vaginal delivery was two (range, 0–3) and percentage of previous abdominal surgery was 28.5% (2/7). The median tumor size was 6 cm (range, 3.7–6.7). The median operative time was 45 min (range, 40–80). The estimated blood loss, calculated as difference between the total amount of suction and irrigation, was minimal (range, 5–300 mL). The decline in hemoglobin from before surgery to postoperative day 1 was from 0.8–3 g/dL, with a median of 1.6 g/dL.
Table 1. Patient characteristics and operative outcomes
BMI, body mass index; UO, unilateral oophorectomy; USO, unilateral salpingo-oophorectomy; VAS, visual analog scale.
Carbohydrate antigen 125(U/mL), median(range)
History of vaginal delivery, median (range)
Mass size(cm), median(range)
% of previous abdominal surgery
Operation for adnexal mass
Additional tubal ligation
Other benign cysts
Conversion to conventional laparoscopy
Estimated blood loss(mL), median (range)
Operative time, minutes median (range)
Postoperative hospital stay, median day(range)
Analgesic injection, numbers, median day(range)
Postoperative VAS pain score, median (range)
Pain score at 12 h
Pain score at 24 h
Pain score at 36 h
Vaginal wound infections
The postoperative course was uneventful for all patients. There were no major complications, including rectal injuries. No patients developed a postoperative fever (temperature, ≥38°C). The median postoperative hospital stay was 2 days (range, 1–3). The five patients were discharged on postoperative day 2 because there is a routine postoperative discharge policy in all transvaginal NOTES for adnexal surgery. One patient who underwent additional perineoplasty was discharged on postoperative day 3 after relieved perineal pain. Another one patient who underwent unilateral salpingo-oophorectomy without additional procedures was discharged on postoperative day 1 because of no discomfort. The median VAS pain scores at 12 h after surgery were 3 (range, 2–5). The median VAS pain scores at 24 and 36 h after surgery were 0 (range, 0–2) and 0 (range, 0–0), respectively. In one case with additional perineoplasty, VAS pain scores at 12 and 24 h after surgery were 5 and 2, respectively. VAS pain scores after postoperative day 1 was nearly 0 except the one case with perineoplasty. Analgesics were administrated in the one case with perineoplasty.
The main operative procedure was a unilateral salpingo-oophorectomy (n = 3), a unilateral oophorectomy (n = 3) and parovarian cystectomy (n = 1). Additional surgical procedures included adhesiolysis (n = 2), contralateral tubal ligation (n = 1) and perineoplasty (n = 1). Histological examination of the excised adnexal masses revealed three serous cystadenomas, one parovarian cyst, one follicular cyst and two other benign cysts.
No postoperative complications and vaginal wound infection were observed during follow-up. No patients complained of pain at the site of the vaginal incision during the pelvic examination at the follow-up visit. All patients were satisfied with the cosmetic result.
Until recently, surgical treatment of a benign adnexal mass implied laparoscopic surgery. In recent years, transvaginal approach for the removal of benign adnexal masses[9-11] as well as ultrasound-guided aspiration techniques, have significantly modified the treatment options for selected cases of adnexal masses. The greatest benefit of transvaginal surgery is that it results in no surgical scarring to the abdominal skin. Moreover, a study reported that vaginal removal of cysts resulted in equal operation time, reduced spillage and faster recovery compared with laparoscopy. When performed successfully, the procedure compares favorably with laparoscopic surgery in terms of its invasiveness. Therefore, these advantages make this procedure a valuable addition to a surgeon's repertoire.
Although there is increasing interest in transvaginal surgery, many gynecologists have been reluctant to perform transvaginal surgery because this approach can be difficult for inexperienced surgeons and is occasionally unsuccessful. Moreover, conversion to conventional laparoscopy because of unsuccessful transvaginal approach is not acceptable to patients who are expecting a minimally invasive surgery with no abdominal surgical scars. One randomized study reported that approximately 40% of patients undergoing the vaginal procedure had to be converted to laparotomy, in comparison with approximately 2% undergoing a laparoscopic procedure. A major limitation of the transvaginal approach is limited field of vision. A relatively limited operative field makes the manipulation more difficult and the surgeons are more likely to abandon this approach. Another limitation of the transvaginal approach is adhesions between the adnexal mass and the uterus which may make it impossible to proceed with the resection of the adnexal masses vaginally. Although most cases are treated transvaginally, in cases with severe adhesions or uncontrolled bleeding, the cystectomy must be resumed laparoscopically. Therefore, vaginal ovarian cystectomy, in which ovarian cysts are removed transvaginally, is a procedure practiced by only a handful of gynecologists. The reluctance to convert to laparoscopy and technical difficulties are the major obstacle to vaginal surgery that can be helped by the laparoscopic support. In this study, we introduced the transvaginal NOTES with our system to maximize benefits and minimize drawbacks of transvaginal surgery without any percutaneous or laparoscopic assistance.
Together with robotic surgeries, NOTES is considered to be the next-generation minimally invasive surgery; thus, numerous efforts in this area are being made in many countries. Since Kalloo et al. introduced the transgastric abdominal approach using endoscopy in animal experiments in 2004, NOTES which was reported only in animal experiments, started to be applied to humans in 2007. The Strasburg group performed the hybrid method of a transvaginal endoscopic cholecystectomy using a 5-mm abdominal trocar successfully for the first time. In Korea, Shin et al. performed hybrid transvaginal endoscopic appendectomy using a abdominal trocar in 2010 for the first time. Most NOTES procedures have been hybrid procedures requiring at least one transabdominal port and the most common procedures are cholecystectomy, appendicectomy and mainly performed via transvaginal access. Thus far, pure transvaginal NOTES have been performed in cholecystectomies,[17, 18] appendectomies[19, 20] and nephrectomy. Only a few of the studies reported pure transvaginal NOTES procedures in gynecological surgery. To preserve the minimal invasiveness of the operation, we adopted a new transvaginal NOTES system. In this study, transvaginal NOTES with our system was performed in seven patients with adnexal masses and was successfully and safely completed in all seven patients without conversion to conventional laparoscopy or E-NOTES and morbidity. All adnexal mass was successfully removed without intraperitoneal spillage during transvaginal NOTES.
In approximately 60% of hybrid and pure NOTES procedures, open colpotomy with conventional open instruments was performed. The other frequently used technique was direct trocar insertion through the vaginal wall. These methods of peritoneal access restricted the range of motion of instrument and are unsuitable in cases with adhesions between the ovarian cyst and the uterus. We used a transvaginal NOTES system consisting of the wound protractor and a surgical glove as the transvaginal approach device and put the rigid laparoscope and instruments in place. This new system has two major advantages. First, the vaginal access is used not only as a working port but also for specimen extraction, and the specimen extraction via the incision of the posterior vaginal fornix was very easy and led to good cosmesis. Second, the flexible nature of a surgical glove in the transvaginal NOTES system is effective in reducing interference among instruments, and enabled us to avoid clashing of the instruments and optimize the range of motion of the instruments. In this report, transvaginal NOTES was successfully accomplished in two cases with moderate pelvic adhesion.
In our opinion, transvaginal NOTES with our system is adaptive to women with benign adnexal masses. This study had the limitations of a small sample size. Additional studies with more patients and a longer follow-up period would help in evaluating the safety and efficacy of transvaginal NOTES for the treatment of adnexal masses.
In conclusion, this report shows our experience with transvaginal NOTES for adnexal masses in seven patients. The findings show transvaginal NOTES with our system to be a feasible and effective surgical technique in properly selected female patients with adnexal masses. With the development of technique and instruments, transvaginal NOTES for adnexal masses may be an alternative technique because of its improved cosmetic results. However, a longer follow-up period for a greater number of patients is needed to evaluate the safety and efficacy of transvaginal NOTES for adnexal masses.