Initial experience of vNOTES with pneumovaginal endoscopic approach for the fornix opening

Abstract

Purpose: NOTES (natural orifice transluminal endoscopic surgery) is a type of endoscopic surgery using a natural orifice. In the field of gynecology, vaginal NOTES (vNOTES) is performed using the vaginal orifice. vNOTES is less invasive than abdominal surgery and the endoscopic approach enables a magnified field of view, resulting in safe and reliable procedures. By contrast, in cases with a narrow vaginal canal such as nulliparity, vNOTES is not ideal as opening the vaginal fornix under direct vision is difficult. In this report, we describe cases where the vaginal fornix was opened with the pneumovaginal approach and vNOTES was completed.

Methods: Among 112 patients in our hospital who underwent vNOTES between February 2020 and July 2022, the opening of the fornix using the pneumovaginal endoscopic approach was attempted in nine cases. Six patients were nulliparous, one had undergone transvaginal mesh surgery, and two were diagnosed with a narrow vagina. The vaginal fornix was opened using the pneumovaginal endoscopic approach. The GelSeal cap (7 cm) was removed from the vaginal canal, and the Alexis retractor and GelSeal cap were reattached to the vaginal fornix opening window; the procedure was then performed as usual. The median operative time was 105 minutes (62-160 minutes), median pneumovaginal endoscopic approach time was 25 minutes (14-112 minutes), and median blood loss was 30 mL (10-240 mL). Five cases of ovarian cystectomy, two cases of salpingo-oophorectomy, one case of total hysterectomy plus salpingectomy, and one salpingectomy were performed. One patient was converted to a conventional laparoscopic procedure due to pelvic adhesions. In eight cases, intraperitoneal access was achieved without adverse events, and the operation was safely completed.

Conclusion: By opening the vaginal fornix using a pneumovaginal approach, vNOTES could be completed safely in patients with narrow vaginas. Based on these results, the surgical indications and techniques for the use of vNOTES in gynecology should be explored further.