Department of Obstetrics and Gynecology, Imelda Hospital, Bonheiden, Belgium.
Fertil Steril. 2018 Jan;109(1):179. doi: 10.1016/j.fertnstert.2017.09.009. Epub 2017 Nov 9.
To demonstrate a new approach for performing a myomectomy via transvaginal natural-orifice transluminal endoscopic surgery (vNOTES) as an alternative to laparoscopic myomectomy.
Stepwise explanation of the technique with the use of original video footage.
Hospital.
PATIENT(S): Eight patients were treated transvaginally for intramural, subserosal, and pedunculated myomas.
INTERVENTION(S): In case of a posterior myoma, a 2.5-cm posterior colpotomy was made under general anesthesia. The pouch of Douglas was opened and a vNOTES port was inserted transvaginally. In case of an anterior myoma, an anterior colpotomy was made and the peritoneum was opened between the uterus and the bladder. A vNOTES port was inserted transvaginally. A pneumoperitoneum was created and the myoma was identified. With the use of conventional endoscopic instruments and a standard endoscope, all inserted through the vNOTES port, the uterine serosa was incised over the myoma and the myoma was resected. After achieving hemostasis the uterine scar was sutured in two layers with the use of a standard absorbable suture or an autolocking suture. An adhesion-preventing barrier was applied over the uterine scar. The myoma was removed through the colpotomy in an endobag. The vNOTES port was removed and the colpotomy was sutured with the use of an absorbable suture. The following data were collected: age, body mass index, number of previous abdominal procedures, myoma size, myoma weight, operating time, length of hospital stay, visual analog scale pain score, and serum hemoglobin drop.
MAIN OUTCOME MEASURE(S): Successful minimally invasive myomectomy via vNOTES without abdominal scars.
RESULT(S): All fibroids were successfully removed via vNOTES without complications or conversions to standard laparoscopy. No peri- or postoperative complications occurred. All patients were discharged within 24 hours, two of them within 12 hours. Anterior myomas can be resected through an anterior colpotomy and posterior myomas can be resected through a posterior colpotomy via the pouch of Douglas. In a low-resource setting, a self-constructed gloveport can be used and the uterine scar can be sutured via vNOTES with the use of a standard absorbable suture. In a first-world setting, the surgical time can be reduced with the use of an autolocking suture and a commercially available vNOTES port.
CONCLUSION(S): Myoma types 0-2 can be resected hysteroscopically. Myoma types 3-7 are traditionally resected via laparotomy, laparoscopy, or transabdominal robotic surgery. vNOTES provides a new less invasive approach for the resection of myoma types 3-7. This first IDEAL stage 1 study confirms the feasibility of vNOTES myomectomy. It remains, however, a novel approach that requires further investigation. It can provide better cosmetic results and improved patient comfort.
展示一种通过经阴道自然腔道内镜手术（vNOTES）进行子宫肌瘤切除术的新方法，作为腹腔镜子宫肌瘤切除术的替代方法。
使用原始视频片段逐步解释技术。
医院。
8 名患者因壁内、浆膜下和有蒂肌瘤接受经阴道治疗。
对于后位肌瘤，在全身麻醉下进行 2.5cm 的后阴道切开术。打开阔韧带囊并经阴道插入 vNOTES 端口。对于前位肌瘤，进行前阴道切开术并在子宫和膀胱之间切开腹膜。经阴道插入 vNOTES 端口。建立气腹并识别肌瘤。使用常规内镜器械和标准内镜，所有器械均通过 vNOTES 端口插入，在肌瘤上方切开子宫浆膜，切除肌瘤。止血后，使用标准可吸收缝线或自动锁定缝线对子宫疤痕进行双层缝合。在子宫疤痕上应用防粘连屏障。将肌瘤通过阴道切开术放入内袋中取出。vNOTES 端口移除，阴道切开术用可吸收缝线缝合。收集以下数据：年龄、体重指数、既往腹部手术次数、肌瘤大小、肌瘤重量、手术时间、住院时间、视觉模拟评分疼痛、血清血红蛋白下降。
通过 vNOTES 成功进行无腹部疤痕的微创子宫肌瘤切除术。
所有肌瘤均通过 vNOTES 成功切除，无并发症或转为标准腹腔镜。没有围手术期并发症。所有患者均在 24 小时内出院，其中 2 例在 12 小时内出院。前位肌瘤可通过前阴道切开术切除，后位肌瘤可通过阔韧带囊的后阴道切开术切除。在资源有限的环境中，可以使用自制手套端口，并且可以通过 vNOTES 使用标准可吸收缝线缝合子宫疤痕。在第一世界环境中，可以使用自动锁定缝线和市售的 vNOTES 端口缩短手术时间。
肌瘤类型 0-2 可以通过宫腔镜切除。肌瘤类型 3-7 传统上通过剖腹手术、腹腔镜或经腹机器人手术切除。vNOTES 为肌瘤类型 3-7 的切除提供了一种新的微创方法。这项 IDEAL 阶段 1 研究首次证实了 vNOTES 子宫肌瘤切除术的可行性。然而，它仍然是一种需要进一步研究的新方法。它可以提供更好的美容效果和提高患者舒适度。
