Robotic vaginal natural orifice transluminal endoscopic myomectomy.

OBJECTIVE

To describe a novel, minimally invasive technique for performing myomectomy, a fertility-sparing procedure.

DESIGN

This technique was developed based on similar techniques for other surgeries that showed a benefit. Liu et al. (1) described vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy, in which a 6-cm myoma was resected transvaginally. An anterior colpotomy was made, and single-site surgical skills were used to perform the entire myomectomy without an abdominal incision and with minimal blood loss (1). Another study showed that this technique was also feasible in 8 patients with type 3-7 myomas, and the patients were discharged within a day (2). Robotic vNOTES surgery has been performed for various gynecologic procedures, including hysterectomy, sacrocolpopexy, and the resection of endometriosis (3-6). One study showed that robotic vNOTES was a viable alternative to traditional vNOTES for hysterectomy, with no differences in operative time, the length of hospital stay, postoperative pain levels, or conversions (3). This study in fact proposed that robotic vNOTES was beneficial because of the opportunity to use wristed instruments to increase an otherwise limited range of motion. Another study showed that if surgeons already have significant experience with laparoscopic single-site and abdominal robotic surgeries, only 10 cases of robotic vNOTES and 10-20 port placements with robotic docking are needed to become proficient in robotic vNOTES (7). Another study showed that robotic vNOTES was a safe and feasible approach for the treatment of endometriosis with hysterectomy and the resection of endometriosis, which may be technically challenging because of distorted anatomy or scar tissue due to endometriosis (4). This video demonstrates a robotic vNOTES for myomectomy, a novel, minimally invasive technique for performing myomectomy. Vaginal surgery is the preferred route for hysterectomy compared with other techniques, and this parallel can also be made for other gynecologic procedures, including myomectomy (8). The vaginal approach is preferred for hysterectomy because it is associated with shorter hospital stays and operative time as well as faster recovery. Given these factors, the vaginal approach is preferred over the more traditional umbilical or abdominal laparoscopy. However, visualization and fine movement can be difficult in vaginal surgery, given the lack of space. Robotic techniques in place of traditional or vaginal laparoscopy do not require the surgeon to have a large amount of space to make fine movements because the camera and small robotic instruments are docked close to the tissue. This allows for precision while suturing and performing more layers in the myometrium after myomectomy. This is more difficult to achieve with traditional umbilical laparoscopy and may potentially reduce the risk of uterine rupture in future pregnancies. Given the advantages of the robotic and vaginal approaches, the robotic vNOTES route was pursued for this procedure because it combines the benefits of robotic and vaginal surgeries and can be considered as a feasible alternative to open, vaginal, or laparoscopic techniques.

SETTING

Academic-center hospital.

PATIENT(S): A 28-year-old presented with heavy periods and pelvic pain. Imaging showed a large, 8-cm posterior fibroid, and the patient strongly desired a fertility-sparing approach.

INTERVENTION(S): Robotic vNOTES for myomectomy for the 8-cm posterior uterine fibroid.

MAIN OUTCOME MEASURE(S): Feasibility and safety of using this technique for myomectomy.

RESULT(S): Robotic vNOTES is a feasible option for performing minimally invasive myomectomy. In this technique, a posterior horizontal colpotomy was made and a gel port was placed through the incision. The DaVinci Robot was docked, and myomectomy was performed using single-incision surgical techniques. The uterine serosa was closed with the V-Loc suture, and an interceed adhesion barrier was placed over the incision. The surgeon should take care to notice that the entire surgery is essentially performed "upside down" compared with the traditional abdominal laparoscopic approach. With this change in perspective, the surgeon should have a very good understanding of the vaginal anatomy and the expected location of the uterine artery, ureter, and rectum to avoid any damage to surrounding structures (the uterus) or increased blood loss. The fibroid was morcellated out of the vagina using The Extracorporeal C-Incision Tissue Extraction technique, and the posterior colpotomy was closed (9). The patient was discharged for home on the same day, with minimal blood loss. A prelabor cesarean section was recommended for all future pregnancies to reduce the risk of uterine rupture. The rate of uterine rupture after myomectomy is approximately 0.6% (10). However, the rate of uterine rupture after classical cesarean section is approximately 1%-12% (11). Given that the incision made was similar to the classical incision, except on the posterior uterus, prelabor cesarean section was recommended, although the uterine cavity was not entered.

CONCLUSION(S): In this video, we demonstrate a myomectomy performed using the robotic vNOTES technique. The traditional vNOTES technique for myomectomy has been previously described (1); however, this technique can be very burdensome for suturing and does not allow for precision, and performing multiple layers is challenging. However, the robotic vNOTES approach solves this issue and can allow the surgeon to perform very precise suturing. While choosing the ideal patient for this procedure, the preoperative considerations include the desire for future fertility, the size and location of the fibroid, ideally 1 large posterior fibroid, and adequate space for vaginal port placement. This technique combines the advantages of both vaginal and robotic surgeries while maintaining low blood loss, and patients may be discharged for home on the same day.