To evaluate surgical outcomes for gynecologic surgery performed by single-incision laparoscopy compared with conventional multi-incision laparoscopy.We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and clinicaltrials.gov through August 2012. We also screened reference lists of retrieved articles and manually searched abstracts from conference proceedings.We included randomized control trials (RCTs) and high-quality observational studies that compared outcomes for single-incision laparoscopy and conventional laparoscopy for gynecologic surgery in patients. Included studies met predefined quality criteria and reported, at minimum, on complications, conversions, and operative time. TABULATION, INTEGRATION, RESULTS: Six RCTs and 15 observational studies met inclusion criteria, with a total of 2,085 patients (899 single-incision laparoscopies and 1,186 conventional laparoscopies). In the pooled analysis, there was no significant difference in the risk of total complications between single-incision laparoscopy and conventional laparoscopy groups (relative risk 1.01, 95% confidence interval [CI] 0.72-1.40; P=.97, random effects model). The meta-analysis was powered to detect a 5% difference in complications (power=0.8, alpha=0.05). Mean operative time for adnexal surgery performed by single-incision laparoscopy was 6.97 minutes longer than conventional laparoscopy (95% CI 0.16-13.77; P=.045; I=47.2; random effects based on three RCTs). There was no significant difference in mean operative time for hysterectomy procedures performed by single-incision laparoscopy (8.29 minutes, 95% CI -5.85 to 22.43; P=.251; I=83.6; random effects based on three RCTs). Clinical outcomes of postoperative pain, change in hemoglobin, length of hospital stay, and scar cosmesis could not be pooled because of paucity of data and lack of uniform reporting.There was no difference in the risk of complications between single-incision laparoscopy and conventional laparoscopy approaches in gynecologic surgery. Studies with imprecise effect sizes suggest that single-incision laparoscopy may have longer operative time for adnexal surgery, but not for hysterectomy. Effects on other surgical outcomes remain uncertain.

The last 30 years have seen a revolution in the provision of minimal access surgery for many conditions, and technological advances are increasing exponentially. Many instruments are superseded by improved versions before the NHS and publicly funded health services can offer widespread coverage. Although we tend to think of minimal access surgery as a modern concept, Parts I and II of this series have shown that there is a 5000-year history to this specialty and our predecessors laid down many principles which still apply today. During the 19th and early 20th centuries, minimal access surgery was driven forward by visionary individuals, often in the face of opposition from colleagues and the medical establishment. However, in the last 30 years, innovation has been driven more in partnerships between healthcare, scientific, financial, educational and charitable organisations. There are far too many individuals involved to detail every contribution here, but this third part of the series will concentrate on some of the important themes in the development of minimal access surgery to its current status.

We present our preliminary experience comparing robotic near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) to 2D laparoscopic white light (WL) and 3D robotic WL illumination, in their ability to visually detect endometriosis lesions during a robotic endometriosis resection procedure in a single center. A total of twenty women were screened and seven of them with symptomatic endometriosis were included in this prospective case series. The mean patient age was 33 years with the mean body mass index being 28.6 kg/m. The NIRF-ICG imaging technique enabled visualization of a statistically significant higher number of lesions compared to that of robotic and laparoscopic WL (13.4 vs 7.4 vs 4.7, p = 0.012). In addition, we explored the extent of quality of life (QoL) measures of these women affected by endometriosis using the validated QoL RAND Short Form Health Survey questionnaire and Numeric Pain Rating Scale. The largest reduction of quality of life was measured for the domains of social functioning (3.28 SD, 95% CI 45.7-61.5, p = 0.0001), physical limitations (3.04 SD, 95% CI 15.1-44.3, p = 0.0002), and physical functioning (3.02 SD, 95% CI 48.7-64.1, p = 0.0002), respectively. There was a significant reduction in the postoperative mean pain score as indicated by the pain rating of 0.57 ± 0.78 (p = 0.0005). We also performed a literature search to review other cases that describe the potential benefits of robotic NIRF-ICG imaging in the visual detection of peritoneal and deep endometriosis. Our study results demonstrate that the ICG fluorescence system may potentially be useful for more complete intraoperative endometriosis lesion detection and excision. Large multicenter trials with larger sample sizes and across surgeons of differing experience levels are needed to investigate the clinical utility, reproducibility and long-term outcomes of the use of this technology for patients with debilitating endometriosis.

To reflect on the complications of transvaginal natural orifice transluminal endoscopic surgery (vNOTES), identify the corresponding risk factors, and provide caution to surgeons when performing this novel surgery.

The advent of transvaginal natural orifice transluminal endoscopic surgery (transvaginal NOTES) aims to minimize surgical trauma and reduce recovery time.Clinical trials comparing transvaginal NOTES and traditional laparoscopy were identified by searching EMBASE, MEDLINE, and Web of Science (from 2004 to March 2018). Major outcomes evaluated were risk of postoperative complications and secondary outcomes were pain on postoperative day (POD) 1, POD2, and POD3, time needed for full recovery, risk of intraoperative complications, the duration of surgery, and hospital stay. The results of the meta-analysis are presented as standardized mean difference (SMD) and risk difference (RD) with 95% confidence intervals (CIs).Thirteen trials with 1340 patients were identified. There were no statistical differences for risk of complications between transvaginal NOTES and traditional laparoscopy (intraoperative complications: RD -0.01, 95% CI -0.03 to 0.01; P = 0.37; postoperative complication: RD -0.02, 95% CI -0.05 to 0.01; P = 0.148). The pain score was lower in transvaginal NOTES on POD1 (SMD: -0.71, 95% CI: -1.30 to -0.11, P = 0.019), on POD2 (SMD -0.41, 95% CI -0.75 to -0.07; P = 0.018), and on POD3 (SMD -0.43, 95% CI -0.63 to -0.23; P < 0.001). Patients in transvaginal NOTES needed much shorter time to fully recover after surgery (SMD -1.36, 95% CI -1.84 to -0.87; P < 0.001). In addition, patients underwent transvaginal NOTES had less pain and shorter time of recovery.It is recommended that patients have cholecystectomy, adnexectomy, and appendectomy using transvaginal NOTES as it is safe and minimally invasive.Copyright © 2019 Elsevier Inc. All rights reserved.

This study aims to objectively assess the effect of three surgical approaches for posterior uterine fibroid resection: transumbilical laparoendoscopic single-site surgery (LESS), vaginal natural orifice transluminal endoscopic surgery (vNOTES) in prone position (vNOTES-P), and vNOTES in the lithotomy position (vNOTES-L). A retrospective analysis was conducted on data pertaining to all patients who underwent vNOTES and LESS for single posterior fibroids at our institution from January 2023 to July 2023. Patients were categorized into three groups based on the surgical approach: vNOTES-P group (n = 30), vNOTES-L group (n = 17), and LESS group (n = 32). Comparative analysis was performed on the demographic characteristics and perioperative outcomes among the three groups of patients. All 79 patients underwent surgery without the need for conversion to laparotomy. There were no statistically significant differences among the LESS group, vNOTES-P group, and vNOTES-L group in terms of operative time, intraoperative blood loss, and perioperative complication rates. In the vNOTES-L group, two patients required conversion to LESS during surgery. Patients had faster return of bowel function (less time to flatus) in the vNOTES group compared to the LESS group (P < 0.05). However, three cases of postoperative infection occurred in the vNOTES group, while none were reported in the LESS group. Compared to LESS, vNOTES demonstrates significant advantages in alleviating postoperative pain, shortening time to passage of flatus, speeding recovery and enhancing cosmetic outcomes. Particularly, vNOTES-P for posterior uterine fibroid resection, as an emerging surgical approach, offers certain advantages in facilitating surgical maneuverability and reducing operative time, rendering it more suitable for posterior uterine fibroid resection.© 2024. The Author(s).

To describe a novel, minimally invasive technique for performing myomectomy, a fertility-sparing procedure.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.Academic-center hospital.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.Robotic vNOTES for myomectomy for the 8-cm posterior uterine fibroid.Feasibility and safety of using this technique for myomectomy.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.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.Copyright © 2022 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.