Transvaginal natural orifice transluminal endoscopic surgery: a new approach to ovarian cystectomy

Objective: To demonstrate a new approach for performing an ovarian cystectomy via transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as an alternative for a laparoscopic ovarian cystectomy. Design: Stepwise explanation of the technique using original video footage. Setting: Hospital. Patient(s): Fourteen patients who provided informed consent and were treated transvaginally to remove a benign ovarian cyst. Intervention(s): The patient was placed in the lithotomy position under general anaesthesia. A 2.5-cm posterior colpotomy was made. The pouch of Douglas was opened and a transvaginal natural orifice transluminal endoscopic surgery (vNOTES) port was inserted transvaginally. A pneumoperitoneum was created, and the ovarian cyst was identified. Conventional endoscopic instruments and a standard endoscope were inserted transvaginally through the vNOTES port. The ovarian cortex was incised over the cyst using cold scissors. The cyst was dissected from the ovarian cortex by a combination of blunt and sharp dissection. Ovarian hemostasis was achieved using bipolar forceps. The ovarian cyst was removed through the colpotomy in an endobag. The vNOTES port was removed, and the colpotomy was sutured using a resorbable suture. The following data were collected: age, body mass index, parity, number of previous abdominal procedures, ovarian cyst diameter, operating time, length of hospital stay, and visual analog scale score. Main Outcome Measure(s): Successful minimally invasive ovarian cystectomy via vNOTES without abdominal scars. Result(s): An ovarian cystectomy was successfully completed in all patients without conversions to standard laparoscopy, and no complications occurred. A fertility sparing cystectomy was performed via vNOTES in all patients; no ovariectomies were performed. All patients were discharged within 30 hours, and nine patients were discharged within 12 hours. Benign ovarian cysts can be treated by vNOTES through a posterior colpotomy via the pouch of Douglas. In a low-resource setting, a self-constructed gloveport and standard reusable endoscopic instruments can be used. In a first-world setting the surgical time can be reduced using a commercially available vNOTES port. Conclusion(s): Transvaginal natural orifice transluminal endoscopic surgery provides a new, less invasive approach for performing an ovarian cystectomy. This first IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study confirms the feasibility of vNOTES ovarian cystectomy although it remains a novel approach that requires further investigation. It can provide improved patient comfort and better cosmetic results. ((C) 2017 by American Society for Reproductive Medicine.)