How do gynecologists feel about transvaginal NOTES surgery?

Background: Natural-orifice transluminal endoscopic surgery (NOTES) is regarded as safer and less invasive than laparoscopic surgery. However, there has been no documentation of the opinions of surgically active, experienced gynecologists about the indications, contraindications, risks, and complications of transvaginal access.

Methods: A two-page questionnaire was distributed to the heads of the gynecological departments at 181 university and major teaching hospitals across Germany, Austria, and Switzerland. Fifty-two questionnaires (28.7 %) were returned and evaluated. The questionnaire contained ten questions, four of which were yes/no questions and another five of which allowed between four and seven answers. The questionnaire contained one additional open question.

Results: Of the respondents, 69.2 % classified transvaginal access for extrapelvic abdominal surgery as ethical; the remaining 30.8 % described it as experimental. Only 28.8 % would recommend NOTES to their patients if NOTES presented the same surgical risks as the laparoscopic approach. When asked about NOTES-associated complications, 73.1 % mentioned the risk of infection, 61.5 % visceral lesions, 44.2 % infertility, and 34.6 % adhesions. In terms of long-term problems, gynecologists are concerned about dyspareunia and infertility. Adopting their patients’ point of view, 17.3 % voted the lack of scarring compared to laparoscopy as important and 57.6 % as unimportant.

Conclusions: While transvaginal NOTES is argued to be a promising access for scarless surgery, gynecologists mention postoperative infection, visceral lesions, infertility, and adhesions as conceivable complications. Since long-term experience has not yet been achieved, potential problems such as dyspareunia, infertility, and the spread of pre-existing endometriosis remain definitely conceivable complications.

References

• 1 Schwenk W, Haase O, Neudecker J. et al . Short term benefits for laparoscopic colorectal resection.  Cochrane Database Syst Rev. 2005;  CD003145
• 2 Harrell A G, Heniford B T. Minimally invasive abdominal surgery: lux et veritas past, present, and future.  Am J Surg. 2005;  190 239-243
• 3 Merrifield B F, Wagh M S, Thompson C C. Peroral transgastric organ resection: a feasibility study in pigs.  Gastrointest Endosc. 2006;  63 693-697
• 4 Bardaro S J, Swanstrom L. Development of advanced endoscopes for Natural Orifice Transluminal Endoscopic Surgery (NOTES).  Minim Invasive Ther Allied Technol. 2006;  15 378-383
• 5 Baron T H. Natural orifice transluminal endoscopic surgery.  Br J Surg. 2007;  94 1-2
• 6 Scott D J, Tang S J, Fernandez R. et al . Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments.  Surg Endosc. 2007;  21 2308-2316
• 7 Benhidjeb T, Witzel K, Barlehner E, Stark M. The natural orifice surgery concept. Vision and rationale for a paradigm shift [in German].  Chirurg. 2007;  78 537-542
• 8 Thompson C C. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model [response to a letter to the editor].  Gastrointest Endosc. 2007;  66 209-210
• 9 Mintz Y, Horgan S, Cullen J. et al . NOTES: the hybrid technique.  J Laparoendosc Adv Surg Tech A. 2007;  17 402-406
• 10 Rolanda C, Lima E, Pego J M. et al . Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video).  Gastrointest Endosc. 2007;  65 111-117
• 11 Meining A, Wilhelm D, Burian M. et al . Development, standardization and evaluation of NOTES cholecystectomy using a transsigmoid approach in the porcine model.  Endoscopy. 2007;  39 860-864
• 12 Kantsevoy S V, Jagannath S B, Niiyama H. et al . Endoscopic gastrojejunostomy with survival in a porcine model.  Gastrointest Endosc. 2005;  62 287-292
• 13 Pai R D, Fong D G, Bundga M E. et al . Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video).  Gastrointest Endosc. 2006;  64 428-434
• 14 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005.  Surg Endosc. 2006;  20 329-333
• 15 Marescaux J, Dallemagne B, Perretta S. et al . Surgery without scars: report of transluminal cholecystectomy in a human being.  Arch Surg. 2007;  142 823-826
• 16 Bessler M, Stevens P D, Milone L. et al . Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery.  Gastrointest Endosc. 2007;  66 1243-1245
• 17 Zornig C, Emmermann A, von Waldenfels H A. et al . Laparoscopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach.  Endoscopy. 2007;  39 913-915
• 18 Zorron R, Filgueiras M, Maggioni L C. et al . NOTES. Transvaginal cholecystectomy: report of the first case.  Surg Innov. 2007;  14 279-283
• 19 Zorron R, Maggioni L C, Pombo L. et al . NOTES transvaginal cholecystectomy: preliminary clinical application.  Surg Endosc. 2008;  22 542-547
• 20 Diekmann A. Empirische Sozialforschung. Grundlagen, Methoden, Anwendungen. Reinbek; Rowohlt 2007
• 21 Bernhardt J, Gerber B, Schober H C. et al . NOTES-case report of a unidirectional flexible appendectomy.  Int J Colorectal Dis. 2008;  23 547-550
• 22 Palanivelu C, Rajan P S, Rangarajan M. et al . Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES – world’s first report.  Surg Endosc. ;  In press 2008
• 23 Pearl J P, Ponsky J L. Natural orifice transluminal endoscopic surgery: a critical review.  J Gastrointest Surg. ;  In press 2008
• 24 Shibahara H, Shimada K, Kikuchi K. et al . Major complications and outcome of diagnostic and operative transvaginal hydrolaparoscopy.  J Obstet Gynaecol Res. 2007;  33 705-709
• 25 Chang W C, Hsu W C, Sheu B C. et al . Minimizing bladder injury in laparoscopically assisted vaginal hysterectomy among women with previous cesarean sections.  Surg Endosc. 2008;  22 171-176
• 26 Lane E. Culdoscopy – useful or useless?.  Int J Gynaecol Obstet. 1980;  17 372-374
• 27 Heidenreich W. Sterilization by colpoceliotomy [in German].  Fortschr Med. 1983;  101 1855-1859
• 28 Varadarajulu S, Tamhane A, Drelichman E R. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy.  Gastrointest Endosc. 2008;  67 854-860