阴道自然孔道腔内镜手术革命：妇科微创手术的下一个前沿

尽管指南断言良性子宫切除术的阴道途径是最微创的方法，但阴道子宫切除术的比率在美国仍然很低。 阴道自然孔道腔内镜手术 (vNOTES) 可能会逆转这一趋势。 与传统的腹腔镜和机器人方法相比，vNOTES 的潜在优势包括可能减少疼痛、减少手术时间、改善美观和降低风险。 重要的是，由于外科医生的因素，vNOTES 可能允许将腹腔镜和机器人路线转换回阴道。

在包括住院和门诊全付费数据库在内的全国子宫切除术数字的最新更新中，赖特和合著者描述了美国过去二十年的一个令人担忧的趋势。良性子宫切除术的总数在 2018 年下降到 452,226 ，两年减少了8%，阴道子宫切除术的数量下降到54,219，同期减少了19%。 在查看因良性适应症而进行的子宫切除术时，只有 12% 的子宫切除术是经阴道进行的； 66% 是通过腹腔镜或机器人完成的。 不幸的是，作者无法确定因盆腔器官脱垂以外的适应症而进行的良性阴道子宫切除术的实际数量和比例（个人交流）。 他们目前正在分析更多数据来回答这个问题，但根据他们的估计和在该领域的经验，怀疑这个百分比非常低。 出于所有实际目的，除了盆腔器官脱垂的情况外，阴道子宫切除术已经绝迹。 尽管包括美国妇产科医师大会 (ACOG) 在内的所有专业妇科外科学会继续断言，在可行的情况下首选经阴道途径进行良性子宫切除术，但目前的实践恰恰相反。

本文旨在描述妇科阴道自然孔腔内镜手术 (vNOTES) 的技术和当前手术情况，并探讨 vNOTES 为何以及如何扭转阴道子宫切除术数量下降的趋势。

阴道自然孔道腔内镜手术革命：妇科微创手术的下一个前沿

图 1。
(A) 经腹多通道商用单点端口 (GelPOINTR Mini)（Applied Medical，Rancho Santa Margarita，CA）置于脐部。 (B) 经腹多通道商用单点端口 (GelPOINT Mini) 放置在脐部，带有一个额外的辅助端口，用于腹腔镜子宫肌瘤切除术设置。  (C) 经腹多通道商用单点端口 (GelPOINTR Mini)（Applied Medical，Rancho Santa Margarita，CA）放置在耻骨上的多端口腹腔镜手术装置中，用于普外科病例。

阴道自然孔道腔内镜手术革命：妇科微创手术的下一个前沿

图 2。
自制双通道单站端口。

阴道自然孔道腔内镜手术革命：妇科微创手术的下一个前沿

图 3。
用于阴道自然孔道腔内镜手术的自制多通道单孔装置。

阴道自然孔道腔内镜手术革命：妇科微创手术的下一个前沿

图 4。
用于阴道自然孔道腔内镜手术（GelPOINTR V-Path）的市售多通道单点端口装置。

参考资料:
1. Wright JD, Huang Y, Li AH, Melamed A, Hershman DL. Nationwide estimates of annual inpatient and outpatient hysterectomies performed in the United States. Obstet Gynecol. 2022;139(3):446–448.  
2. Committee Opinion No. 701 Summary: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2017;129(6):1149–1150.  
3. Moen M, Walter A, Harmanli O, et al.. Considerations to improve the evidence-based use of vaginal hysterectomy in benign gynecology. Obstet Gynecol. 2014;124(3):585–588.  
4. Georgiou AN, Rassweiler J, Herrmann TR, et al.. Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). World J Urol. 2012;30(5):573–580.  
5. Burnett AF, Rojo MO. Vaginal natural orifice transluminal endoscopic surgery for gynecologic and gynecologic oncology procedures. In: Marchand G., editor. Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery. London: Intech Open; 2021. Accessed: May 26, 2022. Available from: https://www.intechopen.com/chapters/76497.
6. Baekelandt J. Total vaginal NOTES hysterectomy: a new approach to hysterectomy. J Minim Invasive Gynecol. 2015;22(6):1088–1094.  
7. Chen YJ, Wang PH, Ocampo EJ, Twu NF, Yen MS, Chao KC. Single-port compared with conventional laparoscopic-assisted vaginal hysterectomy: a randomized controlled trial. Obstet Gynecol. 2011;117(4):906–912.  
8. Greaves N, Nicholson J. Single incision laparoscopic surgery in general surgery: a review. Ann R Coll Surg Engl. 2011;93(6):437–440.   
9. Santos BF, Hungness ES. Natural orifice translumenal endoscopic surgery: progress in humans since white paper. World J Gastroenterol. 2011;17(13):1655–1665.   
10. Aharoni S, Matanes E, Lauterbach R, Mor O, Weiner Z, Lowenstein L. Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse. Eur J Obstet Gynecol Reprod Biol. 2021;260:203–207.  
11. Lowenstein L, Baekelandt J, Paz Y, Lauterbach R, Matanes E. Transvaginal natural orifice transluminal endoscopic hysterectomy and apical suspension of the vaginal cuff to the uterosacral ligament. J Minim Invasive Gynecol. 2019;26(6):1015.  
12. Nulens K, Bosteels J, De Rop C, Baekelandt J. vNOTES hysterectomy for large uteri: a retrospective cohort study of 114 patients. J Minim Invasive Gynecol. 2021;28(7):1351–1356.  
13. Kaya C, Yıldız Ş, Alay İ, Aslan Ö, Aydıner İE, Yaşar L. The comparison of surgical outcomes following laparoscopic hysterectomy and vNOTES hysterectomy in obese patients. J Invest Surg. 2022;35(4):862–867.  
14. Nulens K, Kempenaers R, Baekelandt J. Hysterectomy via vaginal natural orifice transluminal endoscopic surgery in virgin patients: a first feasibility study. J Obstet Gynaecol. 2022;42(1):116–121.  
15. Nulens K, Van Genechten I, Baekelandt J. Repeat vaginal natural orifice transluminal endoscopic surgery: a first feasibility study. Gynecol Obstet Invest. 2021;86(1–2):117–122.  
16. Vanhooren E, Baekelandt J. Vaginal NOTES surgery in patients with prior hysterectomy: a first case series. Asian J Endosc Surg. 2021;14(4):811–815.  
17. Guan X, Welch JR, Wu G. Robotic transvaginal natural orifice transluminal endoscopic surgery for resection of parametrial and bowel deeply infiltrated endometriosis. J Minim Invasive Gynecol. 2022;29(3):341–342.  
18. Baekelandt JF. New retroperitoneal transvaginal natural orifice transluminal endoscopic surgery approach to sentinel node for endometrial cancer: a demonstration video. J Minim Invasive Gynecol. 2019;26(7):1231–1232.  
19. Wang Y, Deng L, Tang S, et al.. vNOTES hysterectomy with sentinel lymph node mapping for endometrial cancer: description of technique and perioperative outcomes. J Minim Invasive Gynecol. 2021;28(6):1254–1261.  
20. Alay I, Kaya C, Cengiz H, et al.. Apical pelvic organ prolapse repair via vaginal-assisted natural orifice transluminal endoscopic surgery: initial experience from a tertiary care hospital. Asian J Endosc Surg. 2021;14(3):346–352.  
21. Levy B, Emery L. Randomized trial of suture versus electrosurgical bipolar vessel sealing in vaginal hysterectomy. Obstet Gynecol. 2003;102(1):147–151.  
22. Magos A, Bournas N, Sinha R, Richardson RE, O'Connor H. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol. 1996;103(3):246–251.  
23. Wong WS, Lee TC, Lim CE. Novel vaginal “paper roll” uterine morcellation technique for removal of large (>500 g) uterus. J Minim Invasive Gynecol. 2010;17(3):374–378.  
24. Pelosi MA, Pelosi MA. The Pryor technique of uterine morcellation. Int J Gynaecol Obstet. 1997;58(3):299–303.  
25. Günthert AR, Christmann C, Kostov P, Mueller MD. Safe vaginal uterine morcellation following total laparoscopic hysterectomy. Am J Obstet Gynecol. 2015;212(4):546.e1-4–546.e4.  
26. Wasson M, Magtibay P, Magtibay P, Magrina J. Incidence of occult uterine malignancy following vaginal hysterectomy with morcellation. J Minim Invasive Gynecol. 2017;24(4):665–669.  
27. Kapurubandara S, Lowenstein L, Salvay H, Herijgers A, King J, Baekelandt J. Consensus on safe implementation of vaginal natural orifice transluminal endoscopic surgery (vNOTES). Eur J Obstet Gynecol Reprod Biol. 2021;263:216–222.  
28. Unger CA, Walters MD, Ridgeway B, Jelovsek JE, Barber MD, Paraiso MF. Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse. Am J Obstet Gynecol. 2015;212(5):.e1-7–603.e7.  
29. Houlihan S, Kim-Fine S, Birch C, Tang S, Brennand EA. Uterosacral vault suspension (USLS) at the time of hysterectomy: laparoscopic versus vaginal approach. Int Urogynecol J. 2019;30(4):611–621.  
30. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol. 2000;183(6):1402, discussion 1410-1411.  
31. Yurteri-Kaplan LA, Zhu X, Iglesia CB, et al.. Differences in postural loading between primary and assistant surgeons during vaginal surgery. Int J Ind Ergon. 2018;65:60–67.
32. Catanzarite T, Tan-Kim J, Menefee SA. Ergonomics in gynecologic surgery. Curr Opin Obstet Gynecol. 2018;30(6):432–440.  
33. Baekelandt J, Kapurubandara S. Benign gynaecological procedures by vaginal natural orifice transluminal endoscopic surgery (vNOTES): complication data from a series of 1000 patients. Eur J Obstet Gynecol Reprod Biol. 2021;256:221–224.  
34. Lowenstein L, Mor O, Matanes E, et al.. Robotic vaginal natural orifice transluminal endoscopic hysterectomy for benign indications. J Minim Invasive Gynecol. 2021;28(5):1101–1106.  
35. Lowenstein L, Matanes E, Weiner Z, Baekelandt J. Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy. Eur J Obstet Gynecol Reprod Biol X. 2020;7:100113.   
36. Koythong T, Thigpen B, Sunkara S, Erfani H, Delgado S, Guan X. Surgical outcomes of hysterectomy via robot-assisted versus traditional transvaginal natural orifice Transluminal Endoscopic Surgery. J Minim Invasive Gynecol. 2021;28(12):2028–2035.  
37. Lee CL, Wu KY, Su H, Han CM, Huang CY, Yen CF. Robot-assisted natural orifice transluminal endoscopic surgery for hysterectomy. Taiwan J Obstet Gynecol. 2015;54(6):761–765.  
38. Yang YS. Robotic natural orifice transluminal endoscopic surgery (NOTES) hysterectomy as a scarless and gasless surgery. Surg Endosc. 2020;34(1):492–500.  
39. Guan X, Guan Z, Koythong T, Liu J. Robot-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse. J Minim Invasive Gynecol. 2021;28(6):1141.  
40. Guan X, Guan Z, Koythong T, Liu J, Delgado S, Wang Q. Integration of a robotic platform for sacrocolpopexy in transvaginal natural orifice transluminal endoscopic surgery: a novel surgical technique. Urology. 2021;154:109–114.  
41. Sunkara S, Guan X. Robotic vaginal natural orifice transluminal endoscopic myomectomy. Fertil Steril. 2022;118(2):414–416.  
42. Zhang Y, Delgado S, Liu J, Guan Z, Guan X. Robot-assisted transvaginal natural orifice transluminal endoscopic surgery for management of endometriosis: a pilot study of 33 cases. J Minim Invasive Gynecol. 2021;28(12):2060–2066.  
43. Zorrón R, Filgueiras M, Maggioni LC, Pombo L, Lopes Carvalho G, Lacerda Oliveira A. NOTES. Transvaginal cholecystectomy: report of the first case. Surg Innov. 2007;14(4):279–283.  
44. Bernhardt J, Gerber B, Schober HC, Kähler G, Ludwig K. NOTES–case report of a unidirectional flexible appendectomy. Int J Colorectal Dis. 2008;23(5):547–550.  
45. Ahn KH, Song JY, Kim SH, Lee KW, Kim T. Transvaginal single-port natural orifice transluminal endoscopic surgery for benign uterine adnexal pathologies. J Minim Invasive Gynecol. 2012;19(5):631–635.  
46. Su H, Yen CF, Wu KY, Han CM, Lee CL. Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): feasibility of an innovative approach. Taiwan J Obstet Gynecol. 2012;51(2):217–221.  
47. International NOTES Society. iNOTESs website. Available from: https://www.notesurgery.org/. Accessed: May 25, 2022.
48. Baekelandt JF, De Mulder PA, Le Roy I, et al.. Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery versus laparoscopy as a day-care procedure: a randomised controlled trial. BJOG. 2019;126(1):105–113.  
49. Baekelandt J, De Mulder PA, Le Roy I, et al.. Adnexectomy by vaginal natural orifice transluminal endoscopic surgery versus laparoscopy: results of a first randomised controlled trial (NOTABLE trial). BJOG. 2021;128(11):1782–1791.  
50. Housmans S, Noori N, Kapurubandara S, et al.. Systematic review and meta-analysis on hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) compared to laparoscopic hysterectomy for benign indications. JCM. 2020;9(12):3959.   
51. Walter A,M. Vaginal hysterectomy is safe and cost-efficient, why aren’t more surgeons perfroming it? Newscope. July-Sept 2014. Available at: https://newsscope.aagl.org/print ... e_Jul-Sep_2014.pdf. Accessed: May 25, 2022.
52. Walter AJ. Why do we argue about route of hysterectomy? A call for dialogue. Int Urogynecol J. 2017;28(3):339–340. Epub 2016 Dec 26.  
53. Kovac SR. Decision-directed hysterectomy: a possible approach to improve medical and economic outcomes. Int J Gynaecol Obstet. 2000;71(2):159–169.  
54. Dorsey JH, Steinberg EP, Holtz PM. Clinical indications for hysterectomy route: patient characteristics or physician preference? Am J Obstet Gynecol. 1995;173(5):1452–1460.  
55. Rogo-Gupta LJ, Lewin SN, Kim JH, et al.. The effect of surgeon volume on outcomes and resource use for vaginal hysterectomy. Obstet Gynecol. 2010;116(6):1341–1347.  
56. Jelovsek JE, Walters MD, Korn A, et al.. Establishing cutoff scores on assessments of surgical skills to determine surgical competence. Am J Obstet Gynecol. 2010;203(1):81.e1-6–81.e6.  
57. Antosh DD, Gutman RE, Iglesia CB, Sokol AI, Park AJ. Resident opinions on vaginal hysterectomy training. Female Pelvic Med Reconstr Surg. 2011;17(6):314–317.  
58. Härkki-Siren P, Sjöberg J. Evaluation and the learning curve of the first one hundred laparoscopic hysterectomies. Acta Obstet Gynecol Scand. 1995;74(8):638–641.  
59. Altgassen C, Michels W, Schneider A. Learning laparoscopic-assisted hysterectomy. Obstet Gynecol. 2004;104(2):308–313.  
60. Mäkinen J, Johansson J, Tomás C, et al.. Morbidity of 10 110 hysterectomies by type of approach. Hum Reprod. 2001;16(7):1473–1478.  
61. Bojahr B, Raatz D, Schonleber G, Abri C, Ohlinger R. Perioperative complication rate in 1706 patients after a standardized laparoscopic supracervical hysterectomy technique. J Minim Invasive Gynecol. 2006;13(3):183–189.  
62. Woelk JL, Casiano ER, Weaver AL, Gostout BS, Trabuco EC, Gebhart JB. The learning curve of robotic hysterectomy. Obstet Gynecol. 2013;121(1):87–95.  
63. Orlando MS, Greenberg CC, Pavuluri Quamme SR, Yee A, Faerber AE, King CR. Surgical coaching in obstetrics and gynecology: an evidence-based strategy to elevate surgical education and promote lifelong learning. Am J Obstet Gynecol. 2022;227(1):51–56.