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Study Objective To describe the surgical techniques and short-term outcomes for 33 cases of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (RvNOTES) to treat endometriosis. Design Retrospective case series study. Setting Academic tertiary care university hospital in Houston, TX. Patients Patients who underwent RvNOTES resection of endometriosis between March 2020 and March 2021. Interventions RvNOTES. Measurements and Main Results A total of 33 cases of patients, with pathology-confirmed endometriosis, who underwent RvNOTES total hysterectomy with resection of endometriosis were included in the study. Thirty-two cases were completed successfully by RvNOTES, and 1 case was converted to robotic transumbilical single-incision laparoscopic surgery plus 1 additional port owing to an obliterated posterior cul-de-sac and upper abdominal wall endometriosis. The average operative time was 141.93 ± 40.22 (85–264) minutes, and the mean estimated blood loss was 52.25 ± 33.82 (25–150) mL. The mean preoperative pain score using the visual analog scale (VAS) score was 8.08 ± 2.39 (2–10). The mean VAS pain score 1 week after surgery was 6.73 ± 2.62 (0–10), which was significantly lower than the preoperative scores (p = .059). The mean VAS pain score in the second and third week after surgery was 4.81 ± 2.42 (0–9) and 2.63 ± 2.36 (0–7) respectively, which were both significantly lower than those before surgery (p = .001). There were 4 postoperative complications: urinary tract infection, pneumonia, headache requiring admission, and conversion disorder. Conclusion RvNOTES is a safe and feasible approach for the treatment of endometriosis, with promising short-term improvements in pain.

Study Objective The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients. Design A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus. Setting The surgeries were performed in a single institution between January 2015 and June 2019. Patients The patients were selected if a laparoscopic intervention was indicated. Interventions The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture. Measurements and Main Results Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up. Conclusion LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.

Our main purpose was to describe the surgical technique and short-term outcomes of single-incision laparoscopic sacrocolpopexy (S-LSC) for the treatment of pelvic organ prolapse (POP).This study consisted of a retrospective analysis of 49 consecutive cases.This study was set at the Third Affiliated Hospital of Guangzhou Medical University from October 2016 to November 2017.The population for this study consisted of women with stage II to IV POP who met eligibility criteria for laparoscopic surgery.S-LSC included the use of V-loc barbed suture and retroperitoneal tunneling, in addition to standard single-incision laparoscopic surgery techniques. All 49 cases were successfully completed. All cases included concomitant procedures; 42 (85.7%) had removal of the uterus and adnexa. The main measured outcomes include patient characteristics, perioperative outcomes, and change in pelvic floor support (Pelvic Organ Prolapse Quantification System), and quality of life (Pelvic Floor Impact Questionnaire).All patients were parous, and 42.9% had a history of previous abdominal surgery. The mean operative duration from skin to skin was 201.20 ± 46.53 minutes. The mean estimated blood loss was 27.0 ± 16.6 mL. The mean pre- and post-operative Pelvic Organ Prolapse Quantification System scores were 2.2 ± 1.1 cm versus -2.6 ± 0.5 cm for the Aa point and 3.2 ± 2.8 cm versus -4.6 ± 0.8 cm for the C point (p.05 for both). The mean pre- and post-operative Pelvic Floor Impact Questionnaire scores were 106.4 ± 18.9 versus 8.9 ± 4.26 (p.05), suggesting that S-LSC significantly improved physical prolapse and quality of life. Four patients suffered from postoperative complications (3 mesh exposure and 1 lumbosacral pain). Six patients complained of new onset of stress urinary incontinence.Single-incision laparoscopic sacrocolpopexy is a feasible method to manage POP. However, the long-term effects and complications need to be further investigated.

To demonstrate tips and tricks for the successful execution of robotic-assisted resection of a large bladder trigone endometriosis nodule while preserving the ureters.Stepwise demonstration with narrated video footage.An academic tertiary care hospital. Our patient is a 36-year-old G0P0 with a symptomatic full-thickness ill-defined nodule located in the posterior wall and trigone of the urinary bladder with anterior cul-de-sac endometriosis.Urinary tract endometriosis is a rare entity occurring in 1% of women with endometriosis and may involve the bladder and/or the ureters [1]. Bladder endometriosis (BE) frequently coexists with endometriosis in other locations such as the ovaries or peritoneum. Frequently seen lower urinary tract symptoms of BE include hematuria, frequency, and dysuria [2]. Previous literature has demonstrated the feasibility of a laparoscopic approach to BE in the trigone. However, there has yet to be any publications investigating the feasibility of robotic resection of bladder trigone endometriosis [3]. Cystoscopy was first performed, and the large mid-trigonal endometriosis nodule was noted to be extending within millimeters of the ureteral orifices. Bilateral ureteral orifices were identified, and double-J ureteral stents were sequentially guided up to the kidneys. The peritoneum lateral to the bladder bilaterally was incised to better define the edges of the bladder. Next, bilateral distal ureters were dissected out circumferentially, and the dissection was carried distally to the posterior bladder wall. Flexible cystoscopy with Firefly technology was then utilized to define the precise location and extent of the trigonal nodule to minimize removal of uninvolved bladder tissue and preserve the ureters. Using cystoscopic guidance, the dissection was first carried through the serosal and muscular layers, and once the circumference of the nodule had been clearly defined, we proceeded with the mucosal layer. The bladder lumen was entered, and the nodule was meticulously excised to avoid injury to the intramural ureters as the dissection was carried distally. We were able to preserve bilateral ureters despite the close proximity to ureteral orifices and also maintain enough bladder tissue for bladder closure. Once the resection of the trigonal nodule was completed, running 3-0 V-loc sutures were utilized in a 2-layer closure. The patient was discharged in 1 day with a Foley catheter and ureteral stents with reports of minimal pain. A cystogram at 10 days after the surgery was negative for leak, and the Foley catheter was removed. The ureteral stents were subsequently removed at 6 weeks after the surgery, and follow-up renal ultrasound demonstrated no hydronephrosis. Tips and tricks: (1) Utilizing robotic assistance in conjunction with cystoscopy aids the surgeon in precisely defining the boundaries of an endometriosis nodule and ureteral identification. (2) The precise dissection permitted by robotic-assisted surgery leads to greater tissue preservation of the bladder with complete endometriosis resection [4-6]. (3) Three-dimensional visualization provides depth of tissue analysis, which allows the surgeon to delicately dissect several centimeters of intramural ureter in the bladder wall and trigone. (4) Cystoscopy with Firefly technology guidance permits more precise localization compared with white light during dissection of the bladder nodule [7,8]. (5) The articulating instrumentation in the robotic surgical platform enables fine suturing technique [9,10].Robotic-assisted resection of bladder trigone endometriosis with cystoscopic guidance may offer a precise and delicate dissection of large bladder trigone endometriomas, thus possibly providing optimal bladder trigone and ureteral preservation.

To demonstrate tips and tricks for the successful use of single-site laparoscopic surgery for pedunculated myomectomy during pregnancy.Stepwise demonstration with narrated video footage.An academic tertiary care hospital affiliated with Baylor College of Medicine. Our patient is a 39-year-old pregnant G1P0010 with a symptomatic 12-cm degenerating pedunculated myoma refractory to conservative pain management.Recent literature has indicated that most laparotomic myomectomies performed during pregnancy showed overall positive pregnancy outcomes and low complications. This indicates that myomectomy in pregnancy is safe and can be used in cases unresponsive to conservative management [1]. However, cases in literature discussing the single-site techniques for laparoscopic myomectomy during pregnancy have been sparse [2]. Four case series were reviewed; a total of 62 pregnant patients underwent laparoendoscopic single-site surgery without any complications [3-6]. Using laparoscopy in myomectomy compared with laparotomy during pregnancy permits decreased postoperative pain, quicker recovery, and lowered risk of postoperative complications [5,7,8]. Single-site laparoscopic surgery also aids in improved patient cosmesis and can be used for the myoma removal. Literature has demonstrated that single-site laparoscopy is safe and feasible during all stages of pregnancy [3,4]. Nevertheless, this approach may be challenging for inexperienced surgeons owing to the lack of triangulation and crowding of instruments in single-site laparoscopy [5]. At 21 weeks and 3 days pregnancy, our patient underwent single-incision laparoscopic surgery myomectomy. A 2.5-cm skin incision was made at the umbilicus to the abdominal cavity, and a GelPOINT Mini was inserted. Through the laparoscope, we can observe that a 12-cm pedunculated myoma was protruding from the right uterine fundus on a 4-cm stalk. A 0-Vicryl suture was tied around the base of the stalk. The stalk was then cauterized with bipolar energy and transected with the harmonic scalpel, completely detaching the myoma. Subsequently, an Endo Catch bag was placed around the myoma and brought up to the umbilical incision. Using a scalpel, bag-contained morcellation was completed within 22 minutes and the contents removed. As a result, the estimated blood loss was 50 cc and the total operative time was 123 minutes. The extended operating time was caused by slow movements to avoid disrupting the fetus. She had an unremarkable postoperative course, no medications were needed for pain management, and she was discharged home on postoperative day 2. At 38 weeks, she successfully delivered with elective cesarean delivery with no complications. Histopathology showed fragments of leiomyoma with diffuse necrosis. Tips and tricks: 1. Single-site entry technique uses the open Hasson technique, which reduces the risk of injury to the pregnant uterus and dilated surrounding vessels. 2. Through a 2.5-cm incision, the surgeon placed a suture in the myoma stalk because other hemostasis agents such as vasopressin are contraindicated in pregnancy. 3. Owing to difficulties related to single-site surgery, the surgeon should possess extensive expertise in single-site surgery. 4. Manipulation of the uterus should be minimized to reduce the disturbance of the pregnant uterus. 5. V-loc suture allows for faster and simplified uterine incision closure. 6. If the surgeon encounters excessive difficulty during the surgery, a 5-mm accessory port can be placed. 7. During tissue extraction, gentle traction should be used to reduce provoking the pregnant uterus. 8. When transecting the myoma stalk, it is important to leave a stump of more than 1 cm to increase suturing ease and prevent accidental suturing of the uterus.Single-incision laparoscopic surgery myomectomy for pedunculated myoma may be a practical technique in women refractive to conservative management. When performed by an experienced surgeon, the patient may benefit from faster specimen removal and recovery.

To demonstrate stepwise techniques for the successful utilization of the Robotic-assisted transvaginal Natural Orifice Transluminal Endoscopy Surgery (NOTES) technique for safely surgically managing deeply infiltrated endometriosis (DIE).Stepwise demonstration with narrated video footage.An academic tertiary care hospital.A 38-year-old woman-G3P3, who had 1 normal spontaneous vaginal delivery and 1 cesarean delivery for twin pregnancy-with worsening chronic pelvic pain. History of laparoscopic ablation of endometriosis 10 years ago. Magnetic resonance imaging demonstrated adenomyosis, deeply infiltrated endometriosis, and intrapelvic adhesions. Robotic transvaginal NOTES hysterectomy has been demonstrated to be feasible and safe in the surgical management of benign gynecology disease compared with traditional NOTES hysterectomy; however, it can be technically challenging to perform, particularly in managing of additional deep infiltrated endometriosis removal surgery after hysterectomy. The researchers demonstrated that robotic vaginal NOTES surgeries are feasible in complex benign gynecologic procedures such as endometriosis and sacrocolpopexy [1-3]. The robotic wristed instruments with 3D visualization, resulting in delicate tissue dissection and easier suturing and knot tying, are beneficial to surgeons for overcoming the cumbersome surgical techniques in transvaginal NOTES complete endometriosis removal [4,5]. Integration of robotic transvaginal single site surgery and resection of DIE is a novel alternative minimally invasive route that is more cosmetic and less painful. The procedure was successfully performed in approximately 200 minutes, with unevenly postoperative recovery. The patient was discharged home the same day. Her pain level was 7 out of 10 in the first week, 5 out of 10 in the second week, and 2 out of 10 in the third week. Pathology confirmed uterine adenomyosis, endometriosis in the right ureteral, right uterine artery pedicle, and rectum with muscular propria involvement.Robotic transvaginal NOTES for deeply invasive endometriosis is challenging but feasible in patients with parametrial and rectal involvement. The advantages of articulating instrumentation and 3D visualization are especially pivotal in complex transvaginal NOTES surgery.

To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green (ICG) under near-infrared fluorescence (NIRF) on the robotic platform.Stepwise demonstration using narrated video footage.An academic tertiary care hospital. A 43 year old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for 2 aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention.In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous ICG has previously been described to assist with resection of endometriosis [1-3]. Alternatively, we describe a technique that allows for easier identification of ureters using ICG injection retrogradely in ureteral stents while visualized under NIRF [4,5].The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3 week postoperative visit, pelvic pain had completely resolved.This case demonstrates the use of intraureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis.

Study Objective To demonstrate stepwise techniques for the successful utilization of the single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. Design Stepwise demonstration with narrated video footage. Setting An academic tertiary care hospital. Patients or Participants The patient is a 69-year-old G2P2002 with a history of SVD x2 who presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap -1). The preoperative vaginal length was measured at 9 cm. Interventions Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomical variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer and effective. Measurements and Main Results The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. Conclusion Robotic-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse.

Study Objective To evaluate the safety and feasibility of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) hysterectomy when compared with traditional vNOTES (T-vNOTES) hysterectomy. Design Retrospective chart review. Setting Academic tertiary setting. Patients Total of 114 patients with benign gynecologic indication for hysterectomy. Interventions T-vNOTES or R-vNOTES hysterectomy performed by a single minimally invasive gynecologic surgeon in the study period. Measurements and Main Results The primary outcome of this study was surgical equivalence, measured principally by total operative time between T-vNOTES and R-vNOTES hysterectomy. Secondary operative outcomes that were measured included estimated blood loss, length of hospital stay, reported postoperative pain levels, and number of conversions. A total of 79 women underwent T-vNOTES hysterectomy, and 35 women underwent R-vNOTES hysterectomy without differences in operative time (p = .37), estimated blood loss (p = .27), length of hospital stay (p = .06), or reported postoperative pain levels at weeks 1, 2, and 3 after surgery (p = .78, p = .36, p = .38, respectively). A total of 6 patients underwent conversion in the T-vNOTES hysterectomy group compared with 0 in the R-vNOTES hysterectomy group; however, this was not statistically significantly different, and there were no conversions to laparotomy. Conclusion R-vNOTES hysterectomy is a feasible approach to surgery when compared with T-vNOTES hysterectomy and warrants further consideration as a skill set in a gynecologic surgeon's toolbox. Wristed instruments may allow surgeons who are inexperienced in single-site laparoscopy to adopt vNOTES more quickly as a new technique when performing hysterectomy through a comparable minimally invasive approach.

Study Objective To demonstrate a novel “in-bag” ovarian cystectomy technique for a large adnexal mass in pregnancy. Design Stepwise demonstration with narrated video. Setting An academic tertiary care hospital. The patient was a 26-year-old woman, gravida 1, para 0, at gestational age of 7 weeks and 3 days who presented to the emergency department with persistent left pelvic pain and was diagnosed with a 16 cm × 10 cm × 12 cm dermoid cyst. She re-presented at gestational age of 16 weeks and 3 days with worsening pelvic pain, and the decision was made to proceed with surgical intervention. Interventions Laparoscopic transumbilical single-site surgery for the surgical management of adnexal masses in pregnancy has been demonstrated to be feasible and safe 1 , 2 , 3 . However, single-site laparoscopic ovarian cystectomy can be very challenging in pregnancy, especially when the need for suturing arises. Exteriorizing the ovary and cyst after intraperitoneal drainage may allow for extracorporeal suturing that is faster and easier; however, it may increase the probability of spillage of cystic contents if it is not performed in a bag, which can then cause peritonitis in cases of dermoid cysts. A combination of in-bag and extracorporeal ovarian cystectomy is a novel alternative minimally invasive approach that is cosmetic, safe, and effective. Several helpful techniques in this novel combination technique include the following: • Creating an umbilical incision of at least 2 cm or one that is large enough for better manipulation of both the surgical bag and adnexal mass. • Tightening the bag appropriately around the infundibulopelvic ligament so that it is not too tight leading to compromised blood supply and tissue necrosis, yet not too loose resulting in leakage of cystic contents. • Ensuring that the infundibulopelvic ligament is stabilized within the surgical bag. • Inserting small-sized wound retractor into the bag for better exposure during cystectomy. • Having a double-suction irrigation setup for large adnexal masses, as demonstrated in this patient, to reduce the spillage of cystic contents. The procedure was successfully performed in approximately 110 minutes, and the fetal heart rate postprocedure was 128 bpm through bedside transabdominal ultrasound. Estimated blood loss was 5 mL, and the patient was discharged the same day with an uneventful 4-week postoperative follow-up. Conclusion Laparoscopic single-site “in-bag” ovarian dermoid cystectomy is feasible, effective, and safe in pregnant patients with a large adnexal mass. This technique results in better stabilization of the ovarian cyst and reduction of cystic content spillage.

Study Objective To demonstrate stepwise techniques for the successful use of the laparoendoscopic single-site surgery (LESS) technique for safely performing pectopexy. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Interventions Patient was a 48-year-old, gravida 2 para 2, having had 2 normal spontaneous vaginal deliveries, with stage III anterior vaginal prolapse and stage III uterine prolapse and posterior vaginal prolapse. The preoperative vaginal length was 6 cm. Laparoscopic sacrocolpopexy is the current gold standard for pelvic organ prolapse demonstrating a low recurrence rate; however, it can be technically challenging to perform, particularly in women with obesity or in the event of an anatomic variation. The pectineal ligament, also known as Cooper's ligament, is familiar to surgeons and can be used for a tension-free mesh suspension in patients with prolapse. Integration of LESS and pectopexy is a novel alternative, minimally invasive approach that is more cosmetic, simpler, and effective. The key steps in LESS pectopexy include the following: • LESS total laparoscopic hysterectomy with bilateral salpingectomy. • Anterior and posterior vaginal cuff dissection. • Exposure of the iliopectineal ligament (Cooper's ligament). • Tension-free mesh anchoring. • Reperitonealization. Measurements and Main Results The procedure was performed successfully in approximately 80 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion LESS is a feasible technique for pectopexy in patients with pelvic organ prolapse. A LESS pectopexy results in better cosmesis and offers an alternative for patients with challenging pelvic organ prolapse, such as those with obesity.

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal natural orifice transluminal endoscopic surgery (NOTES) technique for performing high uterosacral ligament suspension (HUS). Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Interventions A 58-year-old G2P2, NSVDx2 with stage III anterior vaginal prolapse, stage II uterine prolapse, and posterior vaginal prolapse. The preoperative vaginal length was 7-cm. Transvaginal NOTES is a creative yet difficult approach that averts an abdominal incision while simultaneously providing enhanced visualization in comparison with traditional vaginal surgery [1] . However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and bilateral salpingo-oophorectomy was subsequently performed. The following key techniques were used to perform NOTES-HUS: tagging the sutures for bilateral uterosacral ligament before single-site port placement, identifying the ischial spine and ureters, pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament, grasping and lifting the uterosacral ligament while placing a suture, and giving the suture a tug after placement to confirm the correct location 2 , 3 , 4 . The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 5-cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion Transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. There is an increased cost to using laparoscopically assisted NOTES surgery as well as a risk of pneumoperitoneum. Applying the tips and tricks presented here, such as tagging the uterosacral ligament before port placement and so on, the challenging transvaginal NOTES-HUS technique can be performed efficiently and safely.

Study Objective To describe techniques for resection of a cornual heterotopic pregnancy. Design Demonstration of surgical technique with narrative video footage using two case examples. Setting Academic medical center. Patients or Participants A case of an 8-week cornual heterotopic pregnancy with successful delivery of the intrauterine pregnancy and a case of a cornual ectopic at 10 weeks. Interventions We demonstrate the use of a “purse string” technique using robotic assisted single incision laparoscopy to resect a cornual heterotopic with minimal blood loss using a 2-0 V-lock suture. Additionally, we review this similar technique with traditional single-site laparoscopic surgery. Measurements and Main Results Resection of a cornual heterotopic pregnancy can be successful done using a “purse string” technique. This technique allows for minimal blood loss as well as minimal entry into the myometrium, which allows for minimal manipulation of the concurrent intrauterine pregnancy. Conclusion Resection of cornual heterotopic pregnancy can be done using a “purse-string” surgical technique. This technique allows for minimal blood loss in cases where additional techniques for hemostasis cannot be used, such as injection of vasopressin and uterine artery ligation. We also demonstrate that this technique can be successful completed using either traditional or robotic assisted single incision laparoscopic surgery.

Study Objective To demonstrate a novel “in-bag” ovarian cystectomy technique for a large adnexal mass in pregnancy. Design Stepwise demonstration with narrated video. Setting An academic tertiary care hospital. Patients or Participants The patient is a 26-year-old G1P0 at 7 weeks and 3 days gestation who presented to the ED with persistent left pelvic pain and diagnosed with a 16 × 10 × 12 cm dermoid cyst. She re-presented at 16 weeks and 3 days gestation with worsening pelvic pain and decision was made to proceed with surgical intervention. Interventions Laparoscopic transumbilical single-site surgery for the surgical management of adnexal masses in pregnancy has been demonstrated to be feasible and safe. However, single-site laparoscopic ovarian cystectomy can be very challenging in pregnancy, especially when the need for suturing arises. Exteriorizing the ovary and cyst after intraperitoneal drainage may allow for extracorporeal suturing that is faster and easier; however, it will increase the probability of spillage of cystic contents if it is not performed in a bag, which can then cause peritonitis in cases of dermoid cysts. A combination of in-bag and extracorporeal ovarian cystectomy is a novel alternative minimally invasive approach that is more cosmetic, safer, and effective. Measurements and Main Results The procedure was successfully performed in approximately 110 minutes, and the fetal heart rate post-procedure was 128bpm via bedside transabdominal ultrasound. Estimated blood loss was 5 mL, and the patient was discharged the same day with an uneventful four-week post-op follow-up. Conclusion Laparoscopic single site “in-bag” ovarian dermoid cystectomy is feasible, effective, and safe in pregnant patients with a large adnexal mass. This technique results in better stabilization of the ovarian cyst and reduction of cystic content spillage.

Study Objective To educate surgeons on the advantages of robotic techniques in hysteroscopic-assisted single-site resection of cesarean scar defect. Design A step-by-step video presentation detailing the complete surgical procedure. Setting University Hospital, Baylor College of Medicine, Houston, Texas. Patients The first patient was a 34-year-old G2P2002 who complained of dysmenorrhea and menorrhagia, with an expressed desire for a single-site cesarean scar defect correction. Her surgical history included 2 cesarean deliveries, in 2012 and 2014. The second patient was a 34-year-old G4P3013 who complained of dysmenorrhea and a persistent mucus vaginal discharge, with an expressed desire for a cesarean scar defect correction in anticipation of conception. Her surgical history was notable for 3 previous cesarean deliveries. Neither patient's ultrasound report showed adenomyosis or any other pathologies. Interventions In both patients, hysteroscopic-assisted robotic single-site resection of the cesarean scar defect was performed, using a monopolar hook, wristed needle drivers, cold scissors, and a diagnostic vs operative hysteroscope. Entry was made through the umbilicus with a 15-mm incision and carried down through the subcutaneous tissue until the fascia was grasped and entered using Mayo scissors. The abdomen was inspected. The bladder was carefully disected off of the lower uterine segment and then backfilled to aid identification of the correct plane for dissection. Once the bladder was adequatetly dissected off of the uterus, the suspected defect could be identified. The monopolar hook was used to incise the defect, and the tip of the hysteroscope was placed through the defect to fully delineate it. The edges were trimed with cold scissors (Endoshears) in the first surgery and the monopolar hook in the second surgery. The uterine defect was closed with 2 layers of countinuous running V-Loc suture. The peritonium was closed with an additional V-Loc suture in a running fashion. Finally, hysteroscopy was performed. The closure was noted to be watertight, verifying successful repair of the defect. In the second case, an intercede was placed over the defect to help prevent future adhesive disease. In addition, after consulting with experts in cesarean scar repair, an energy device was recommended, and thus the monopolar hook over cold scissors was used for the second case due to its superior cutting effect. In both cases, the pelvis was inspected, and hemostasis was observed throughout. Measurements and Main Results The 2 cases had similar outcomes, with successful repair of the cesarean scar defect and resolution of the patient's symptoms. The thickness of the residual myometrium in cesarean scar defect was 2.8 mm in the first case and 2.3 mm in the second case. This video is exempt from Institutional Review Board review. In the first case, the surgery was completed in 90 minutes with only 15 mL of blood loss. The patient was discharged home on the day of surgery and denied any postoperative complications at her follow-up appointment. In the second case, the surgery was completed in 85 minutes with only 10 mL of blood loss. The patient was discharged home on the day of surgery. At her follow-up appointment, she had a positive pregnacy test and denied any postoperative complications. When contacted at a later date, she revealed that she was 15 weeks pregant. Conclusion Hysteroscopic-assisted single site resection of a cesarean scar defect is a feasible method for the resection of cesarean scar defect. Use of the robot makes the difficult surgical techniques required for this operation easier and more accessible.

Study Objective To demonstrate stepwise techniques for the successful use of the laparoscopic single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting Academic tertiary care hospital. The patient, aged 69 years gravida 2 para 2-0-0-2 with a history of SVD × 2, presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap −1). The preoperative vaginal length was measured at 9 cm. Interventions Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, the retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomic variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer, and effective. Several helpful techniques in robot-assisted transvaginal single-site include the following: (1)The use of a 30°-angled scope alternating between “facing up” and “facing down” depending on the need for dissection or suturing. (2) The use of 3-dimensional visualization with a robotic camera that can highlight the depth of the surgical anatomy, therefore facilitating easier identification in the dissection of a surgical pedicle. (3) The use of wristed instruments that permit increased articulation and triangulation that are lacking in traditional laparoscopic single-site surgery, allowing for much easier and proficient suturing and knot tying. (4) Integration of the robotic platform that stabilizes the fine motor movement in a surgeon's hands improving the precision of the suturing and knot tying. The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. Conclusion Robot-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse. Patients experience improved cosmesis, decreased postoperative pain, and faster recovery compared with abdominal sacrocolpopexy.

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal NOTES technique for preforming HUS. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Patients or Participants A 58-year-old G2P2, NSVDx2 with Stage III anterior vaginal prolapse, Stage II uterine prolapse & posterior vaginal prolapse. The preoperative vaginal length was 7 cm. Interventions High uterosacral ligament suspension (HUS) is well accepted for apical prolapse due to its advantages of good apical support and simplification of intraperitoneal suture passage. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel minimally invasive approach that avoids an abdominal incision while providing improved visualization, leading to simplified intraperitoneal suture placement. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and BSO was subsequently performed. The following key techniques were utilized to perform NOTES-HUS: ○ Tagging the sutures for bilateral uterosacral ligament before single-site port placement ○ Identifying the ischial spine and ureters ○ Pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament ○ Grasping and lifting uterosacral ligament while placing a suture ○ Giving the suture a tug after placement to confirm the correct location Measurements and Main Results The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion The transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. Applying the tips and tricks presented here, such as tagging uterosacral ligament before port placement, etc., the challenging transvaginal NOTES-HUS can be performed efficiently and safely.

Study Objective To demonstrate the advantages of using transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for both hysteroscopic polypectomy and cervical myomectomy. Design Video presentation of the surgical procedure. Setting University hospital. Patients or Participants A sexually inactive patient with numerous comorbidities presented with irregular vaginal bleeding in the setting of worsening pelvic pain and bladder pressure for three year. Pelvic MRI showed multiple cervical fibroids and an endometrial polyp. Interventions After the patient was anesthetized, a narrow vagina with no visibility of the cervical os was detected. vNOTES hysteroscopic polypectomy and cervical myomectomy were determined to be more appropriate than conventional methods. A GelPOINT mini port was first placed in the vagina, which allowed for entrance into the uterine cavity. A Myosure hysteroscope and laparoscopic tenaculum were inserted through the port, and polyps in the uterine cavity were then removed. After polypectomy, a transverse incision was made on the anterior cervix through the same port for cervical myomectomy. The tenaculum was used to grab the fibroid and a harmonic scalpel was then applied for enucleation. V-loc was used to close the incision and reconstruct the cervical canal. After suturing, hysteroscopy was performed again to confirm normal anatomy. A Foley catheter was placed to prevent cervical stenosis. Measurements and Main Results Complete resection of cervical myoma and uterine polyp were performed, with postoperative relief of symptoms (i.e. bladder pressure). The surgery was 70 mins with Conclusion For patients with cervical polyps and/or myomas who cannot be operated by conventional methods, NOTES hysteroscopy and myomectomy may be an attractive option and lead to less surgical complications, reduced pain, and faster recovery.

Study Objective To demonstrate key techniques that can be utilized in laparoendoscopic single-site surgery (LESS) for removal of an adnexal mass in pregnancy. Design This video demonstrates skills for removal of an adnexal mass in pregnant patients using LESS. If able to be contacted, patients were followed until delivery. Setting All surgeries were performed at an academic hospital. Patients or Participants Three pregnant women who each required removal of an adnexal mass underwent LESS. First, a 30-year-old G1P0 presented with a persistent 7.1 cm simple ovarian cyst concerning for torsion. Second, a 21-year-old G2P0010 had a 17.4 cm benign ovarian mucinous cystadenoma. Third, a 32-year-old G3P2002 presented with a 10.5 cm complex adnexal mass. Interventions LESS was performed in three pregnant women. An adnexal mass can be removed through the single-site umbilical incision with several key techniques that can be applied to enhance and simplify LESS in pregnancy: (1) gauze placement under a simple ovarian cyst to absorb spillage and to isolate the cyst in order to prevent inadvertent injury; (2) use of V-Loc suture to reapproximate the ovarian parenchyma to preserve ovarian function and avoid difficult knot-tying; (3) extracorporeal surgical approach after drainage of cystic contents and delivery of the collapsed ovarian cyst through the incision; and (4) in-bag tissue extraction of concerning ovarian pathology at the incision. Measurements and Main Results Two simple cystectomies were uncomplicated. The third patient had an uncomplicated oophorectomy after intraoperative pathology revealed a stage IIIA germ cell tumor. The first and third patient had full-term uncomplicated vaginal deliveries, and the second was lost to follow-up at 35 weeks. Conclusion LESS in a gravid uterus is technically challenging due to loss of triangulation of instrumentation. Application of the techniques demonstrated in this video can simplify LESS for removal of an adnexal mass in pregnant women with preservation of pregnancy and resolution of symptoms.

Study Objective To demonstrate a novel approach to transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with bilateral salpingectomy using robotic assistance Design Video presentation of the surgical procedure. Setting University hospital. Patients or Participants A 34-year-old G2P1011 with one prior cesarean section and myomectomy complained of dysmenorrhea and chronic pelvic pain and requested for the most minimally invasive form of hysterectomy. Interventions A robotic-assisted transvaginal hysterectomy with bilateral salpingectomy was performed. The surgery began as a conventional transvaginal hysterectomy. An anterior and posterior colpotomy were performed, as which point, a camera was inserted to improve visibility. This allowed for confirmation of suspected adhesions from the patient's surgical history, most notably present in the anterior cul-de-sac between the bladder and uterus. Wristed instruments of the robot, the monopolar scissors and bipolar grasper, were also placed which enabled better navigation in the narrow surgical space. The remainder of the surgery, including the lysis of the dense adhesions, was completed smoothly with robotic assistance. The vaginal cuff was closed with a continuous running v-loc. The pelvis was inspected upon conclusion of the procedure and hemostasis was observed throughout. Measurements and Main Results The surgery was completed in 90 mins without complications. The patient was discharged on the same day. On follow-up, the patient noted that her post-operative pain was significantly less than what she had experienced after her previous myomectomy. Conclusion We showed that robotic-assisted NOTES is a novel and feasible option for transvaginal hysterectomy in indicated patients, particularly those with abnormal pathologies such as dense adhesions. In addition to image-guidance, robotic surgery allows for full articulation of instruments required for this surgery, which improves ease and access over other methods like laparoscopic surgery.

Study Objective To demonstrate the feasibility and advantages in applying the robotic system with additional ports to single-site laparoscopic resection of ureteral endometriosis. Design Video presentation of surgical techniques. Setting University hospital. Patients or Participants Three patients with endometriosis obstructing the ureter(s). Interventions A bipolar grasper, wristed needle drivers, and scissors with monopolar energy were used. Additional ports were inserted due to the complexity of the operation. Entry was made at the umbilicus and carried down into the abdominal cavity, and the pelvis was inspected for endometriosis lesions. The first patient was a 38-year-old G0P0 with an absent right kidney and ureter from a congenital Mullerian fusion defect who complained of one-year duration of pelvic pain. Superficial endometriosis nodules were identified on the left ureter. The lesions were trimmed with cold scissors to avoid thermal damage. The second patient was a 44-year-old G1P1001 who presented with left kidney failure following a longstanding history of chronic pelvic pain and endometriosis with urinary symptoms. Multiple gynecologic procedures were required, including resection of bilateral deep-infiltrating endometriosis lesions, total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, and lysis of adhesions. Structured segments of the left ureter were excised and then left ureteroneocystostomy was carried out. The third patient was a 33-year-old G0P0 with recurrent Stage IV endometriosis who had bilateral ureteral strictures. Bilateral robotic laparoscopic ureterolysis and ureteroneocystostomy were indicated. Notably, for the anastomosis, the bladder was sufficiently mobilized and a Psoas hitch was performed on the right to ensure no tension at the repair site. Measurements and Main Results Final abdominal survey was performed, and hemostasis was ensured. All patients had successful outcomes with minimal blood loss and no known complications to date. Conclusion Robotic-assisted single-site laparoscopy with additional ports is an effective method for ureteral endometriosis removal. A combined effort between gynecology and urology may be needed for highly advanced cases.

STUDY OBJECTIVE To describe the surgical technique and short-term outcomes for 26 cases of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy for the treatment of pelvic organ prolapse (POP). DESIGN Retrospective case series study (Canadian Task Force classification II-2). SETTING Academic tertiary care university hospital in Guangdong, China. PATIENTS Women diagnosed with stages II to IV POP between May 2017 and May 2018. INTERVENTIONS vNOTES sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS A total of 26 patients were identified. vNOTES sacrocolpopexy was standardized after case 4, and 23 cases were completed successfully. Operative duration was a median of 184 minutes (interquartile range, 158.5-202.5), and mean estimated blood loss was 30.87 ± 20.8 mL. Mean pre- and postoperative POP Quantification System scores for the Aa point were, respectively, 1.4 ± 1.7 cm (range, -2 to 3) versus -1.85 ± .6 cm (p

Study Objective To investigate the advantages of using robotic assistance in tubal reanastomosis surgery. Design A narrated instructional video. Setting University Hospital, Baylor College of Medicine, Houston, Texas (Canadian Task Force Classification III). Patient A 33-year-old woman, G2P2003, who regretted her prior tubal ligation; she continued to request for a tubal reversal with a desire to conceive in the near future. A single-site approach was decided on when she expressed concern for the cosmetic aftermath of multiport surgery. Interventions Robotic single-site tubal reanastomosis. Measurements and Main Results We performed robotic single-site tubal reanastomosis on the patient. We used the energy instruments of the monopolar hook and the bipolar slotted grasper. Entry was performed in the umbilicus, after which an abdominal survey was conducted to determine and locate the blocked fallopian tubes. A cold scissor, to avoid additional damage to the tubes, was used to resect the portion of the right blocked tube, and a neonatal feeding tube was inserted though both sections of the tube to ensure proper alignment during the repair. Additionally, a figure of eight suture was placed in the mesosalpinx to reduce the amount of tension during the tubal reanastomosis. We used 4 interrupted 5-0 PDS sutures, with 2 wristed needle drivers, to establish and precisely align the 2 sections of tube, first in the mucosal layer and then in the serosal layer, to achieve proper retention. Upon successful chromopertubation with methylene blue dye, the process was repeated on the left side. A successful tubal reanastomosis was completed and chromopertubation clearly demonstrated that the tubes were patent. Total operation time was approximately 100 minutes, resulting in a successful surgery. Estimated blood loss was only 20 mL. At 2 months after surgery a fluoroscopic hysterosalpingogram was conducted to verify the patency of the tubes. We concluded that both tubes were patent. Conclusions The single-site robotic approach provides a potent and valuable method for tubal reanastomosis, rendering difficult surgical techniques more accessible.

Video Objective Pectopexy is the most effective procedure to treat pelvic organ prolapse and can be used as an alternative to sacrocolpopexy. The minimally invasive access for pectopexy is divided into single-port and multi-port with or without robotic assistance. Transumbilical natural orifice transluminal endoscopic surgery (transumbilical laparoendoscopic single site surgery, transumbilical LESS) is an emerging minimally invasive approach, which reduces abdominal incision and enhances aesthetics. Pectopexy is an ingenious combination of the two approaches, which achieves a good clinical effect. These advantages outweigh the difficulties in learning the new technique. Our purpose was to show the surgical skills of the transumbilical LESS. Setting Xinxiang City Central Hospital Gynecologic Oncology, China Interventions Transumbilical single-site laparoendoscopic pectopexy was performed, which was a combination of laparoendoscopic and single-site surgeries. Conclusion Transumbilical LESS allows the surgeon to perform iliopectineal ligament after accessing the entire abdomen via a single port. This procedure can achieve a good clinical effect.

Study Objective To investigate the feasibility and clinical application of early cervical application of nano-carbon tracer imaging of sentinel lymph node (the SLN) under laparoscopic 3D. Design 50 patients diagnosed with early cervical cancer patients, cervical injection nanometers from preoperative Carbon-suspended injection.3D laparoscopic direct recognition of black-stained lymph nodes as SLN and excision, followed by laparoscopic pelvic lymphadenectomy + extensive hysterectomy (+ abdominal para-aortic lymph node sampling). Setting Xinxiang City Central Hospital Gynecologic Oncology, China. Patients or Participants 50 patients diagnosed with early cervical cancer patients were enrolled. Interventions 3D laparoscopic direct recognition of black-stained lymph nodes as SLN and excision, followed by laparoscopic pelvic lymphadenectomy + extensive hysterectomy (+ abdominal para-aortic lymph node sampling). Measurements and Main Results A total of 1476 lymph nodes were removed from 50 patients. SLN was successfully detected. The detection rate of SLN was 100% (50/50). A total of 445 SLNs were detected, accounting for 43.20% (445/1030) of the total number of lymph nodes. SLNB detection sensitivity 100% (50/50), specificity 100.00% (50/50), SLN prediction of pelvic lymph node status and postoperative pathological examination coincidence rate of 100% (50/50), negative predictive value of 100.00% (50/50). Conclusion The metastatic state of SLN in early cervical cancer is consistent with the true metastatic state of pelvic lymph nodes, which has a more accurate pathological representative significance. Laparoscopic detection of SLN in early cervical cancer using nano-carbon tracer is a comparative method. Safe and feasible, SLNB has to replace traditional cervical cancer pelvic lymphadenectomy, narrowing the scope of surgery and reducing trauma.

Study Objective The study objective is to assess the safety and effectiveness of LESS for management of non-obstetric, gynecological disease processes in pregnant patients. Design A case series of 11 pregnant women [23-42 years] who underwent LESS for various gynecological pathology is presented. If permitted, patients were followed until delivery of the fetus. Setting Surgeries were performed in two institutions between 2015 and 2018. Patients or Participants Patients were selected if laparoscopic intervention was indicated. Interventions The cases include four ovarian cystectomy, three salpingo-oophorectomy, one myomectomy, one salpingectomy, one cerclage, and one paratubal cyst. LESS was performed at the umbilicus. For cases involving simple cysts at the umbilicus, cysts were drained and removed from the single site, and laparotomy was performed without extending the incision. Measurements and Main Results Data including surgical/obstetric history, gestational age at surgery, ultrasound results were collected; and operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring, pathologic findings, conversion and pregnancy outcomes were measured. Three cases were performed in the first trimester and seven in the second trimester with surgeries lasting between 109 to 298 minutes. Estimated blood loss ranged from 5 to 300 mL, and postoperative symptoms of pelvic or abdominal pain were reported. There was one surgery requiring additional ports but no open surgery conversions or complications. Fetal heart rates were between 136 and 175 bpm. Six patients agreed to follow-up and had successful deliveries. Conclusion LESS can be safely performed by experienced surgeons on pregnant patients requiring a variety of gynecological surgery. Most notably, an open surgical technique can be used through the single-site incision in suitable situations. However, further case studies at multiple centers with large sample sizes are needed for further utilization of this technique.

Study Objective To investigate the efficacy, feasibility, and safety of cold scissor ploughing technique in hysteroscopic adhesiolysis for intrauterine adhesions. Design Retrospective cohort study. Setting University-affiliated hospital. Patients or Participants A total of 179 intrauterine adhesion (IUA) patients who had undergone hysteroscopic adhesiolysis (HA) at the Third Xiangya Hospital of Central South University were enrolled in this study from January 2016 to October 2017. They were divided into three groups according to the surgical technique used. The groups were: cold scissors ploughing group (PG) (n=81); traditional group (TG:) (n=42); and, electrosurgical group (EG) (n=56). Interventions PG: use cold scissors to dissect the adhesion and cut the scar tissue using a ploughing technique; TG: use cold scissors to dissect the adhesion, but not deal with the scar tissue; and, EG: use resectoscope to dissect the adhesion with an energy L-hook electrode. Measurements and Main Results American Fertility Society (AFS) scores, along with adhesion types and areas; visible uterine horn and tubal ostia; menstrual recovery; pregnancy rates and live birth rates were evaluated to determine surgical efficacy. Feasibility was evaluated by technique replacement rates. Safety was evaluated by intra- and post- operative complication rates. Neither patient pre-operation history or adhesion rates were significant (P>0.05). There were significant differences between PG and TG, as well as PG and EG in: postoperative AFS scores; IUA reverse rates; reduced adhesion areas; pregnancy rates and live birth rates (P Conclusion Cold scissor ploughing is effective, feasible, and safe for HA, which is worth further study.

STUDY OBJECTIVE To compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery. DESIGN A randomized controlled trial (Canadian Task Force classification level 1). SETTING An academic gynecologic surgeon's practice. PATIENTS Private patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017. INTERVENTIONS Ninety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder. MEASUREMENTS AND MAIN RESULTS Using a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p

Background Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure but can be challenging for many to perform as evidenced by its declining rate. Vaginal removal of the adnexal structures can be difficult because of poor visualization. Factors such as abnormal pathology, incidental finding of early-stage endometriosis or adhesions from previous cesarean section or surgery, and obesity may further complicate the procedure. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) may be performed during vaginal surgery using basic laparoscopic single-site skills as a “rescue” procedure for the complete removal of the adnexae. This allows the surgeon to complete the procedure vaginally without requiring conversion or addition of abdominal incisions. The combination of total vaginal hysterectomy (TVH) with NOTES as a “rescue” procedure may be a useful tool for gynecologic surgeons for removal of the adnexae and performance of other pelvic procedures. Study Objective To demonstrate various common pelvic procedures that can be performed by transvaginal NOTES after completion of TVH. Design Variety demonstrations of the transvaginal NOTES technique as a “rescure” for total vaginal hysterectomy with narrated video footage (Canadian Task Force classification III). Setting Academic tertiary care hospital. Patients Patients with various surgeries including prophylactic bilateral salpingectomy, salpingo-oophorectomy, adhesiolysis, and incidental finding of superficial endometriosis resection. This video is exempt from institutional review board review at our institution. Interventions Transvaginal NOTES adnexal surgery and other procedures using basic laparoscopic single-site surgical skills. Measurements and Main Results Salpingectomy, oophorectomy, lysis of adhesions, and resection of endometriosis can be performed using NOTES at the time of vaginal hysterectomy. Conclusion NOTES allows the surgeon to survey the pelvis for pathology and to complete other pelvic procedures transvaginally during TVH with no additional abdominal incisions. Transvaginal NOTES can be considered a “rescue” approach and can be a helpful tool for the pelvic surgeon.

Study Objective Transvaginal surgery is the most minimally invasive surgery for a gynecologic procedure, but it has the limitation of lack of exposure and limited surgical space when using traditional vaginal surgical instrumentation, such as in a hysterectomy for a uterus without descent or for a myomectomy. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) offers similar benefits of traditional vaginal surgery but also expands the horizon of transvaginal surgery by allowing the surgeon to perform procedures that are typically limited to an abdominal approach. The advantages of NOTES may include no incisional pain as well as a better cosmetic outcome. These benefits help outweigh the obstacle of learning this novel approach. Our objective is to demonstrate the transvaginal NOTES technique as a combination of traditional vaginal surgical skill with single-site surgical skill. Design Stepwise demonstration of the transvaginal NOTES technique for myomectomy with narrated video footage (Canadian Task Force classification III). Setting Academic tertiary care hospital. Patient A 42-year-old woman. Interventions Transvaginal NOTES myomectomy with combined transvaginal surgical and single-site surgical skills. Measurements and Main Results A 42-year-old woman (gravida 2 para 2) with a preoperative transvaginal ultrasound diagnosis of a 6-cm left anterior myoma requested myoma removal with uterine preservation. She presented with a 2-year history of left pelvic pain and menorrhagia. The myoma was removed with minimal blood loss, and pathology revealed a necrotic myoma. The patient had resolution of her left-sided pelvic pain. Conclusions Combined with traditional transvaginal anterior colpotomy, single-site surgical skills allow the surgeon to access the entire abdomen and perform myomectomy through a transvaginal single port. Transvaginal NOTES myomectomy is not only possible but allows myomectomy to be performed with no abdominal incision.

Study Objective To demonstrate step-by-step the technique of hysteroscopic adhesiolysis (HA) by means of a blunt spreading technique using double-action forceps to dissect and restore the layer between the anterior and posterior uterine walls in a patient with severe intrauterine adhesions (IUAs), particularly in cases in which the endometrial lining is obscured on ultrasound imaging and the endometrial cavity is completely occluded on hysteroscopy. Design A step-by-step explanation of the technique using videos and pictures (educative video) (Canadian Task Force Classification III). Setting A university-affiliated hospital. Patient A 36-year-old, gravida 3, para 1, abortus 2 woman presenting with amenorrhea for 5 months after surgical termination of a 53-day intrauterine pregnancy. She had no cyclic lower abdominal pain. Ultrasound revealed an obscure endometrial stripe and no obvious hematometra. Both the urine human chorionic gonadotropin test and the progesterone withdrawal test were negative. One month before admission, hysteroscopic adhesiolysis failed because the uterine cavity was inaccessible because of adhesions completely occluding the lower uterine cavity. Additionally, the uterine cavity could not be explored with a probe because the anatomic layer of the endometrial lining could not be easily identified by transabdominal ultrasound. Intervention HA using a blunt spreading dissection technique with double-action forceps to restore the uterine cavity followed by “ploughing” of the intrauterine scar tissue using cold scissors [1] . Measurements and Main Results An intraoperative technique with commentary highlighting tips for a successful dissection. The uterine cavity was successfully restored using the blunt spreading dissection technique. There were no complications, including false uterine wall passage, uterine perforation, or fluid overload. Postoperative hysteroscopy at 1 month revealed an almost normal uterine cavity. Conclusions HA using a blunt spreading dissection technique to restore the uterine cavity is a simple, effective, and safe hysteroscopic skill, especially when the endometrial stripe is obscured on ultrasound imaging and exploring the uterine cavity by means of a probe has failed. Furthermore, this technique may serve as an alternative to resectoscopic techniques because it uses cold forceps and scissors, which provide better protection for the endometrium.

Study Objective To investigate the delivery outcome of women in the third trimester who previously underwent hysteroscopic adhesiolysis (HA). Design Retrospective cohort study. Setting University-affiliated hospital. Patients or Participants A total of 127 women with a history of HA before pregnancy and delivery in the third trimester from May 2011 to May 2018 were enrolled (Study Group). Additionally, a total of 127 women with a negative history of HA were randomly selected from those with delivery in the third trimester during the same period of time (Control Group). Interventions None. Measurements and Main Results We investigated demographic characteristics, obstetrics parameters, and infant parameters to evaluate the history of HA and its effects on third trimester delivery outcomes. There was neither significant difference between the Study and Control Groups in delivery gestational age (38.71±2.3 weeks versus 38.71±3.0 weeks), nor in birth outcomes of the newborn (P>0.05). However, the cesarean section rate in the study group was significantly higher than that of the control group (60.0% versus 44.1%, P Conclusion The history of HA might be an important risk factor inducing placental problems and postpartum hemorrhage in the third trimester. More attention should be paid to the labor of pregnant women with a history of HA.

Study Objective This study was the first to investigate the application of phthalocyanine green and nano-carbon suspension injection as a lymphatic tracer in laparoscopic radical resection of cervical cancer. The comparative value of its application in lymphatic imaging and sentinel lymph node identification was analyzed. The factors of the tracer results provide a reference for the application of clinical tracers. Design The patients were divided into nano-carbon group and indocyanine green group. Setting Xinxiang City Central Hospital Gynecologic Oncology, China. Patients or Participants Seventy-five patients with early stage cervical cancer were enrolled. Interventions Nano-carbon suspension injection and indocyanine green were injected from the cervix before operation, and black was recognized under laparoscopy. Lymph nodes and fluorescent lymph nodes were taken as SLN and excised. All patients underwent laparoscopic pelvic lymphadenectomy plus extensive hysterectomy (+ abdominal para-aortic lymph node sampling). All specimens were sent to routine examination. Measurements and Main Results There were no significant differences in age, tumor stage, and histological type between the two groups (P>0.05). SLN was detected in 25 cases of phthalocyanine green group, totaling 1006, the detection rate was 100%; the accuracy of SLN biopsy was 100%. There were 50 cases of nano-carbon suspension group, 39 cases of SLN were detected, a total of 1476, the discovery rate was 78%, the specificity was 76%; there was no statistical difference between the two groups (P> 0.05) However, the difference in the operation time between the two groups was statistically significant (P Conclusion The application of phthalocyanine green and nano-carbon suspension in the detection of SLN in cervical cancer is feasible, but the phthalocyanine green fluorescence detection method is more prominent in visual effect, which can significantly shorten the operation time.

Study Objective To investigate the safety and feasibility of robotic single-site for surgical resection of stage I to IV endometriosis in chronic pelvic pain patients. Design A retrospective cohort study via chart review collected data. All procedures were performed by a single surgeon between January 2015 and April 2019. Setting An academic university hospital. Patients or Participants A total of 272 patients with chronic pelvic pain and pathology confirmed endometriosis were managed with surgical resection via the robotic single-site laparoscopy. All of the patients were chronic pelvic pain who incurred symptoms of dysmenorrhea, menorrhagia, deep dyspareunia, although other symptoms may be present such as dysphasia, lower back pain, urinary, or intestinal symptoms. Interventions All procedures were completed successfully with robotic single-site resection; however, an additional port was added in fourteen cases due to deep infiltrating endometriosis with colorectal, urinary tract involvement and extensive pelvic adhesion. Measurements and Main Results The median operative time was 110 min (range, 45-480 min), and the median blood loss was 50 mL (range, 15-300 mL). The length of hospital stay was less than 24 hours for 90.8% of patients (247/272). The incidence of complication was 5.9% (16/272). All but two surgeries had no severe complications, which included eight wound infection, one vaginal cuff dehiscence, four urinary tract infection and pelvic abscess. One patient with symptomatic bowel endometriosis nodule developed in the right abdominal wall and perineal hematoma after lower anterior bowel resection. The other patient, who had undergone a double ureteral malformation, ureteral endometriosis, and severe adhesion, had injured the left ureteral ten days after extensive pelvic and bladder nodule endometriosis resection. Conclusion Robotic single-site laparoscopic resection of endometriosis surgery appears to be a reasonably safe and feasible method for the surgical management of women with endometriosis. Adding a port is a good alternative if challenging cases encountered.

Video Objective To present a thorough yet concise explanation of the methodology for the completion of a successful transvaginal hysterectomy via natural orifice transluminal endoscopic surgery. Design A narrated instructional video guide detailing each procedure (Canadian Task Force Classification III). Setting University Hospital, Baylor College of Medicine, Houston, Texas Patients Our patient is a 46-year-old G2P1011 who had two notable previous surgeries: a tubal ligation and an adnexa removal surgery. She possessed a narrow vagina and non-descent uterus while having a strong preference for maintaining a high level of cosmesis. Interventions A complete transvaginal hysterectomy utilizing solely natural orifice transluminal endoscopic surgery was performed on the patient. Transvaginal entry was established and with the gelpoint mini port in place we began circumferential dissection of the cervix anteriorly at the bladder fold. Utilizing the laparoscopic single tooth tenaculum, we hooked the anterior lip of the cervix for countertraction and hydro dissected the anterior cervix with 20 units of Vasopressin (Pitressin) in 20 ml of saline. Next, the monopolar hook was employed to cut the anterior colpotomy and begin the circumferential incision around the cervix. Following this, we used the LigaSure bipolar forceps to sever bilateral ureteral sacral ligament. The same strategy is used at the anterior cervix to separate the bladder from the uterus. Following bladder mobilization, the cardinal ligaments and uterine arteries were cauterized and transected by LigaSure. The right fallopian tube was removed utilizing the LigaSure first, before proceeding with the left fallopian tube; the pelvis was inspected with hemostasis noted throughout. Finally, the vaginal cuff was closed in traditional vaginal fashion after the deflation of the abdomen. Conclusion Despite certain drawbacks, utilizing pure natural orifice transluminal endoscopic surgery in hysterectomy is a safe and feasible procedure that maintains a high-level of cosmesis for patients while still offering the most minimally invasive route.

Study Objective To demonstrate the tips and tricks of a simpler technique for single-site sacrocolpopexy using barbed suture anchoring and retroperitoneal tunneling to make the procedure more efficient and reproducible. Design Step-by-step description of surgical tutorial using a narrated video (Canadian Task Force classification III). Setting Academic tertiary care hospital. Patients Patient with Stage III uterine prolapse. Interventions Sacrocolpopexy is increasing utilized since the FDA warning about complications of vaginal mesh surgery. It is the gold standard for repair of apical prolapse. However, there is great variation in the sacrocolpopexy procedure techniques and they have not been standardized. Traditional single-site laparoscopic sacrocolpopexy is very challenging as the procedure time is long and suturing is difficult. The advantages of suturing with wristed needle drivers in robotic single-site surgery simplify this complex procedure. Furthermore, using barbed suture anchoring and peritoneal tunneling technique potentially decreases the surgeon's learning curve and makes the procedure reproducible. In this video, we demonstrate a supracervial hysterectomy with a stepwise explanation of the correct technique for performing a robotic single incision sacrocolpopexy. Measurements and Main Results Sacrocolpopexy is increasing used since the US Food and Drug Administration warning about complications of vaginal mesh surgery. It is the gold standard for repair of apical prolapse. However, a great variation exists in the sacrocolpopexy procedure techniques that need to be standardized. Traditional single-site laparoscopic sacrocolpopexy is very challenging because the procedure time is long and suturing is difficult. The advantages of suturing with wristed needle drivers in robotic single-site surgery simplify this complex procedure. Furthermore, using the barbed suture anchoring and peritoneal tunneling technique potentially decreases the surgeon's learning curve and makes the procedure reproducible. In this video, we demonstrate a supracervical hysterectomy with a stepwise explaation of the correct technique for performing a robotic single-incision sacrocolpopexy. Conclusion The possibility of using the barbed suture and peritoneal tunneling technique with wristed needle drivers in robotic single-site sacrocolpopexy offers the possibility of an effective, safe, reproducible, and cosmetic surgical option.

Objective To describe and demonstrate the single-incision laparoscopic technique with an articulated energy device for a uterus larger than 20 cm. Design Stepwise demonstration of the single-site surgical technique and tissue extraction with narrated video footage (Canadian Task Force classification III). Setting Single-incision laparoscopic hysterectomy can be difficult because of the long operating time, steep learning curve, and need for articulated instruments, and it is especially challenging in patients with a uterus larger than 20 cm. However, the advantages of single-site laparoscopic surgery may include less bleeding, infection, and pain and a better cosmetic outcome. Interventions A 49-year-old G3P3 female with a 24 weeks-sized fibroid uterus requesting supracervical hysterectomy presented to our tertiary academic medical center with a 2-year history of pelvic pain and menorrhagia with a normal Pap smear history. Uterine weight was 1900 g. Laparoscopic single-incision supracervical hysterectomy with contained bag tissue extraction was performed. Rotating between the patient's right and left side allowed the surgeon to access the entire abdomen from a single umbilical port. There was no complications or conversions to multiport in the surgery. Conclusion Single-incision laparoscopic hysterectomy for a uterus larger than 20 cm is possible and leads to better outcomes.

Study objective To determine whether laparoscopic hand-assisted hysterectomy for a large uterus had different surgical outcomes compared with traditional open hysterectomy. Design Retrospective cohort study (Canadian Task Force classification II-2). Setting Academic tertiary care hospital. Patients Women who had undergone laparoscopic hand-assisted hysterectomy for a large uterus were included as the hand-assist group. The control group comprised patients with similar final specimen weight (>1 kg), characteristics (body mass index, age), and surgical history, who underwent open hysterectomy for a large uterus. Intervention Laparoscopic hysterectomy using a hand-assist port for laparoscopic portion of the case. Results The 2 groups were similar in terms of specimen weight (median, 1765.5 g for hand-assist vs 1215.50 g for controls; p = .29). In univariate analysis, the median operating time was longer in the hand-assist group compared with controls (241.5 minutes vs 185.0 minutes; p = .002), whereas median length of stay was shorter in the hand-assist group (1.0 day vs 3.0 days; p .05) between the 2 groups, although the change in hemoglobin was less in the hand-assist group compared with controls in multivariable analysis (adjusted mean.74 vs. 1.8; p = .04). Complications were divided into intraoperative complications (transfusion, consultation, bowel injury, bladder injury, ureter injury, and other), hospital postoperative complications (reoperation, transfusion, slow return of bowel function, ileus, poor pain control, fever of unknown origin, venous thromboembolism, pneumonia, and neuropathy), and complications after discharge (readmission, wound infection). The 2 groups had a similar low rate of complications (p > .05). Conclusion Laparoscopic hand-assist hysterectomy is a feasible alternative to open hysterectomy in patients with a large uterus.

Study Objective To demonstrate the feasibility of robotic single-site resection of advanced endometriosis using new technology. Design We show a video that demonstrates our technique for accomplishing single-site laparoscopic resection of advanced endometriosis. The video is a step-by-step explanation of robotic single-site resection of endometriosis nodules overlying the ureter and rectum. Background Laparoscopic surgery has been shown to effectively improve pain and fertility in women with endometriosis [1]. Compared with traditional multiport laparoscopy, single-incision laparoscopy is associated with similar incidence rates of blood loss, conversion to open laparotomy, and wound complications, but it has superior cosmetic outcomes and high patient satisfaction [2–5]. Furthermore, robotic single-incision laparoscopy combined with robotic Firefly technology potentially increases the removal of invisible endometriosis. Without complete resection of endometriosis, patients are less likely to achieve full pain relief postoperatively. Setting University hospital. Patient A 36 year old G1P1 female was referred for chronic pelvic pain. She described her pain as hip pain, pain with walking, dyspareunia, dyschezia and right anterior abdominal wall pain. Intervention To improve detection of endometriosis, we injected the patient with indocyanine green (ICG), a fluorescent dye with widespread medical applications in identifying increased vascularity of tissues. We then visualized the tissues with robotic Firefly technology, a fluorescence-detection tool built into the da Vinci SI Surgical Systems (Intuitive Surgical, Inc, Sunnyvale, CA). Main Results Because endometriosis lesions are associated with a high degree of neovascularization, the ICG turned the endometriosis tissues dark green, thereby enabling us to detect endometriosis that would not have been seen as readily with conventional single-site laparoscopy. This video demonstrates our technique for successfully accomplishing a single-site laparoscopic resection of advanced endometriosis, including ureterolysis, adhesiolysis, peritoneal stripping, and a rectal nodule excision. Conclusions We found that Firefly technology and ICG facilitated identification of endometriosis in single-site robotic surgery. We were able to successfully perform single-site laparoscopic resection of advanced endometriosis nodules overlying the ureter and rectum with complete resolution of pelvic pain symptoms and excellent cosmetic results.