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Background To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors. Methods A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined. Results Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210). Conclusion The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Study Objective This study was designed to evaluate the learning curve of transvaginal natural orifice surgery (NOS) for adnexal tumors based on the type of procedure (adnexectomy or cystectomy). Design Retrospective cohort study. Setting Tertiary-care university hospital. Patients One hundred thirty-six women with adnexal tumors. Interventions A series of 136 consecutive transvaginal NOS for adnexal tumor were performed between April 2011 and June 2016. Eighty-five patients (62.5%) had undergone cystectomy, and 51 patients (37.5%) had undergone adnexectomy. Measurements and Main Results The transvaginal NOS procedures included vaginal, endoscopic, single-port access techniques and were divided into 2 categories: adnexectomy and cystectomy. Operating time was electronically recorded and was defined as the time from the creation of a posterior colpotomy incision until the complete closure of the posterior colpotomy opening. The average operating time for the cystectomy and adnexectomy groups was 42.7 and 37.7 minutes, respectively (p = .015). The learning curve was analyzed using the cumulative summation method and showed that 36 cases were needed to achieve proficiency in transvaginal NOS for ovarian cystectomy. However, there was no significant cut-off point to determine the number of patients who had undergone adnexectomy. Conclusion A well-trained gynecologic endoscopist can achieve surgical proficiency in transvaginal NOS cystectomy after 36 cases. It is suggested that the surgical transvaginal NOS procedure should begin with adnexectomy rather than with cystectomy to avoid initial technical challenges.

Objective To demonstrate an innovative idea for a four-petal method for performing laparoscopic adenomyomectomy on a patient with focal-type adenomyosis. Design A step-by-step explanation of the technique with narrated video footage. Setting University hospital. Patient(s) A 38-year-old female with a 7 × 4 cm adenomyoma at the anterior uterine wall. Intervention(s) Laparoscopic adenomyomectomy began with a cruciate incision to turn the adenomyoma into the shape of a blooming four-petal flower to fully expose the tumor and maximize the removal of adenomyotic tissue. During excision of the lesion, around a 1 cm thickness of the myometrium was preserved at the subendometrial region and around a 0.5 cm thickness of the serosa flap was also left in each “petal.” Suture repair in the method introduced is different from closing the wound by approximation of myometrium to myometrium as in traditional myomectomy; instead, herein we repaired the adenomyomectomy wound by anchoring the serosal flap to the subendometrial tissue, with care taken to avoid dead space. Main Outcome Measure(s) Subjective clinical symptoms as well as serial ultrasonographic measurement of the uterine size, shape, and wall thickness. Result(s) The specimen removed was 92 g in weight. The symptoms have dramatically decreased since the procedure and dysmenorrhea improved from visual analog scale 8 to 1 postoperatively. Besides achieving satisfactory symptomatic relief, the ultrasonographic measurement of the myometrium was of adequate thickness (2.3 cm) after the operation and did not increase in a serial follow-up of 33 months. Conclusion(s) The four-petal method of adenomyomectomy with cruciate incision offers full exposure to the localized adenomyosis. It greatly facilitates a balance between the maximized resection of the lesions and tailored reserves of myometrium. Subsequent repair by anchoring the serosal flap to the subendometrial tissue ensures adequate thickness of the uterine wall after the operation.

This study was designed to evaluate the learning curve of applying Seprafilm (modified hyaluronic acid and carboxymethylcellulose; Genzyme, Cambridge, MA, USA) during laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy. In this retrospective cohort study, 35 patients who underwent laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy were enrolled. The Seprafilm was cut into 4 pieces, rolled up with a trimmed plastic sleeve and delivered through an incision wound made for the 5-mm ancillary trocar. The membrane was unrolled and placed on the rough surface after hysterectomy or subtotal hysterectomy with or without adnexectomy. The time from the insertion of the first piece of membrane into the abdominal cavity to the complete removal of the trimmed plastic sleeve was recorded. The median time for Seprafilm placement was 3 min. The learning curve was analyzed using the power-law method and suggested that 10 cases were required to achieve proficiency in the procedure. The presence of adnexectomy was significantly associated with the time required for Seprafilm placement (P

Study objective: To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES). Design: Prospective observational study. Setting: Tertiary referral medical center. Methods: From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results: Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144±4.5 (138â149) minutes with an average estimated blood loss of 133±62 (50â200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140±59 (56â188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy. Conclusion: Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars. Keywords: laparoscopic hysterectomy, laparoscopy, myoma uteri, natural orifice transvaginal endoscopic surgery (NOTES), subtotal hysterectomy

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe.

Objective: To evaluate the efficacy and effectiveness of applying LigaSure™ Tissue Fusion System in hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES) in comparison with using the conventional bipolar device. Materials and methods: Eighty women scheduled for hysterectomy by transvaginal NOTES were prospectively randomized into applying LigaSure (study group) or conventional bipolar instrument (control group) in an intention-to-treat analysis. Primary endpoints were the device-related efficacy; secondary endpoints were surgical effectiveness measured by operative time, blood loss, postoperative pain and adverse events. Results: In the eligibly allocated patients, three in the control group (n = 39) converted to applying LigaSure and one converted to conventional laparoscopy intraoperatively, while none in the LigaSure group (n = 38) found such conversions. Patients who completed full analysis in the LigaSure (n = 36) and control (n = 35) groups did not differ significantly in operative time, estimated blood loss, and the length of hospital stay. In the subgroup of women who underwent hysterectomy only, the LigaSure group (n = 22) showed significantly reduced operative time than the control group (76.50 ± 24.74 min versus 93.96 ± 27.10 min, p = 0.029). Postoperative pain scores were statistically higher in the LigaSure group within 36 h; however, the difference was not clinically significant. The incidence of postoperative adverse events between the groups was not different; nevertheless, device-related adverse events was not found in the LigaSure group. Conclusion: LigaSure™ tissue fusion technology was feasible and efficacious without compromising surgical procedures for hysterectomy by transvaginal NOTES compared with the conventional bipolar hemostasis device. Keywords: Hysterectomy, Transvaginal, Natural orifice transluminal endoscopic surgery, Ligasure, Operating time

Objectives: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique in the area of minimally invasive procedures. Preliminary reports have confirmed transvaginal NOTES to be a safe and feasible method for performing hysterectomy and adnexal procedures. However, there are limitations regarding the feasibility of performing transvaginal NOTES hysterectomy in various uterine sizes. Materials and methods: Two hundred and seventy-five women who had undergone transvaginal NOTES hysterectomy for benign pelvic lesions were recruited from May 2012 to May 2016. Their medical records were retrospectively reviewed. All patients were placed into one of three groups depending on weight of the surgical specimen in order to assess surgical outcomes. Results: One hundred ninety-one patients (69.46%) had a uterine weight of

Objectives: To evaluate the accessibility of transumbilical single-port laparoscopy for hysterectomy in difficult conditions. Materials and methods: This prospective observational study recruited patients with benign diseases who were scheduled for laparoscopic hysterectomy between March 2010 and October 2011 to undergo the transumbilical single-port approach with straight instruments and a laparoscope. Results: In total, 109 patients were included with a mean [± standard error of the mean (SEM)] age of 45.9 ± 0.4 years and mean body mass index of 23.9 ± 0.3 kg/m2. The yielded mean uterine weight was 403.4 ± 25.3 g, with 28 (25.7%) weighing ≥500 g, including four specimens >1000 g, and 44 (40.4%) needed concurrent adhesiolysis. The operative time was 117.2 ± 4.2 minutes, estimated blood loss was 270.3 ± 22.9 mL, and the postoperative hospital stay was 2.8 ± 0.1 days. Patients with a uterus weighing ≥500 g had a higher intraoperative blood loss in comparison with those with a uterus weighing

Objective To assess the feasibility and survival outcomes of laparoscopic staging for patients with stage I ovarian cancer. Materials and methods Consecutive patients who underwent laparoscopic staging surgery for stage I ovarian cancer from January 2002 to December 2014 were evaluated retrospectively by chart review. Results Twenty-four patients with mean age 43.9 ± 9.9 years and mean body mass index 24.0 ± 3.8 kg/m2 were included, in which 12 (50%) patients were in stage IA and 12 (50%) in stage IC. The histological types included serous in 6 (25%), mucinous in 7 (29.1%), endometrioid in 6 (25%), clear cell in 5 (20.8%) patients. The mean surgical time was 306.4 ± 98.5 min, and the mean blood loss was 204.2 ± 188.6 mL. None of the patients required conversion to laparotomy. The median numbers of resected pelvic and para-aortic lymph nodes were 20 and 4, respectively. One (4.1%) patient encountered bowel injury intraoperatively, and the other 1 (4.1%) patient hydronephrosis postoperatively. The overall survival rate was 95% in the current series in a median follow-up of 31.5 months. Conclusion Laparoscopic staging surgery performed for early stage ovarian cancer has better long term survival outcomes than the literature report. Laparoscopic treatment by a trained gynecologic oncologist is an ideal alternative for early stage ovarian cancer with the advantage of minimal invasiveness.

Study Objective To study the outcome of a novel method of laparoscopic neovaginal reconstruction using rudimentary uterine horn serosa and the pelvic peritoneum as a graft. Design Canadian Task Force classification II-1. Setting A university hospital. Patients A retrospective study of 14 patients from 2000 to 2014 of patients with vaginal agenesis who underwent laparoscopic neovagina reconstruction using rudimentary uterine horn serosa and the pelvic peritoneum as a graft. Intervention Patients with vaginal agenesis associated with mullerian agenesis who requested surgery. Tertiary referral center and laparoscopic unit. The creation of a neovagina using rudimentary uterine horn serosa and the pelvic peritoneum as a graft via a combined laparoscopic and vaginal route. Measurements and Main Results Data were collected retrospectively including postoperative vaginal length and width, complications, stenosis or reoperations, dyspareunia, and sexual satisfaction. There were no major complications from the surgery with no rectal perforation or bladder or ureteric injury. The postoperative mean (±SD) vaginal length was 6.0±0.7 cm and a width of 2 fingerbreadths. The mean operation time was 142.7±45.9 min. Median blood loss was 100 ml (range: 10 to 300 mL). The mean duration of the hospital stay was 6.6±1.6 days. The follow-up period ranged from 3 to 84 months with a median follow-up of 11 months. Conclusion Lee's method of neovaginoplasty using rudimentary uterine horn serosa and the pelvic peritoneum as a graft is a good method for neovagina creation with minimal morbidity, fast recovery, and minimal complications. This method results in good anatomic and functional outcome and can be a method that is widely used.

Study Objective To evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES). Design Prospective observational study (Canadian Task Force classification II-3). Setting Tertiary referral medical center. Patients From May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included. Intervention Total hysterectomy via transvaginal NOTES. Measurements and Main Results The study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment. Conclusion Transvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.

Objective Our aim was to create a neovagina with the least surgical morbidity and the best functional outcome. Materials and methods We hereby describe a new technique (Lee's neovaginoplasty) using a combined laparoscopic and vaginal approach in the creation of a neovagina using the uterine serosa layer from the rudimentary uterus and the peritoneum as a graft to line the vagina. This procedure was performed in three patients who were followed-up for a duration of 4 months to 2 years. Vaginal dilation was maintained with a vaginal mold daily for 3 months and three to four times a week thereafter. Results Adequate vaginal length of 6-7 cm and width of 2.5 cm was achieved postoperatively. There were no surgical complications and postoperative recovery was fast. Vaginal examination 1 month later showed healthy vaginal tissue with no necrosis or infection. Long-term follow-up did not show any shortening or stenosis of the vagina. Patients were able to have satisfactory sexual intercourse with no pain. Conclusion The laparoscopic-vaginal approach of using a uterine serosa and peritoneal graft for creation of a neovagina is a simple and effective approach with minimal surgical morbidity that can create a passageway for satisfactory intercourse.

Objective To evaluate the use of Tisseel, a 2-component fibrin sealant agent for the control of minor bleeding and repair of the ovarian defect at the end of laparoscopic cystectomy (LC) of endometriomas. Materials and methods From January 2011 to December 2015, an observational study of all patients who underwent LC of endometrioma using Tisseel (group A) was performed. The demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative hospital stay duration were recorded. A contemporary cohort of patients, who underwent LC of endometrioma without Tisseel (group B) was also retrospectively compared. Results A total of 274 patients were recruited in this study (53 LCs with Tisseel and 221 LCs without Tisseel, respectively). Complete hemostasis was achieved in all patients. The mean size of main mass was significantly larger in the group A than in the group B (7.8 ± 2.4 cm vs . 7.0 ± 2.3 cm, p = 0.033) but the mean operating time, operative blood loss, febrile morbidity, and length of hospitalization were not significantly different between the two groups. Conclusion This preliminary series demonstrated the use of Tisseel in LC of endometriomas without any bipolar coagulation and/or suturing of ovarian tissue is clinically safe and feasible.

Objective To assess the long-term outcomes of laparoscopic staging surgery (LSS) in treating patients with endometrial carcinoma. Materials and Methods Patients with endometrial cancer who underwent LSS between June 1995 and June 2014 were prospectively registered. Perioperative data, complications, disease recurrence, and long-term survival were measured. Results The study included 287 consecutive patients [mean age (± standard deviation), 53±10.4 years; mean body mass index, 27.3±6.7 kg/m 2 ] with a median follow-up ranging from 1 to 216 months. No laparotomy conversion was recorded for any patient. The mean operative time was 207±63.5 minutes, and the mean blood loss was 183±166.7 mL. The mean numbers of pelvic nodes and para-aortic nodes removed were 18±4.8 and 8±5, respectively. More than 80% of the patients had an International Federation of Gynecology and Obstetrics (FIGO) Stage 1 disease. The overall complication rate was 3.1%, including two patients of bladder injuries and one with bowel injury intraoperatively, and postoperatively one patient with pelvic abscess, three with urinary tract infection, one with voiding difficulty, and one with bowel perforation. The overall survival rates were 94% in 5 years and 92.7% in 20 years. No port-site metastasis was recorded in this study. Conclusions Patients with endometrial carcinoma treated by LSS had compatible or even better long-term survival outcomes and less complication in comparison with the published data, in addition to the benefits of its minimally invasive characteristics. LSS should be the treatment of choice for endometrial cancer.

Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri weighing >500 g because some reports show increased complications and morbidities and high laparoconversion rate in the past. With familiarity of laparoscopic procedures and progress in surgical techniques, the issue should be discussed and reviewed by evidence again. Hence, we conducted a systematic review of laparoscopic hysterectomies for large uteri.

Objectives To report the surgical outcomes of transumbilical single-port laparoscopic hysterectomies for benign uterine diseases. Materials and methods This prospective observational study recruited patients with benign diseases and scheduled for laparoscopic hysterectomy from March 2010 to April 2011 to undergo transumbilical single-port laparoscopy, and recorded the surgical outcomes. Results A total of 56 patients were included, with mean (±standard error of the mean) age 46.5 ± 0.5 years and mean body mass index 23.5 ± 0.5 kg/m2. Among these patients, 32 (57.1%) had a history of previous abdominal surgeries, whereas in 55 (98.2%) the procedures were completed with transumbilical single-port access and without any ancillary trocar. Mean surgical time was 121.1 ± 5.7 minutes. Mean intraoperative blood loss was 279.5 ± 38.4 mL. Mean uterine weight was 392.3 ± 34.2 g. The single additional trocar (1.8%) was needed for extensive enterolysis. Two patients (3.6%) needed blood transfusion. The median of postoperative hospital stay was 3 days. There were no major intraoperative or postoperative complications. Conclusion In the hands of experienced laparoscopists, transumbilical single-port laparoscopy is a safe and feasible method of hysterectomy for patients with benign uterine diseases.

Summary Objective The robotic surgical system is reported to overcome some technical difficulties in traditional laparoscopic hysterectomy. This study aimed to evaluate the feasibility and surgical outcomes of a robotic surgery program for endometrial cancer. Materials and Methods Patients with endometrial cancer with the intention to receive treatment using robotassisted laparoscopic staging surgery were recruited in a university hospital from July 2007 to August 2008. All of these surgeries were performed with the da Vinci system. Results Six patients (mean age, 47.5 ±1.4 years; mean body mass index, 26.2 ±3.5 kg/m 2 ) were enrolled and completed robot-assisted laparoscopic staging surgery. The robot docking time was 45.0 ±13.6 minutes and the robot-assisted operation time was 200.3 ±30.0 minutes. The mean estimated blood loss was 180.0 ±147.6 mL. The mean number of lymph nodes retrieved was 23.2 ±7.4. No laparoconversion and no intraoperative or postoperative complications occurred. All patients were alive and free of disease up to the date of this report, at a median follow-up of 6.5 months (range, 5-17 months). Conclusion Robot-assisted laparoscopic staging surgery is a feasible treatment and helps overcome the technical limitations in conventional laparoscopy for endometrial cancer.

Objective To evaluate the efficacy of laparoscopy in treating large submucous fibroids with deeply intramural invasion. Study design Twenty-eight women with a main submucous fibroid >4 cm and with >50% intramural extension were enrolled in this study. Laparoscopic myomectomy was performed instead of hysteroscopic surgery. Results Median fibroid diameter and weight were 5.0 cm [interquartile range (IQR) 4.6–6.0 cm] and 50.0 g (IQR 36.3–77.5 g), respectively. Median operating time was 60 minutes (IQR 50.0–73.8 minutes) and blood loss was 50 mL (IQR 50–100 mL). Median postoperative hospital stay was 2 days (IQR 2–3 days) and no patient developed complications. Seven women had coexistence of intramural and/or subserosal fibroids (median number of fibroids removed was 1, IQR 1–2). Conclusion When the diagnosis of submucous fibroid >4 cm with >50% intramural extension is made, laparoscopic myomectomy can be performed instead of hysteroscopic surgery for the sake of safety and removal of nonsubmucous type fibroids concomitantly.

A 35-year-old woman with persistent vaginal bleeding and a history of prior cesarean delivery was diagnosed with cesarean scar pregnancy (CSP) by transvaginal ultrasonography at 7 weeks of gestation. The patient was initially treated with a single dose of systemic methotrexate (MTX) injection. However, both follow-up β-hCG levels and transvaginal ultrasonography had shown evidence of ongoing pregnancy. Finally, she was treated with hysteroscopic resectoscope, by which the gestational tissue was removed completely. No intra-operative or post-operative complication occurred. Serum β-hCG level returned to normal limit four weeks after the surgery. In our experience, systemic MTX injection provides an alternative choice of treatment for carefully selected women with CSP, and hysteroscopic removal of CSP, which offers good prognosis, can serve both as the initial treatment and as the rescue management after a failed MTX treatment attempt.

Objective To evaluate the feasibility and safety of performing a hysterectomy using the transvaginal natural orifice transluminal endoscopic surgery (NOTES). Materials and Methods From May through December 2010, 16 patients with benign uterine diseases who were eligible for laparoscopic hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results All of the included hysterectomies were completed via transvaginal NOTES without conversion to conventional laparoscopy. The mean (± standard error of mean (SEM)) uterine weight was 538.8 ± 102.9 g, the mean operative time was 122.7 ± 17.6 minutes, and the mean blood loss was 379.4 ± 95.4 mL. The mean postoperative hospital stay was 2.8 ± 0.2 days. No intraoperative or postoperative complications were noted in this series. Conclusion Hysterectomy for the treatment of benign diseases can be feasibly carried out via transvaginal NOTES. However, prospective studies are needed to determine its full clinical applications.

From August 2010 to June 2011, 10 consecutive patients underwent transvaginal NOTES of the adnexa, including tubal sterilization in 3, salpingectomy because of ectopic pregnancy in 3, and ovarian tumor enucleation in 4. The mean (SD; 95% CI) age of the patients was 34.8 (9.7; 27.9-41.8) years, and their body mass index was 21.6 (2.8; 19.4-23.8). In 9 of the 10 patients, the procedure was completed. The 3 tubal sterilization procedures were completed in 18 to 30 minutes, with negligible blood loss. Operative time for the 3 salpingectomies because of ectopic pregnancy was 62 to 116 minutes. One of these procedures included management of 2000 mL hemoperitoneum. Three of the 4 attempts at ovarian enucleation were successfully completed within 64 to 162 minutes, with estimated blood loss ≤ 50 mL. One NOTES procedure failed because of a misdiagnosed peritoneal mucinous tumor located anterior to the uterus and inaccessible, leading to subsequent conversion to transabdominal laparoscopy. Our preliminary results show that purely transvaginal NOTES is feasible and safe for use in performing uterine adnexal procedures in selected patients. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.

Objective To report a novel technique for cervical reconstruction in a patient with congenital agenesis of the cervix. Design Case report. Setting University-based tertiary care hospital. Patient(s) A woman with congenital absence of the cervix, functional vagina, and adenomyosis uteri. Intervention(s) Laparoscopic-assisted creation of an uterovaginal fistula followed by placement of a polytetrafluoroethylene graft lined with vaginal mucosa graft to create the neocervix. Main Outcome Measure(s) Follow-up examinations with the hysteroscope confirmed unobstructed menstrual outflow through the patent neocervix. Result(s) The neocervix was completely mucosalized on the inner surface by 12 days postoperatively. The patient had return of menstrual bleeding at 4 weeks postoperatively. She has resumed normal sexual activities and had maintained regular menstrual cycles at the 6-month clinical follow-up. There were no complications related to the graft. Conclusion(s) Prosthetic reconstruction of the cervix using vaginal mucosa-lined polytetrafluoroethylene is easy to perform and effective. It offers an alternative treatment option for patients with cervical agenesis to preserve their reproductive potential.

Background : The aim of this study was to present our experience with a novel approach called the pierce and push (PP) method which uses a stainless steel centimeter probe instead of a 5 mm claw forceps to enucleate fibroids in a laparoscopic myomectomy (LM). Methods : A retrospective chart review of 90 women with symptomatic uterine fibroids who underwent an LM was performed. Cases of LM with the PP method were compared with a matched control group of LM with a 5 mm claw forceps. The operative time, tumor separation time, specimen removal time, amount of blood loss, requirement for blood transfusion and length of hospital stay were compared between groups. Results : The two groups were matched by age, body mass index, previous cesarean delivery, main fibroid size, and number and weight of fibroids. The tumor separation time was significantly shorter in the PP group than the claw forceps group (9.7 ± 3.1 minutes versus 17.1 ± 4.4 minutes, p < 0.001). The length of the operation, hospitalization time, specimen removal time, amount of blood loss, and requirement for blood transfusion were not significantly different between groups. Conclusion : A stainless steel centimeter probe has an advantage over a 5 mm claw forceps in pushing and pulling fibroids. Our findings indicate that the PP method was much more effective in excision of fibroids than a 5 mm claw grasper in LM.

Objective The objective of the study was to determine the long-term disease-free and overall survival outcomes of laparoscopic treatment of early-stage cervical cancer. Study Design This was a longitudinal study of prospectively registered patients of cervical cancer undergoing laparoscopic surgery from June 1994 to December 2005. Results A total of 139 patients were included, in which 60 patients were in International Federation of Gynecology and Obstetrics stage IA, 76 in IB, and 3 in IIA. Mean operation time was 231.1 ± 6.1 minutes. Median number of pelvic lymph node retrieval was 16. Major intraoperative complications included 1 great vessel injury, 1 ureteral injury, 1 colon injury, and 6 cystotomies. In a median follow-up of 92.1 months, the mean ± SEM cumulative disease-free and overall survival rates were 91.01% ± 2.77% and 92.78% ± 3.06%, respectively. Conclusion The laparoscopic approach has favorable long-term survival outcomes and perioperative morbidity. With the advantage of minimal invasiveness, laparoscopic treatment by experienced surgeons is an ideal alternative for early-stage cervical cancer.

Objective To describe the surgical procedures of robot-assisted natural orifice transluminal endoscopic surgery (NOTES) for hysterectomy and to evaluate its feasibility. Materials and methods From December 2014 to February 2015, four patients with benign diseases who were eligible for robot-assisted NOTES at Chang Gung Memorial Hospital were recruited to this study. Intraoperative and postoperative surgical outcomes were evaluated. Results Robot-assisted NOTES hysterectomy was successfully performed in all these patients. None of the patients had vaginal delivery, with two being nulliparous. The mean ± standard error of the mean uterine weight was 365.5 ± 69.2 g, the mean operative time was 198.8 ± 39.0 minutes, the mean docking time was 38.3 ± 2.4 minutes, the mean blood loss was 180.0 ± 56.1 mL, and the mean postoperative hospital stay was 2.5 ± 0.3 days. The final pathologic diagnoses were adenomyosis and/or leiomyomas. Conclusion The novel robot-assisted NOTES technology created scarless skin wounds. More importantly, the device allows the surgeon to reach deeper places to achieve hemostasis, and perform surgery on larger tumors using the curved cannulae-wristed instrument. However, its implementation is limited by the lack of appropriate instrumentation, which requires further development and break through. At this stage, robot-assisted NOTES is only useful for limited applications in highly selected patients.

Objective: This study was conducted to describe the feasibility of treating endometrial cancer with hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymphadenectomy by natural orifice transluminal endoscopic surgery (NOTES). Methods: Women with early-stage endometrial cancer underwent surgical staging by transvaginal NOTES in a tertiary referral medical center, and surgical outcomes were measured. Results: Three patients with a mean age of 46.3 [standard deviation (SD) = 2.5] years and a body mass index of 27.7 (SD, 2.4) kg/m2 were selected. The average operative time was 249.3 (SD, 49.3) minutes. All patients had minimal blood loss during the operation (

Objective To present our initial experiences in transvaginal natural orifice transluminal endoscopic surgery (NOTES) for adnexal surgeries and hysterectomies. Materials and Methods From September 2010 to December 2010, a total of 15 patients with benign adnexal or uterine diseases who were eligible for laparoscopic surgeries were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. Results Transvaginal NOTES was successfully completed in five adnexal surgeries and 10 hysterectomies without complications, an ancillary port on the abdomen, or conversion to conventional laparoscopy or laparotomy. For the 10 hysterectomies, the surgical time was 93.4 ± 6.3 minutes (mean ± standard deviation), intraoperative estimated blood loss 245 ± 54.0 mL, uterine weight 440.1 ± 76.5 g, and the postoperative hospital stay 2.7 ± 0.3 days. No patients required intraoperative blood transfusion. The two tubal sterilizations were completed in 18 minutes and 30 minutes, respectively, with negligible blood loss. The two salpingectomies, including one ruptured ectopic pregnancy with 2000 mL hemoperitoneum, were completed in 62 minutes and 116 minutes, respectively. The enucleation was completed in 64 minutes with 20 mL estimated blood loss. Conclusion Our preliminary results indicate that transvaginal NOTES for adnexal surgeries and hysterectomies is feasible and safe. However, this procedure is still new and should only be used as an alternative for conventional laparoscopic surgery in highly selected cases.

Objective This study aims to describe the feasibility of treating uterine leiomyoma with myomectomy by natural orifice transvaginal endoscopic surgery (NOTES). Materials and methods Women with leiomyoma underwent myomectomy by transvaginal NOTES in a tertiary referral medical center and surgical outcomes were measured. Results Three patients underwent the surgery at a mean age of 46.7 [standard deviation (SD), 6.2] years and mean body mass index of 21.6 (SD, 2.1) kg/m 2 . The average operative time was 128 (SD, 55) minutes. The average blood loss in the operation was 317 (SD, 207) mL without blood transfusion. No intra- or postoperative complications were noted. No cases were converted to traditional laparoscopy or laparotomy. Conclusion Our preliminary results showed the safety and feasibility of transvaginal NOTES in laparoscopic myomectomy. It is one of the minimally invasive surgeries and results in scarless healing. However, it should be evaluated in more cases.

Objective: The purpose of this article is to describe the application of hysteroscopy in different cases of gestational trophoblastic disease. Materials and methods: Three patients who presented with gestational trophoblastic disease were managed with hysteroscopy. The first case was a hydatidiform mole that underwent transcervical resection with endometrial curettage. The second case had a history of suction curettage for hydatidiform mole. She underwent transcervical resection for retained products of conception. The third case had a history of suction curettage for hydatidiform mole. In contrast with the second case, the patient had rising β human chorionic gonadotropin (β-HCG) values prior to transcervical resection and eventually underwent chemotherapy in the form of methotrexate. Results: The surgical procedure was uneventful in all three patients. All three operations were performed in

Objective The purpose of this article is to describe a new minimally invasive technique for an extremely large ovarian tumor. Materials and Methods From July 2010 to June 2011, three patients with large pelvic cystic tumor which extended up to or beyond the level of the umbilicus were recruited. All these patients were managed through a transumbilical 2-cm ultraminilaparotomy protected by the Alexis wound retractor and then combined with a single-port laparoscopy, which was accessed through three 5-mm cannulas fixed on the glove fingers. In ultraminilaparotomy mode and protection of spillage the tumor fluid was sucked out, and then the collapsed ovarian tumor was exteriorized for enucleation and repair. Finally the laparoscopic mode resumed for check-up and complete surveillance of the whole abdominal cavity. Results The procedures were completed uneventfully in all three patients, with a small amount of blood loss and shortened operation time. We found this approach offers the advantages of attentive prevention of tumor spillage and wound contamination over traditional laparoscopy, and a better cosmetic outcome and more comprehensive ability to manage the associated pathologies outside the reach of pure ultraminilaparotomy. Conclusion This application not only provides both advantages of ultraminilaparotomy and laparoscopy but it also overcomes the limitations of both approaches. Therefore, it is the surgical approach of choice for a patient bearing an extremely large ovarian cystic tumor.