Robotic Vaginal NOTES Hysterectomy: Two New Surgical Techniques

Objective: The aim of this research was to compare two new hysterectomy techniques by robotic vaginal natural orifice transluminal endoscopic surgery and to demonstrate that transvaginal robotic hysterectomy can be performed in nulliparous patients by natural orifice transluminal endoscopic surgery (NOTES). Materials and Methods: This research was conducted in a case series format. Previous experience with total vaginal NOTES hysterectomy (TVNH) and with transvaginal robotic surgery for robotic vaginally assisted NOTES hysterectomy (RVANH), led to the decision to combine these techniques to perform robotic TVNH (RTVNH) in nulliparous patients. Twenty patients were included in this study. In 10 nulliparous patients, RTVNH was performed. A gloveport was inserted into the vagina to create a pneumovagina. A Da Vinci Xi surgical robot was side-docked between the legs of each patient. The hysterectomy was performed via transvaginal NOTES using the surgical robot. Once the hysterectomy was completed, the robot and gloveport were removed. The colpotomy was closed as in classical vaginal surgery. The data of these patients were compared to that of 10 parous patients who underwent RVANH. Results: All procedures were completed without conversion to transabdominal laparoscopy or laparotomy. Mean patient data and results for RTVNH/RVANH were: age, 49–63; body mass index, 26.4–27.8; total operating time, 90–118 minutes; hemoglobin drop, 1.2–1.3 g/dL; uterus weight, 149–213 g; pain scores at day 1, 2–2, and at day 2, 2–2. There was one complication in the RVANH group: superficial thrombophlebitis. Conclusions: This cohort study confirmed that robotic transvaginal surgery is feasible and can be used to perform total hysterectomy. RTVNH enabled hysterectomies to be performed without any abdominal incisions in nulliparous patients, who had been determined as unsuitable candidates for classical vaginal hysterectomy. RTVNH and RVANH are novel techniques and require further validation. Further developments in robotic technology will help overcome the practical problem of arm collision and will increase the time efficiency of the procedure. (J GYNECOL SURG 32:270)