Endoscopic and Robotic Assisted Transvaginal Hysterectomy: A Feasibility Study

Purpose: To perform a feasibility study of the novel approach “transvaginal natural orifice transluminal endoscopic surgery” (vNOTES) with Da-Vinci robotic assistance. The primary objective of the study is to describe best surgical practices using a case series of robotic-assisted vNOTES in select patients. Methods: An institutional review board approved prospective single-arm, surgical intervention trial was performed. Outcomes measured included operative time, operative complications, estimated blood loss, hemoglobin changes, postoperative pain scores, and need for conversion to traditional robotic or laparoscopic hysterectomy via the abdominal approach. Patients who were referred to the gynecology oncology clinic to undergo hysterectomy for benign indications and met the study’s inclusion and exclusion criteria were consented. Patients were included if they had benign causes of abnormal uterine bleeding or pelvic pain, endometrial hyperplasia, cervical dysplasia, need for risk-reducing surgery for hereditary cancer syndromes or need for transgender-affirming surgery. Patients were excluded if they had prior rectal surgery, evidence of fixed uterus, posterior cul-de-sac obliteration and/or adhesions based on physical exam and/or imaging, evidence of narrowed vagina on physical exam, virginity, current pregnancy or history of advanced pelvic organ prolapse. Furthermore, obesity, nulliparity, or no history of spontaneous vaginal delivery are characteristics that may be deemed as risk factors for failure of a transvaginal approach and clinical judgment was used to determine eligibility for study inclusion. Patients deemed eligible were then enrolled for robotic-assisted transvaginal hysterectomy and bilateral salpingectomy with or without oophorectomy. In the pilot case, the surgery began as a traditional vaginal hysterectomy starting with a posterior colpotomy followed by transection and ligation of the bilateral uterosacral ligaments. Identification of the vesicouterine peritoneal reflection anteriorly was difficult and the GelPoint V-Path was placed only through the posterior colpotomy. The Da Vinci robot was docked and a 0-degree Da Vinci camera, monopolar scissors, Vessel Sealer and AirSeal assist port were placed through the 9.5 cm GelPoint transvaginal platform in a diamond configuration. The Vessel Sealer was used to transect across the uterine arteries. Due to poor visualization, conversion to the traditional abdominal robotic approach was required and the remainder of the surgery was completed in the usual fashion. In the subsequent two cases, a single laparoscopic port was placed abdominally to perform an initial survey of the pelvis. The abdomen was then deflated and the surgery was initiated in a fashion similar to the pilot case. Anterior and posterior colpotomy were successfully performed and the GelPoint platform was optimally placed. Vagina-pneumoperitoneum was obtained to 15 mmHg. In the second case, the 30-degree Da Vinci camera, the Vessel Sealer, ProGrasp Forceps, monopolar scissors, AirSeal assist port and a 9.5 cm GelPoint transvaginal platform were utilized. In the final case, three robotic arms were used rather than four (0-degree Da Vinci camera, the Vessel Sealer, ProGrasp Forceps) along with an AirSeal assist port through a 7 cm GelPoint transvaginal platform to improve ergonomics. The remainder of surgery was completed with robotic assistance with good visualization of the upper abdomen, pelvis and bilateral ureters. The vaginal cuff was closed by placing multiple figure-of-eight sutures similar to a traditional vaginal hysterectomy. Results: Two cases were successfully completed while the pilot case required conversion to the traditional robotic abdominal approach. This was due to difficulty in identifying the anterior vesicouterine peritoneal reflection. Intra-abdominal laparoscopic survey revealed anterior cul-de-sac adhesions with pathology-confirmed endometriosis. The most ergonomic set up was found to consist of three robotic arms (0-degree da Vinci camera, the Vessel sealer, ProGrasp Forceps) and an AirSeal assist port through a 7 cm GelPoint transvaginal platform in a diamond configuration. In the two successful cases, both patients had uncomplicated postoperative courses with pain scores of 2-3 on floor arrival and 0 at their two- and six- week post-op visits. Estimated blood loss of the second and third cases were 75 cc and 30 cc, respectively. The operative time of the third case significantly improved compared to the second case, from 195 minutes to 99 minutes. Conclusion: We demonstrated that robotic-assisted vNOTES is a feasible option in appropriately selected patients. As demonstrated by operative time changes, there exists a learning curve even when performed by experienced robotic surgeons. Compared with traditional vaginal hysterectomy, robotic surgery allows for improved visualization of and access to the adnexal structures and upper abdomen with improved dexterity in comparison to traditional laparoscopy instruments.