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SECTION 2 Current Clinical Applications and Techniques
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however, as previously noted with other NOTES procedures, development of robotic -specifi c NOTES platforms and
instrumentation would facilitate clinical translation.
A novel hybrid approach was reported by Baldwin et al.
[12], describing porcine nephrectomy using a transureteral
NOTES approach in conjunction with two 2 –3 mm needlescopic transabdominal ports. Using an experimental integrated balloon dilator and sheath, the ureter was dilated to
33 F, facilitating placement of a 150 mm bariatric 12 mm
laparoscopic trocar. An offset hysteroscope (Gyrus ACMI,
Southborough, MA, USA) was advanced, and a hook electrode was used to incise the ureter medially for retroperitoneal access and subsequently for dissection around the
kidney. For hilar vascular control, an experimental 5 mm
bariatric bipolar sealing device (LF5544 Ligasure, Covidien,
Mansfi eld, MA, USA) was used. Morcellation was carried
out with the bipolar sealing device by cutting the tissue into
strips, and fragments were then removed transurethrally
using a stapling device. The ureteral stump was closed internally with a 10 mm titanium clip applier (Ethicon Endosurgery, Cincinnati, OH, USA). The authors noted that lack of
an effective morcellation instrument for this NOTES portal
made morcellation diffi cult. Additionally, this access technique does not allow for simultaneous dissection and
suction. Thus, considerable modifi cations in instrumentation must be made prior to clinical application of this hybrid
approach.
Clinical applications
Due to a paucity of adequate instrumentation for pure
NOTES, initial human NOTES procedures employed the use
of transabdominal ports in addition to natural orifi ce access
as described by Branco et al. in the fi rst hybrid transvaginal
NOTES nephrectomy [13]. In contrast to prior reports utilizing the vagina solely for kidney extraction following laparoscopic nephrectomy [14,15], this hybrid NOTES approach
involved using vaginal access for a working port as well as
an extraction site. As this procedure was performed for
benign disease, the kidney was removed using a polypectomy snare after which the colpotomy was closed using a
single running 2 -0 absorbable suture. The 23 -year -old
woman was dismissed 12 hours postoperatively and resumed
activities of daily living on postoperative day 3. During this
case, authors noted lack of endoscope stability resulting in
limited control during dissection, as well as diffi culties with
visualization.
Since this fi rst description, application of hybrid NOTES
nephrectomy has been extended to malignant disease. After
their initial description of transvaginal NOTES -assisted
laparoscopic nephrectomy for renal cancer [16], Alcaraz
et al. performed transvaginal NOTES nephrectomy with the
assistance of two 5 and 10 mm transabdominal ports in a
series of 10 patients with T1 –T3a renal cell carcinoma [17].
Of note is that the vaginal port was only used for the camera,
while all surgical steps for performing radical nephrectomy
were performed through the abdominal ports. One patient,
with history of previous abdominal and pelvic surgery, suffered a major surgical complication in the form of a colon
injury requiring temporary colostomy. This underscores the
need for careful patient selection for NOTES procedures. The
experience by Sotelo et al. [18] corroborates this important
point, as during hybrid NOTES transvaginal nephrectomy,
three of four cases required conversion to standard laparoscopy secondary to rectal injury during vaginal entry in their
fi rst patient, failure to progress in the second, and bleeding
during suprahilar mobilization in the third. Moreover, long term follow -up is necessary to determine oncologic effi cacy
as well as patient functional outcomes.
Transvesical NOTES
Laboratory studies
Of paramount concern when considering intraperitoneal
access through a NOTES portal is ensuring a safe access
technique. Thus, feasibility studies in ex vivo and in vivo
porcine models were performed by Gettman to evaluate the
bladder as a portal for NOTES. Initially, ex vivo studies using
porcine stomach to represent simulated bladder and an
infl ated latex balloon to simulate bowel were carried out to
assess transvesical access techniques. Two blunt tip prototypes as well as an injection needle with guidewire placement and balloon dilation were tested. With respect to force
of entry, the preferred access technique in this experiment
was the needle/balloon dilation approach, as the blunt -tip
prototypes required increased force. However, the size of the
defect created by the dilation technique was larger than that
of the blunt -tip prototypes. No observed injuries to the simulated bowel were encountered with either technique.
In the in vivo porcine model, two animals were placed
under general anesthesia, and access was obtained using a
blunt-tip prototype in one and the needle/balloon dilation
technique in the other. The irrigation port of the ureteroscope was used as an insuffl ation port to maintain pneumoperitoneum. Diagnostic peritoneoscopy and subsequently
liver biopsies were performed utilizing a rigid ureteroscope
(13.5 F, Richard Wolf, Knittlingen, Germany), endoscopic
grasping forceps, and an electrocautery probe placed through
the working channel of the ureteroscope. Although an
access-related bowel injury occurred with the needle/
balloon dilation technique, it did not preclude proceeding
with and completing the procedure successfully. Female
cadavers were also utilized to demonstrate feasibility of
transvesical peritoneoscopy, appendectomy, and division of
the falciform ligament.
Lima et al. [19] also evaluated the utility of transvesical
access in the porcine model. Through a cystoscope, an open ended ureteral catheter was used to puncture the ventral
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CHAPTER 16 Urologic Applications of NOTES
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bladder wall. After placing a guidewire, a 5.5 F overtube was
advanced into the peritoneal cavity, and peritoneoscopy was
performed using a 9.8 F ureteroscope. Liver biopsy and division of the falciform ligament were performed. The bladder
was left to heal by secondary intention and a postoperative
indwelling catheter was left for four days, at which time
necroscopy revealed completely healed cystotomy sites and
no evidence of intraperitoneal complications.
Transvesical peritoneoscopy was then translated to the
human experimental model as detailed by Branco et al. [20]
in two adult male cadavers. Access to the peritoneal cavity
was obtained transurethrally through a 9.5 Fr rigid ureteroscope (Storz 27002 L, Karl Storz, Tuttlingen, Germany) using
a 5 Fr splitting forceps (Storz 27424U) for mucosal incision
at the bladder dome followed by a 5 Fr Peres Castro forceps
(Storz 27452R) to traverse the bladder wall. Pneumoperitoneum to 12 mmHg was achieved via the irrigation port, and
following peritoneoscopy, the Peres Castro forceps were
used to obtain a liver biopsy. The cystotomy was not formally closed in this experiment.
Though cystotomy sites are known to heal by secondary
intention with bladder drainage, reliable closure techniques
for the transvesical NOTES portal are necessary in order to
limit the time needed for postoperative indwelling catheter.
Accordingly, Lima et al. [21] described endoscopic full thickness closure of 10 –20 mm cystotomy sites in a survival
porcine model. A 19 -gauge needle catheter (Cook Endoscopy, Winston -Salem, NC, USA), with the needle preloaded
with a metal T -tag attached to a 90 cm 3 -0 Monocryl thread
(Ethicon, Somerville, NJ, USA), was advanced through the
working port of the cystoscope and then transmurally
through one cut edge of the cystotomy, after which a stylet
dislodged the T -tag, thus deploying it outside the bladder
(Figure 16.1). This was repeated on the opposite cut edge of
the cystotomy, and the threads were then locked and cut
using a prototype device (Davol, CR Bard, Murray Hill, NJ,
(a)
(d) (e) (f)
Figure 16.1 Diagram of the T -tags appliance and locking in the bladder wall. (a) Endoscopic needle approaching the edge of vesicotomy; (b) release
of the fi rst T -tag; (c) endoscopic needle approaching of the other edge of the vesicotomy; (d) release of the second T -tag; (e) lock advancement; (f) lock
release. (Reprinted from European Urology, volume 56, Lima et al, “Endoscopic Closure of Transmural Bladder Wall Perforations ”, pp. 151 –8, © 2009,
with permission from Elsevier.)
(b) (c)
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SECTION 2 Current Clinical Applications and Techniques
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USA) and thread locks from a Bard (Davol) EndoCinch kit
(Bard Billerica, Boston, MA, USA). Under laparoscopic guidance in two animals, methylene blue was instilled in the
bladder and demonstrated a watertight suture line. At
necroscopy 15 days postoperatively, sutured cystotomy sites
were completely healed with no evidence of infection or
intraperitoneal adhesions.
Metzelder et al. [22] described a technique for vesicotomy
closure in piglets after transvesical NOTES nephrectomy. Of
note is that this technique was not performed purely transvesically but also employed a transabdominal port. After
transumbilical specimen removal, an endoloop device placed
transumbilically was used to close the bladder while a 2 mm
transurethral endoscopic clamp was used for assistance. At
the conclusion of the procedure, bladder fi lling revealed the
closures to be watertight, and at necroscopy, adequate
bladder closure was again tested using air fi lling pressures
and again found to be impermeable.
Clinical applications
The fi rst published clinical application of transvesical
NOTES was reported by Gettman and Blute in a 56 -year old gentleman in 2007 [23]. Consent was obtained for
suprapubic catheter placement in conjunction with robotic assisted laparoscopic prostatectomy. Pneumoperitoneum
was obtained and laparoscopic ports were placed in the
standard fashion for robotic prostatectomy. Through a standard rigid cystoscope placed transurethrally, a fl exible injection needle was advanced through the bladder wall under
simultaneous laparoscopic and endoscopic guidance (Figure
16.2a–c). Over a guidewire, a balloon dilator (UroMax,
Boston Scientifi c, Natick, MA, USA) was used to dilate the
cystotomy tract, a fl exible ureteroscope (DUR -8, Gyrus
ACMI, Maple Grove, MN, USA) was advanced, and transvesical peritoneoscopy was performed (Figure 16.2d,e).
Pneumoperitoneum was maintained through the working
channel of the ureteroscope during the procedure. All intraperitoneal structures were visualized with a direct line of
sight. Upon removal of the ureteroscope, the cystotomy site
decreased in size but was not watertight, thus the site was
closed with 2 -0 Vicryl fi gure -of-eight sutures prior to proceeding with robotic prostatectomy.
Beyond this single report, other applications of transvesical NOTES in humans have not been published, likely secondary to a number of technical obstacles inherent to this
access portal. With current endoscopes, working channels
are in -line with the scope and lie within the same sheath,
hindering the ability to acquire the proper angle to approach
the target organ, as well as restricting triangulation. Modifi cation of laparoscopic articulating instruments for application in transvesical NOTES may aid in overcoming some of
these obstacles. Moreover, urethral diameter is a limiting
factor as large -diameter scopes and accompanying instruments may require urethral dilation, a procedure associated
with potential urethral injury and bleeding. Thus, development of NOTES -specifi c surgical platforms and instruments
is germane to further advancement of the transvesical
approach.
Transgastric NOTES
The transgastric route for NOTES has been described for
urologic procedures mainly in hybrid approaches, detailed
later in this chapter. To date, pure transgastric urologic
NOTES procedures have been limited to laboratory experiments. Concerns exist regarding this access portal that must
be addressed prior to mainstream urologic application in
humans. Risk of intraperitoneal contamination with gastric
or bowel contents is plausible even with peri -operative irrigation. Additionally, with gastric access, the ability to maintain spatial orientation is limited and working instruments
are in -line with the camera, further augmenting the diffi culty of complex procedures. Moreover, specimen extraction
with a pure transgastric approach would be limited due to
size constraints of the peroral route.
One report of a urologic procedure performed using a
transgastric approach is renal cryoablation in a porcine
model as described by Crouzet et al. [24]. Pneumoperitoneum was fi rst established transabdominally using a Veress
needle. Through a dual -channel video gastroscope (Olympus
America Corp.), gastrotomy was created by incising with a
needle-knife followed by radially dilating with a 15 mm
balloon over a guidewire. Dissection of the upper pole of the
kidney was carried out using monopolar cautery and scissors. Subsequently cryoablation was performed percutaneously through the prior Veress needle puncture site under
gastroscopic guidance using a 2.4 mm cryoablation probe
PERC-24, R2.4 (Endocare, Irvine, CA, USA). For gastrotomy
closure, T -fasteners that had been deployed into the stomach
prior to incision were secured and locked, and the site was
found to be watertight.
Boylu et al. reported feasibility of partial nephrectomy
through a transgastric approach in a porcine model [25].
Pneumoperitoneum was gained using a transabdominal
Veress needle, and a 2 cm gastrotomy was created using an
electrocautery needle under gastroscopic guidance. After
advancing the scope through the gastrotomy, a thulium laser
(RevoLix, AllMed Systems, Pleasanton, CA, USA) at 30 W
was used to perform partial nephrectomy without hilar
clamping or use of any hemostatic measures such as sealing
agents, bolsters, or sutures. Upon removing the specimen
through the stomach using a wire loop, the gastrotomy site
was closed endoscopically with metal clips. A major limitation of this approach for partial nephrectomy is the lack of
a specimen entrapment sac that could be placed gastroscopically, thus introducing the risk for tumor spill/seeding upon
extraction.
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(a)
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CHAPTER 16 Urologic Applications of NOTES
(b)
(e)
(d)
(c)
Factor
CMAYO
2007
EC1273200–001–0
Figure 16.2 Transvesical access to the peritoneum. (a) A rigid
cystoscope is placed transurethrally, and a fl exible injection needle is
advanced through the working port of the scope and through the
bladder wall. (b) A guidewire is passed through the injection needle, and
(c) a balloon dilator is used to dilate the cystotomy tract. (d) After dilating
Factor
CMAYO
2007
EC1273200–002–0
the cystotomy tract, the balloon dilator, injection needle, and rigid
cystoscope are removed while the guidewire remains in place.
(e) A fl exible ureteroscope is then advanced over the guidewire and into
the peritoneum. (By permission of Mayo Foundation for Medical
Education and Research. All rights reserved.)
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SECTION 2 Current Clinical Applications and Techniques
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NOTES partial cystectomy via transgastric access was demonstrated by Sawyer et al. [26]. Following needle -knife incision and advancement of a gastroscope near the bladder,
endoscopic loop devices (PolyLoop, Olympus, Center Valley,
PA, USA) placed through working channels were closed to
envelop the bladder specimen. Next, a needle -knife and wire
snare (SnareMaster Soft, Olympus) were used to cauterize
an incision between the closed loops. The specimen was
grasped and removed through the gastrotomy site. The
cystotomy was closed with endoscopic clips, but the gastrotomy site was not closed in this experiment. A major
concern with this technique is inadvertent entrapment of
tumor within the loop device and thus risk of tumor spillage
and/or incomplete resection.
Transurethral NOTES
Laboratory work
As urologists are adept at performing transurethral procedures for various disease entities, translation of NOTES
technology to this access portal to include partial - and
whole-organ resection as with partial cystectomy and radical
prostatectomy seems to be a natural next step but has
only recently been employed with only a few reported
experiments.
In addition to transgastric partial cystectomy, Sawyer
et al. [26] performed transurethral NOTES partial cystectomy in a porcine model. Through a 22 Fr rigid multichannel
cystoscope, a grasping forceps device advanced through one
channel and through the loop of the endoscopic loop device
(PolyLoop, Olympus), placed through a second channel, to
grasp the mucosal site of interest. After withdrawing the
bladder wall tissue through the loop and subsequently
cinching the loop, a braided wire -snare loop (SnareMaster
Soft, Olympus) was placed around the entrapped mucosa
and excised the specimen on cutting current. The cystotomy
site was then closed with endoscopic clips (Resolution,
Boston Scientifi c and/or Quickclip2, Olympus). Obviously
the size of the loop device may limit the amount of tissue
resected using this technique, thus size of targeted specimen
may restrict its potential use.
The initial description of transurethral NOTES radical
prostatectomy (NOTES -RP) was in fresh frozen cadavers as
reported by Humphreys and colleagues in 2009 [27]. Using
a 26 Fr resectoscope, a 7 Fr laser stabilizing catheter (Cook
Medical Inc, Bloomington, IN, USA) was placed through
which a 500 μm end -fi ring laser fi ber (SlimLine Reusable
Holmium Laser Fiber, Boston Scientifi c Corp, Natick, MA,
USA) was advanced. A 100 W holmium:yttrium -aluminumgarnet (YAG) laser (Verapulse, Luminis, Inc., Santa Clara,
CA, USA) was used for cutting and dissection, starting lateral
to the verumontanum and extended circumferentially
(Figure 16.3). Care was taken to stay below the dorsal
venous complex as well as preserve the neurovascular
bundles. In this experiment, the seminal vesicles and vas
deferens were transected and left in situ. Specimen removal
was accomplished by open extraction in the fi rst cadaver and
transurethrally using a tissue morcellator in three cadavers.
During the open extraction case, visual inspection of the
pelvis revealed intact endopelvic fascia, robust neurovascular bundles, and peri -rectal fat in the empty prostatic fossa
(Figure 16.4). Vesicourethral anastomotic sutures were
placed using the SR5 suture device (LSI solutions, Victor, NY,
USA) through either a 26 Fr or 27 Fr offset nephroscope.
Technically, the procedure was feasible with laser performance similar to that experienced with live human tissue.
These authors noted that placement of vesicourethral
anastomotic sutures was diffi cult secondary to limitations
of existing instrumentation, and the anastomosis was not
tested in this experimental model. Moreover, ability to evaluate hemostasis could not be achieved in the cadaver model.
Thus, this group subsequently performed NOTES -RP in six
non-survival canines [28]. Through a perineal urethrostomy, a resectoscope was placed and prostate resection was
carried out as previously described, with the holmium laser
successfully used to achieve hemostasis. Vesicourethral
anastomosis was completed in one canine using perineal
Vest sutures. A signifi cant drawback to the canine model was
the intra -abdominal location of the bladder and prostate, as
fl uid displacement following capsular incision hindered surgical progress in cases lasting longer than one hour, requiring abdominal incision to evacuate excess fl uid in four cases.
Again, the authors noted diffi culty completing vesicourethral anastomosis due to lack of appropriate endoscopic
equipment and suturing devices.
Clinical application
Upon demonstrating feasibility in experimental models with
subsequent development of specialized instruments, Humphreys et al. have since described clinical experience with
NOTES radical prostatectomy in two patients [29] (Video
16.1). Nerve -sparing resection of the prostate was carried
out as previously described, after which the prostate was
pushed into the bladder. A prototype cannula scope and
urethra-vesico anastomosis device (UVAD, LSI Solutions Inc,
Victor, NY, USA) was employed to perform a six -point interrupted anastomosis using 3 -0 monofi lament suture. Following placement of the suture through bladder and urethra,
the anastomotic device was removed and a titanium knot
(LSI Solutions Inc.) was placed and cinched, and a 20 Fr
catheter was advanced over a wire with 10 ml in the balloon
(Figure 16.5). Cystogram performed after endoscopic suturing confi rmed a watertight anastomosis. To obtain complete
pathologic analysis as well as confi rm margin status, a 2.5 cm
suprapubic cystotomy incision was created for specimen
extraction. Estimated blood loss was 45 and 85 ml and resection time 37 and 94 minutes in patients 1 and 2, respectively.
178
Capsule cut from
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the 7 to 9 o’clock
position to begin
extra prostatic
dissection.
Dissection carried
towards the bladder
neck anterior to the
prostate but below
the level of the dorsal
venous complex.
CHAPTER 16 Urologic Applications of NOTES
7
5
12
Bladder entered
anteriorly at 12
o’clock position
preserving as
much of the
bladder neck
as possible.
Figure 16.3 Representation of the natural orifi ce translumenal endoscopic surgical radical prostatectomy (NOTES -RP). The dissection is carried out in
the retropubic space below the level of the dorsal venous complex. (By permission of Mayo Foundation for Medical Education and Research. All rights
reserved.)
NVB
Bladder neck
Trigone
Figure 16.4 Post-NOTES-RP at time of pelvic exploration performed on cadaver number 1. The intact endopelvic fascia, levator ani, neurovascular
bundles (NVB), and trigone can be observed. Peri -rectal fat is noted in the bed of the post -prostatectomy cavity.
Pubic arch
Levator ani
Peri-rectal fat
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NOTES-specifi c operating platforms and instrumentation
unique to each access portal. With respect to malignant
disease, long -term follow -up is necessary to determine
cancer -specifi c recurrence and survival rates after NOTES
procedures compared to rates achieved with currently available surgical techniques.
Chapter video clip
Video 16.1 NOTES radical prostatectomy: the initial surgical
experience. (Reproduced by permission of Dr Mitchell R. Humphreys.)
Figure 16.5 Illustration demonstrating six -point vesicourethral
anastomosis completed transurethrally after NOTES -RP.
Final pathology revealed Gleason 3 + 3, pT2aNXMXR0 in
the fi rst patient and Gleason 3 + 4, pT2cNXMXR0 in the
second patient. Both patients were dismissed on postoperative day two and are awaiting follow -up prostate specifi c
antigen (PSA) screening.
It is notable that the holmium laser is utilized in the
setting of normal saline irrigation, and it is expected that
some fl uid absorption will occur during NOTES -RP secondary to incision of the prostate capsule. However, with limited
resection time in the setting of normal cardiac and renal
function, this should be endured without consequence in
most patients. Indeed, in this clinical series, postoperative
serum sodium rose by only 2 and 1 mmol/l, respectively.
As NOTES -RP is not inclusive of pelvic lymph node dissection or complete removal of the seminal vesicles, patients
must be carefully selected to have organ -confi ned disease
with low risk of involvement based on validated data [30,31].
Although long -term follow -up is necessary to determine
oncologic durability, continence, and erectile function outcomes, feasibility has been proven. In time, this technique
has potential to become accepted for mainstream application
as a minimally invasive treatment alternative for prostate
cancer.
Summary
Signifi cant advances in urologic NOTES procedures have
been made in the laboratory setting and subsequently translated to clinical applications. A variety of NOTES portals
have been utilized to successfully perform a variety of urologic procedures. However, there are limitations with existing instrumentation warranting further development of
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Gynecologic Applications of NOTES
Antoine Watrelot ,1Géraldine Chauvin,1& Arnaud Wattiez
1
Hôpital NATECIA, Lyon, France
2
IRCAD (Research Institute Against Digestive Cancer), Strasbourg, France
Introduction
The gynecologic natural orifi ce was one of the fi rst access
points of natural orifi ce translumenal endoscopic surgery
(NOTES). Although the transvaginal approach is only available for half of the population for obvious reasons, it was
relatively simple to develop, especially since it had already
been mastered by gynecologists.
However, transvaginal surgery has few direct applications
in gynecologic surgery; other routes such as transgastric, the
hybrid route, and combined techniques are probably more
useful.
The interest in gynecologic NOTES is similar to that of
other NOTES applications: there are no visible scars, and the
minimally invasive nature of procedures allows us to expect
quicker postoperative recovery, less pain, and possibly fewer
complications.
We are at the beginning of a new era and nobody knows
today what the future holds for gynecologic NOTES.
However, it seems noteworthy to review the current state of-the-art as well as outcomes that should be reasonably
expected.
2
the primary surgical site instead of been used as a pathway
to perform intrapelvic or abdominal operations, and, second,
because most of these techniques are not endoscopic,
thereby leading to specifi c complications and inappropriate
to the defi nition of NOTES.
The fi rst real gynecologic NOTES procedure was the introduction of fertiloscopy (or transvaginal endoscopy) 10 years
ago. All the characteristics of a NOTES procedure were
brought together: it used a natural orifi ce and it was an
endoscopic method. Thereafter, the transvaginal approach
has also been a route for non -gynecologic procedures, the
most popular example being the gallbladder removal made
popular by J. Marescaux and his team [1].
Today, it seems valuable fi rst to review the different transvaginal techniques used and, second, to explore the possible
gynecologic NOTES procedures that may be performed.
Surgical techniques for gynecologic NOTES
Transvaginal routes
Two techniques are available, the “standard” posterior colpotomy and the endoscopic technique.
Defi nition and history
In the nineteenth century, vaginal surgery had already been
used mostly for vaginal hysterectomy or for treatment of
vaginal conditions such as genital prolapse. In the 1940s,
culdoscopy met with great success before the era of laparoscopy, but was quickly abandoned due to the superiority of
laparoscopy and to the complications induced by culdoscopy
itself (mostly infection).
All these “vaginal” techniques have little to do with
“gynecologic NOTES. ” First, this is because the vagina was
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
182
Standard colpotomy
This technique is well known to gynecologists and consists
of a transverse incision 1 cm below the cervix, between the
two uterosacral ligaments (Figure 17.1). The dissection then
allows access to the peritoneum of Douglas ’s pouch, which
is incised, hence leading to the peritoneal cavity (Figure
17.2). At that stage the gynecologic surgeon inserts a retractor since the posterior colpotomy is usually an operative step
in vaginal hysterectomy.
Should it be for a NOTES procedure, a fl exible endoscope
is introduced and a purse string suture is performed on the
vaginal wall to avoid CO
leakage. This technique as such is
2
Figure 17.1 Conventional colpotomy: opening of vagina between the
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two uterosacral ligaments.
CHAPTER 17 Gynecologic Applications of NOTES
Figure 17.3 Principle of fertiloscopy (transvaginal hydropelviscopy).
Endoscopic approach
Fertiloscopy was described (Figure 17.3) after the initial
work of Gordts et al. [2].
Figure 17.2 Conventional colpotomy: opening of the peritoneum.
simple but sometimes is not easy to carry out because of the
diffi culty in fi nding the right plane, with the risk of false
route behind the peritoneum and also a potential risk of
rectal injuries. These diffi culties are mostly due to the depth
and limited space available in the posterior fornix.
Additionally, the surgical opening of the peritoneum associated with the required manipulations potentially increases
the risk of infection due to the large communication space
between the vagina and the peritoneal cavity.
At the end of the procedure, it is necessary to close the
peritoneum and the vaginal wall. There is a risk of postoperative dyspareunia if we refer to dyspareunia described
after vaginal surgery such as vaginal hysterectomy.
Fertiloscopy (see Video 17.1)
Purpose of f ertiloscopy
Fertiloscopy has been designed to explore the pelvic cavity
in a minimally invasive fashion, more acceptable than standard laparoscopy. The technique of fertiloscopy has been
extensively described [3] (see Video 17.2), but it basically
consists in an hydrolaparoscopy, which means that, in the
same way as standard laparoscopy, a Veress needle is inserted
into the pouch of Douglas; instead of instilling CO
, saline
2
is instilled, hence providing the working space.
Thereafter, a special sharp trocar, 6 mm in diameter, fi tted
with a balloon at its end is inserted into the pouch of
Douglas. The balloon is used to prevent the trocar from
being pulled out inadvertently from the peritoneal cavity.
The scope is then inserted in the special trocar, allowing for
the exploration of the genitalia initially. The scope is rigid
and has a 30 ° lens as the structures to be observed are
located above the incision. A 0 ° lens would not allow for an
appropriate view of the tubes, ovaries, and uterus. At the
end of the procedure, it is not necessary to close the trocar ’s
introduction site.
Advantages of f ertiloscopy
Fertiloscopy is a truly minimally invasive operation, which
may be performed under local anesthesia or mild sedation.
In all cases fertiloscopy is practiced as an outpatient procedure. In some countries, such as the USA, fertiloscopy is
allowed to be performed as an inpatient procedure [4]. As
mentioned above, one of the criticisms of the “conventional”
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