Single-Port surgical robot-assisted transvaginal natural orifice translumenal endoscopic surgery (v-NOTES) hysterectomy and double salpingectomy with pneumoperitoneum-free: surgical technique

Hysterectomy is a common surgical procedure in gynecology ( 1 - 4 ). Although vaginal surgery is recommended due to its quick recovery and less bleeding, it is still being gradually replaced by laparoscopic surgery due to its limited field of vision. The vaginal hysterectomy combined with transvaginal natural orifice translumenal endoscopic surgery (v-NOTES) technology has expanded the scope of treatment for vaginal surgery and is more visual. However, the classic v-NOTES lacks an operational triangle and has limitations in the direction of suturing and lateral pelvic wall dissection, making the surgery often difficult ( 5 , 6 ). To address this challenge, gynecologists have introduced more flexible robotic systems in v-NOTES to alleviate this difficulty. The feasibility of Da Vinci Xi robot in v-NOTES has been confirmed in various benign gynecological surgeries, including hysterectomy, myomectomy, sacrocolpopexy and tumor surgery ( 7 ). The Single-Port robotic surgery is highly compatible with the v-NOTES surgical concept, performing larger surgeries through smaller incisions. Our region has not yet approved the Da Vinci SP robots, but the application of other Single-Port surgical robots in v-NOTES hysterectomy is an exploration ( 8 ). We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-42/rc ).

A 49-year-old patient required hysterectomy due to grade 3 cervical intraepithelial neoplasia (CIN3) with a positive resection margin. The patient with rheumatic heart disease, mitral stenosis and pulmonary hypertension has mild physical activity restrictions and is less tolerant of pneumoperitoneum pressure. They are more suitable for a pneumoperitoneum-free state. Iodophor solution was used for vaginal irrigation 2 days before the operation. We administered cefmetazole 1.0 g to the patient 30 minutes before the surgery to prevent infection. General anesthesia was used for the operation, and the patient was placed in the lithotomy position with the bladder exposed, assisted by an endoscope in a head-down and hip-up position. The equipment used was the SHURUI ® laparoscopic Single-Port surgical system (SR-ENS-600). All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from the patient for the publication of this article and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Transvaginal surgery: transvaginal circumferential incision of the vaginal wall, pushing up on the bladder; opening the posteriorly depressed peritoneum. Transvaginal surgery: clamping, cutting, and ligating the uterosacral ligament and uterine vessels. Transvaginal surgery: place the PORT base without the upper cover. Transvaginal surgery: in order to minimize occlusion, the cervix is truncated at the isthmus of the uterus. Install a pneumoperitoneum-free suspension device in the lower abdomen of the patient ( Figure 1 ). Figure 1 Pneumoperitoneum-free device. Pneumoperitoneum-free device. Connect the robotic arm of the SHURUI ® laparoscopic Single-Port surgical system and insert it into the vaginal surgical channel ( Figure 2 ). Figure 2 SHURUI ® laparoscopic Single-Port surgical system. SHURUI ® laparoscopic Single-Port surgical system. The broad ligament, the proper ligament of the ovary, the round ligament and the mesentery of the fallopian tube were treated with the assistance of a Single-Port surgical robot endoscope. The whole procedure is shown in Video 1 . Single-Port surgical robot-assisted transvaginal natural orifice translumenal endoscopic surgery (v-NOTES) hysterectomy and double salpingectomy without pneumoperitoneum: surgical technique video.

The operation lasted 117 minutes (including the time for docking the robot), with approximately 40 mL of blood loss. There was no blood transfusion and no complications. No analgesic drugs were used after the operation. The patient began to consume liquid food after the anesthesia ended. Within 48 hours after the operation, 1.0 ivgtt q12h of cefmetazole was administered to prevent infection. The patient was discharged 72 hours after the operation. Half a month later, a postoperative follow-up examination was conducted and the recovery was good.

The installation of the Single-Port laparoscopic PORT base does not require a cover. During this operation of the Single-Port robot, a direct-view aspirator can be used to remove the smoke in the surgical field. Transvaginal surgical removal of the cervix can effectively reduce occlusion during endoscopic surgery.

Hysterectomy is a common operation in benign gynecological diseases. The surgical approaches include transabdominal, laparoscopic, transumbilical laparoendoscopic single-site surgery, v-NOTES, Da Vinci Xi robot-assisted laparoscopy and so on. The American College of Obstetricians and Gynecologists (ACOG) still recommends the vaginal approach ( 9 ). Laparoscopic-assisted vaginal surgery (v-NOTES approach) can extend the surgical field visually, avoiding the exposure difficulties of simple vaginal surgery. Especially for patients like this one who do not have a downward shift of the uterus and have a relatively high position of the sacral ligament, it can better utilize its advantages of quick recovery and less bleeding. The classic v-NOTES surgery has directional limitations in terms of suturing and surgical targets of the pelvic side wall, and it is often difficult to reach the surgical area ( 5 ). Since the Da Vinci Robotic Surgical System was approved for clinical use by the Food and Drug Administration (FDA) in 2000, the robotic surgical system has been widely used in the field of gynecological surgery. The Da Vinci Xi system, with its 7-degree-of-freedom “wrist-like” surgical instruments, offers greater freedom of movement than human hands and can perform complex operations such as rotation and suturing in confined spaces ( 10 , 11 ). The combination of robotic surgical system and v-NOTES can make full use of the surgical advantages of robotic rotatable wrist instruments in narrow space, make clamp cutting more accurate and convenient, filter hand tremor during direct operation. It is easier to handle lesions in special areas such as the pelvic lateral wall and help to improve surgical quality and ensure patient safety ( 12 ). There have been many reports on the use of Da Vinci Xi robot-assisted v-NOTES in hysterectomy surgeries ( 13 ). The horizontal arrangement of the Xi robot’s mechanical arms (with each arm spaced 8–10 cm apart) was changed to a triangular arrangement. Multiple mechanical arms crowded between the patient’s legs, resulting in a narrow space. The robot arms were thick and the vaginal opening was narrow, which increased the operation time for the preoperative preparation of the robot and the machine docking. Moreover, when the Xi robot’s arms occupied the space between the patient’s legs, the operating space for the assistant would be reduced, and the intraoperative cooperation between the assistant and the surgeon would also decrease. Since the Da Vinci SP system was not approved in the surgical region (China) ( 14 , 15 ), the SHURUI ® laparoscopic Single-Port surgical system (SR-ENS-600) was used. These Single-Port surgical robot arms are thinner, more advantageous in single-incision laparoscopy, and more able to overcome the difficulties caused by the absence of operating triangle in narrow space ( 15 ). This patient has heart and lung diseases. To avoid putting greater pressure on the patient’s heart and lung functions during the operation, it is the preferred indication for laparoscopy without pneumoperitoneum. However, when extended to patients with normal heart and lung functions, the pneumoperitoneum-free state also helps to more smoothly navigate the perioperative period and has a lower incidence of subcutaneous emphysema, hypercapnia, gas embolism, postoperative shoulder pain, nausea and vomiting, etc. On the other hand, the pneumoperitoneum-free state brings more convenience for the docking of the robot. In the SHURUI Single-Port robot-assisted v-NOTES surgical approach, the flexible bending of the robotic arm enhances the controllability of the surgical operation, making it easier and faster to achieve tissue coagulation and separation ( 16 , 17 ). However, due to the suspension of the manipulator arm, the Single-Port robot will have a sense of instability during operation. This kind of feeling requires more surgeries to adapt to and learn. This combination represents a new attempt at the application of Single-Port surgical robots, but it has been carried out in relatively small numbers ( 7 ).

The hysterectomy performed under natural orifice transluminal endoscopic surgery (v-NOTES) with the assistance of the Single-Port surgical robot can effectively avoid the limitations caused by the vaginal anatomy in direct-arm robot surgery. It is an effective combination of robots and v-NOTES surgery, but this combination is still in the initial exploration stage and more prospective controlled clinical evaluation are needed before it is widely applied.

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