We reviewed the medical charts and all consecutive cases of vNOTES hysterectomy for benign indications with uterus weighing ≥ 1kg performed by a single surgeon (Y.S. C) at the Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China, between January 2019 and March 2020. The baseline demographic data were recorded, including age, parity, body mass index (BMI), comorbidity, and history of surgery. The perioperative outcomes, such as operative time, estimated blood loss, uterine weight, changes in hemoglobin levels, hospital stay, any peri- or postoperative complications (fever, bowel injury, or genitourinary tract injury), and final pathologic diagnosis was recorded. The change in hemoglobin was calculated as the preoperative hemoglobin value minus the hemoglobin value on the first day after surgery. The length of hospital stay was calculated from the first day after surgery. Organ damage was considered as intraoperative complication. This study was approved by the Institutional Review Board and Ethics Committee (Number 2019-32) of Obstetrics and Gynecology Hospital, Fudan University.
All women were performed a routine preoperative assessment including a bimanual pelvic examination or vagino-recto-abdominal examination, a Papanicolaou smear, magnetic resonance imaging, and urinary ultrasound. Women with abnormal uterine bleeding were given diagnostic hysteroscopy and endometrial biopsy. All patients were given the written informed consent to the surgical procedure and to the use of individual data for research.
Patients were administered general anesthesia and placed in the dorsal lithotomy, and a Foley catheter was then inserted for constant urinary drainage. After injection of a water cushion, the circumcision of the vaginal mucosa around the cervix was performed, and the posterior portion was carried out by pushing up the vaginal mucosa along with the uterine-cervical fascia at the posterior fornix, then the rectovaginal space was opened (Fig. 1). The posterior colpotomy was easily underwent, however, sometimes the anterior colpotomy was not completed and was performed during the laparoscopy. The bilateral board ligaments, the transverse cervical and the uterosacral ligament complexes were coagulated and cut, then sutured. Then the single- ports device (Hangtian technology, China) was established (Fig. 2). The endoscope we used was a 10-mm, 30-degree endoscope (Karl Storz GmbH & Co KG, Tuttlingen, Germany).
After the creation of pneumoperitoneum, the bilateral broad ligaments of the uterine vessels were ascertained by grasping the cervix and pushing toward the contralateral site with endoscopic allis clamp. The uterine vessels were fixed and cut by a 5-mm bipolar Ligasure vessel sealer (Covidien, Mansfield, MA). Following the stump of the uterine arteries and the anterior border of uterus, the uterovesical junction was traced and identified (Fig. 3). After dissecting the uterovesical junction with ultrasonic knife, the anterior colpotomy was completed under laparoscopic guidance. If there were pelvic adhesions, ultrasonic knife or scissors was used for decompose adhesion. The remaining board and round ligaments were grasped and cut off step by step using Ligasure. The uterus was placed inside a large endobag, specimen was cut rotatingly by a cold knife, and extraction of the uterus was accomplished transvaginally (Fig. 4). Finally, the peritoneum and vaginal vault were closed with Vicryl suture (Vicryl; Ethicon Inc.). Pelvic floor reconstruction was performed in some cases. The surgical procedures were seen in the supplementary information.
Antibiotic prophylaxis was administered 0.5 hour before surgery; antithrombotic prophylaxis was given in accordance with the Caprini deep vein thrombosis assessment. The Foley catheter was removed on the first day after the operation. The patients were discharged, if their vital signs were stable and there was no evidence of surgical complications. Patients were required to forbid sex activity for at least 6 weeks after the operation and to return the outpatient one month after operation for follow-up examinations.
Descriptive statistics were expressed in terms of quantitative value as mean standard deviation (SD) or median and range and percentage. Linear regression was conducted to assess the sign of the slope of the regression for the learning curve. Independent t-tests were used to compare the continuous variables. A p-value less than 0.05 was considered statistically significant. SPSS software (SPSS version 22.0; SPSS Inc, Chicago, IL) was used to calculate.