Cystectomy of a 17-cm Adnexal Mass Using vNOTES

INTRODUCTION: The patient is a 19-year-old G0 with no past medical history who presented for surgical management of a large cystic adnexal mass. OBJECTIVE: To demonstrate the efficacy of the vNOTES (vaginal natural orifice transluminal endoscopic surgery) surgical device in a single case report of a 19-year-old female patient with a 17-cm cystic adnexal mass. METHODS: This is a case report. RESULTS: The patient presented with a pelvic mass that caused significant daily pain and mass effect. The pelvic exam was notable for a soft, non-tender, mobile midline mass extending past the umbilicus to approximately 21 cm. Pelvic ultrasound showed a simple unilocular cyst arising from the right ovary measuring up to 17.2 cm without nodularity or septations. MRI of the abdomen was consistent with pelvic ultrasound and favored benign etiology. CA-125 was normal. Recommendation was made for cystectomy with minimally invasive surgery. Given the patient’s young age and desire for cosmetic results, vNOTES was selected as the optimal surgical approach. The peritoneal cavity was entered by making a small incision at the posterior cervico-vaginal junction. An Alexis-O retractor was placed in the posterior cul-de-sac to retract the uterus anteriorly and the bowel posteriorly. The vNOTES gel port was placed and pneumoperitoneum was established. An endoscope was passed into the peritoneal cavity. The adnexal cyst was punctured with a laparoscopic needle and drained. The gel port was removed, and the cyst wall was resected transvaginally. After complete resection, the gel port was replaced to re-establish pneumoperitoneum and complete an abdominal survey. The abdominal cavity appeared normal, and both fallopian tubes and ovaries were hemostatic. All instruments and devices were removed, and the posterior vaginal cuff was closed with suture to complete the procedure. CONCLUSIONS: The patient was discharged home the same day with no visible incisions. vNOTES is a novel minimally invasive approach that can be successful for the appropriate adnexal pathology. There are several additional benefits from combining laparoscopic and vaginal surgical techniques, including better visualization, fast recovery, and no visible incisions.