Application of the prone position in myomectomy by transvaginal natural orifice transluminal endoscopic surgery

Introduction
Natural orifice transluminal endoscopic surgery (NOTES) is a new concept of minimally invasive surgery. It could prevent complications related to the trocar in laparoscopic surgery, and help achieve ideal cosmetic outcomes.

Aim
To describe the safety and feasibility of the prone position in transvaginal NOTES (V-NOTES) resection of posterior uterine myoma.

Material and methods
Seventeen patients were included in the study from February to December 2019. All the patients were diagnosed with solitary posterior uterine myoma and underwent V-NOTES myomectomy in the prone position. We measured the characteristics and the surgical outcomes of these patients, to evaluate the safety and feasibility of the prone position in V-NOTES myomectomy.

Results
The mean age of the patients was 38.71 ±7.68 years and the mean body mass index was 22 ±2.02 kg/m2. Five patients had a cesarean section once, and 1 patient had a history of two operations (cesarean section and laparoscopic cholecystectomy). The remaining patients had no history of surgery. The mean myoma volume in the ultrasound report was 121.99 ±125.24 cm3. The mean operation time was 107.48 ±34.16 min. The mean hemoglobin decrease 48 h after the operation was 1.37 ±0.66 g/dl. The mean weight of the myoma was 183.88 ±144.29 g. The mean VAS score 12 h and 24 h after surgery was 2 ±0.87 and 1.18 ±0.73, respectively. The mean postoperative hospital stay was 3.18 ±0.39 days. One patient was converted to TU-LESS. No other complications such as massive hemorrhage, infection or injury occurred.

Conclusions
The prone position in V-NOTES myomectomy is safe and feasible. It expands the operative space and reduces the difficulty of surgery. Perhaps it can be used as a standard position for posterior uterine myomectomy by V-NOTES.