Total vNOTES Approach for the Removal of a Giant Adnexal Cyst

To describe the successful minimally invasive management of a giant paratubal cyst using total vaginal Natural Orifice Transluminal Endoscopic Surgery (tvNOTES), an emerging alternative to conventional laparoscopy for large adnexal masses [1].

Stepwise demonstration of a surgical technique with narrated video, illustrating the tvNOTES approach for a giant adnexal mass.

Tertiary referral center specializing in minimally invasive gynecologic surgery.

A 34-year-old multiparous woman presented with abdominal discomfort and a visible lower abdominal bulge, a typical mode of revelation for giant paratubal cysts [2]. Magnetic resonance imaging revealed a giant unilocular cyst (28 × 25 × 12 cm) with pure fluid content occupying the entire abdominopelvic cavity. Hypertrophy of the right utero-ovarian ligament suggested a right adnexal origin, and tumor markers were within normal limits, arguing against borderline paraovarian pathology [4]. A tvNOTES approach was selected given its established safety and efficacy in benign adnexal disease [3], combining endoscopic precision with no visible scar, clear visualisation, and improved surgeon ergonomics. Building on the original tvNOTES technique [5], and contrary to conventional vNOTES, in which the inner ring of the Alexis O Retractor (Applied Medical, Rancho Santa Margarita, CA) is positioned within the peritoneal cavity, a 7-cm Alexis O Retractor was placed circumferentially within the vagina around the cervix. The GelSEAL Cap (Applied Medical) with four trocars was then secured to the anterior perineum. Pneumovagina was maintained at 12 mmHg using a thoracic drainage bottle, with active smoke evacuation. A 3 cm posterior colpotomy was performed under endoscopic guidance, revealing a giant right paratubal cyst. The cyst was incised at its most dependent point and drained of 5 liters of clear fluid. A right salpingectomy was performed due to fallopian tube elongation, preserving the ovarian blood supply. The procedure lasted 40 minutes without complications. The patient was discharged 6 hours postoperatively with minimal pain.

TvNOTES allows all surgical steps under endoscopic visualization, with the potential for rapid recovery, minimal postoperative pain, and ovarian preservation, even in cases involving very large paratubal masses. TvNOTES may represent a feasible approach for the minimally invasive management of giant adnexal cysts.