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BackTable / OBGYN / Article
vNOTES Surgery Basics & Patient Benefits
Melissa Malena • Updated Jul 8, 2024 • 247 hits
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a laparoscopic technique characterized by entrance via vaginal incision. vNOTES can be implemented for hysterectomy, myomectomy, adnexectomy, and many other gynecological procedures. Compared to the traditional abdominal approach, vNOTES surgery can lower pressure levels, lessen patients’ pain, and accelerate recovery. Gynecologic surgeon Dr. Jan Baekelandt shares the basics of his vNOTES techniques with BackTable OBGYN, and expands on the advantages of this up-and-coming procedure.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The Backtable OBGYN Brief
• vNOTES is a laparoscopic surgical technique where the incision is within the vagina as opposed to the abdomen.
• vNOTES surgeries typically use lower pressures, with levels ranging from 8-12 Pa.
• vNOTES patients often require less time in the Trendelenburg position than other techniques, optimizing anesthesia performance with the minimum amount of medication used.
• Implementing vNOTES procedures into practice necessitates that surgeons undergo thorough training and work progressively upward in difficulty.
Table of Contents
(1) vNOTES Procedure Technique
(2) Advantages of the vNOTES Approach: Vaginal vs Abdominal Incisions
(3) Becoming Proficient with vNOTES
vNOTES Procedure Technique
In standard vNOTES cases, a 20 to 25-degree Trendelenburg positioning is implemented. However, these cases use significantly lower pressures, ranging from 8-12 Pa, and patients are in the Trendelenburg position for less time. Bowel packing should be used cautiously as it increases adhesion risks, but can be helpful in challenging cases with high BMI patients.
In patients with endometrial cancer, the vNOTES approach allows for sentinel node resection to be done retroperitoneally, possibly avoiding Trendelenburg positioning completely. The retroperitoneal is accessed by injecting intraureteral indocyanine green (ICG) into the cervix for visualization then approaching the retroperitoneal space via the obturator area. From there, resection can continue upward via a lateral vaginal fornix incision or an anterior vaginal wall incision.
[Dr. Mark Hoffman]
Are there specific techniques? I think about the bowel. There's two things, I guess, with the patients that are obese. Getting in certainly is a challenge, but I typically can find ways to get in, things like Palmer's point where there's usually an opportunity to do that and get a pneumoperitoneum, but it's putting a patient upside down. We're not dealing with the same challenges as the bariatric surgeons who are operating in the upper abdomen.
When they are operating, their patients are in reverse Trendelenburg, and all of their bowels go down, and there's decreased pressure on their chest. Those patients, they're not getting as many complaints from the anesthesiologist saying, "I can't breathe this patient," where in laparoscopy for gynecologic surgery, our patients are on their heads and we get them in T-berg and it's like, "Guys, we can't do this." T-berg is what, as you know, allows us to get the bowel up and out of the pelvis so we can operate safely. Is the degree of Trendelenberg required for vNOTES? Do you still have to put them upside down or are you able to use less Trendelenberg, and then in terms of your peritoneum, is it similar pressure for vNOTES?
[Dr. Jan Baekelandt]
I think on the standard case we use the same degree of Trendelenburg. We use 20, 25 degrees for the endoscopic part. There's a vaginal part as well where the patient's flat, so it's a shorter term of the procedure that they need to be in Trendelenburg. We use the same degree at Trendelenburg. We use lower pressures for vNOTES. Laparoscopically will traditionally work 12 to 15. I think that's very much a local habit, and you could work lower, but that's what we have in our practice. For vNOTES, we stand at work from 8 to 10. I think that's really a collaboration with your anesthesiologist. The more they relax the patient, the lower pressure you can work on.
I think for the very obese patients, we need to give them Trendelenburg as well, and that's always a balance. It's the same with vNOTES. You need to find that balance with your anesthesiologist. The pressures are a bit lower and even then we tend to try and give even lower pressures.
I know for the super-high BMI patients that you can also try and pack the bowels. Vaginally, you have access to put a big swab in and pack the bowel out the way. I think for most cases we try to avoid doing that, and I think we only do it, or I only do it for the very high BMI, because when you pack your bowels, you get more adhesion. We try to avoid that in general, but in those challenging cases, that can help as well.
I think another thing for our endometrial cancer patients, which is typically the very high BMI population, there with vNOTES, we're now doing our sentinel nodes retroperitoneally, and that really helps because as long as we're doing a transvaginally retroperitoneally, but there you don't need any Trendelenberg at all because you're working retroperitoneal, so for that whole part of the procedure where if you're doing it laparoscopically, robotically, your patient's upside down already.
With vNOTES, the patient's flat and it's only for the small endoscopic part of the hysterectomy, which is actually the smaller part of the oncologic procedure that the patient needs to go to in Trendelenburg. The majority of the time, for both sides, the sentinel node, the patient's still flat on the table. I think there's an advantage to that, I think. I want to say for oncology we don't have a lot of evidence yet. That's all still in study settings.
[Dr. Mark Hoffman]
Talk me through that. You're doing this lymph node dissection primarily prior to the hysterectomy. You're getting into the retroperitoneal space prior to getting access to the peritoneal space?
[Dr. Jan Baekelandt]
Correct. We inject ICG into the cervix, as you would do for any case. Then we make our way transvaginally into the retroperitoneal space, actually to the obturator area, to the place where your obturator nerve exits the pelvis at the level of the obturator muscle. Then from there, you start your dissection caudally to cranially down to upwards. Actually, the CO2 does most of the dissection for you. It opens the space up.
I think, besides the fact that it's less invasive in your patient's flat, another advantage, you follow the sentinel node as it is distributed naturally to ICG, you go down to up, whereas if we come laparoscopically from above, we see a green node and you may get excited and say, "Oh, I've got the sentinel node. I'm going to take this one out." You got to be careful not to take the second or the third node because that can be green by the time you come already as well.
Whereas in vNOTES you don't have that risk. You come from the bottom. The first green node you see is automatically the sentinel node. I think that's an advantage that in time with more studies there will be a good place for vNOTES in that group I think.
[Dr. Mark Hoffman]
That's done posteriorly initially with the access for the node dissection is that?
[Dr. Jan Baekelandt]
Now, there's two routes of dissection. Initially we started with a lateral vaginal fornix incision, and then dissected the paravesical space. It works; it's a bit more difficult to teach that access. Now we're actually moving to an anterior vaginal wall incision similar to what you do for an anterior repair and do the dissection from there. We found that it's easier to teach that access to people who don't have as much experience. It's like you're doing an anterior repair, you just go a little bit more lateral and you jump over the arcus tendineus and then you get into the right space paravesically.
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Advantages of the vNOTES Approach: Vaginal vs Abdominal Incisions
The vNOTES approach removes the need for an abdominal incision in favor of a solely vaginal incision, sparing patients from additional scarring. Patients often find incisions in the vaginal wall less painful than abdominal wall incisions, due to differing levels of innervation. According to Dr. Baekelandt, the data (although limited) suggests that vNOTES is safe for later vaginal deliveries.
Special care and technique is required in incision placement in order to avoid dyspareunia. In vNOTES hysterectomies, the uterus must be pulled into the posterior fornix. In non-hysterectomy procedures, the posterior colpotomy incision must be 1-2 inches from the rectum. In both vNOTES hysterectomy and non-hysterectomy procedures, enough mucosa must be left around the incision to ensure successful closure.
[Dr. Mark Hoffman]
Let's talk about non-hysterectomy surgeries briefly as we get towards the end here. I think, when doing laparoscopy, we always say fives are free. I hate putting tens in. I never use tens for any of my surgeries, 10 millimeter or larger ports, because I don't want to close fascia. I want to minimize my hernia rates. Single site you mentioned, I am not a fan. I think those 2 to 3 centimeter umbilical incisions have such a high hernia rate. If I'm morcellating, I make a mini-lap Pfannenstiel at the same size and do most of my morcellation that way because the hernia rate from a Pfannenstiel, as obstetrician-gynecologists, we are and should be confident making Pfannenstiel incisions. They're great incisions to close.
I try to avoid larger incisions in the abdomen all the time because of concern for hernia and also just pain. Huge umbilical incisions, patients do not like those, and they don't like their belly buttons to be messed with. When performing a colpotomy for a single-site vaginal incision, what are the hernia rates? I imagine the vaginal hysterectomy closures are the same as a TVH. For a non-hysterectomy case and you're doing a posterior colpotomy and doing a vNOTES for adnexals, what are the risks of vaginal cuff dehiscence or vaginal colpotomy dehiscence or hernia rates for those surgeries?
[Dr. Jan Baekelandt]
For the listeners, for a hysterectomy, we make the same incision and we have the same scar, so that's it. If we're doing vNOTES for other indications, and as I said, we do it for the whole spectrum of gyn procedures, that's where we're going to need evidence to prove that it's safe because with hysterectomy we're reducing our number of scars or a number of incisions. We're taking abdominal incisions away and we're just keeping the vaginal incision.
Now we're in adnexal or myomas or whatever, we're taking the abdominal incision away, but we're replacing it with a different incision. There's your question very correctly, are we not taking any other risks by putting an incision in a different location? I think what we noticed is that those incisions are less painful because the innervation to the vagina is different to the abdominal wall, so there's an advantage.
As far as I know, in the database, there's no dehisces described for a posterior colpotomy. We've had hematomas from the posterior colpotomy, but no dehiscence, as far as I know. I haven't had any. I think the vaginal wall is very forgiving. We know that from obstetrics as well it heals very well and it doesn't get infected as easily. The two big questions that we always get there is one is, what about deliveries, if we do this on young patients for ectopic pregnancy routinely, and two, what about sexual intercourse? Are we causing dyspareunia for these patients?
I think the answer for the first one is that it's a worry in our head because, from endometriosis, many of us are in the habit. If we've had rectovaginal endometriosis, we've shaved the rectum and we've resected part of the vaginal wall. We tell our patients to have a cesarean section and not a vaginal delivery.
I think it's different in vNOTES because we don't have that rectal shaving and we just have a scar in the colpotomy. I think the data that we have on vNOTES is limited. I think there's only one publication we've made. It's from personal experience. We've had lots of deliveries after vNOTES and have not seen any problems. I think scientifically we have data from specimen extraction studies, people who do adnexectomies and take the specimen out through the colpotomy.
Those data also suggest that that incision is safe for a vaginal delivery after that. I think that's not an issue that I worry about. We do it on our young patients. I routinely do all the ectopic pregnancies that way, and we let them deliver vaginally, and our C-section rates or our tear rates are not higher.
I think dyspareunia is a much more important question to look at. There we need to have big data. There's studies ongoing on that. We have data from the RCTs that we've done, or an RCT on annexectomy that don't show any higher problem rates. Those are small, small data up to now. Again, very technical. I'm going to try and explain it anyway. I think it's really important where you place that incision. If you make your posterior colpotomy incision on the same location where you would do it for a hysterectomy, the problem then becomes that your vaginal mucosa retracts a bit and when you close it afterwards, you don't have a lot of mucosa between the cervix and your incision to close.
[Dr. Mark Hoffman]
Right. I imagine if you're right up next to the uterus, which is where you want to be for a hysterectomy, you don't have much with which to close.
[Dr. Jan Baekelandt]
Exactly. What you do then is you actually pull your uterus into the posterior fornix. You pull your uterus backwards, and then you don't have a posterior fornix anymore, which could be a cause for dyspareunia. That's something that I think is really an important issue to teach is to where to place that incision. For a non-hysterectomy case, your posterior colpotomy incision must be at least 1.5, 2 centimeters lower, closer to the rectum, but then your dissection has to be upwards. Then you have a lot of space to suture. You need to retrain that colpotomy from people who are used to making it for hysterectomy, you need to make it in a slightly different location. Then I think, from my experience, it's not a problem. I don't see any dyspareunia problems with that, but I make my incisions very low, far away from the cervix.
[Dr. Mark Hoffman]
I've seen folks that do colpotomy for tissue extraction for myomectomies, patients who are going to get pregnant or at least planning on getting pregnant who are wanting to get smaller abdominal incisions, so robotic or laparoscopic. Myomectomies don't want to make that big incision, but you don't have colpotomy or vaginal incisions from a hysterectomy, but they're making a posterior colpotomy incision and it seems like it works pretty well. How are you closing those? Are you just doing a barbed suture single layer? Are you doing it in two layers? How do you close those incisions?
[Dr. Jan Baekelandt]
Single-layer, but probably whichever suture is probably not that relevant there. We do single layers. I try to approximate peritoneum and vaginal mucosa together because it's that dissection space between the peritoneum and the mucosa is where your oozing is, where your risk for hematomas is. If you can compress those two layers together, then-- but I think whether you do that in a running suture or in a separate figure of eights probably doesn't matter. I think it's very forgiving there.
Becoming Proficient with vNOTES
The successful introduction of vNOTES into surgical practice requires physicians to go through in-depth training. After receiving sufficient training, surgeons should implement vNOTES in simple cases before progressing in complexity. vNOTES expertise builds with repetition, for both the practicing surgeon and the entire surgical team. Although possible, Dr. Baekelandt does not recommend combining vNOTES with robotic procedures as it offers no benefit and increases procedure difficulty.
[Dr. Mark Hoffman]
I feel like I could ask another a hundred questions about this. I know you're a busy surgeon and we're grateful you spent time. Any last thoughts for our listeners on vNOTES on things that they should think about when introducing this into their surgical practices?
[Dr. Jan Baekelandt]
Yes, I think go through the proper training pathways. They're available and they're available all over the world. I think you have listeners all over the world. These courses are being given in the same way everywhere. What worries me most is people watching a YouTube video and thinking, "I can do this." It's not difficult surgery, but as with any technique, there's just lots of little tips and tricks. Surgery's always in the detail, and if somebody explains all those details, it will just be so much safer for your introduction.
Then a second thing, I think once you get started, is to start with the very, very easy cases. If you start with very easy cases, then you can gradually build it up. It will just be nicer. It would be safer for your patient, it'd be nicer for your whole team because it's a new procedure, and not just for yourself, but for your whole OR team, and you have to get them involved in the process. You have your scrub nurses and your anesthesiologists, and you have to get everyone involved in the process.
If you can then make sure that your first cases go smoothly, you keep everybody motivated and it's a safe and easy implementation. I think the problem we see is people who try to run before they can walk, and they start with a 800-gram uterus. That's not the way to start a new technique.
[Dr. Mark Hoffman]
I think that's not different from what we see with our colleagues, whether they're trying to start laparoscopic surgery or jumping in, doing two to three hysterectomies per year, and think, "Oh, we'll go ahead and just do this one-kilo case." It's like, "Make sure I'm around for that one."
I think, like anything, with surgery, repetition, repetition, repetition is everything. Minimize variability. It is getting as many of these as you can so you can start to see the subtle differences and nuances, if anything, but yes, it sounds like, though it's a new approach, old adages are true, and it's all about developing techniques. Start easy and work your way up, and give yourself the space and patience, and your whole team the time and energy, but starting with that training.
I can say from personal experience, having done the training, it's done really well. It definitely was important for us to do that, and as we started doing them, where we are now, I think the reason we're going to have good outcomes is because of the training and because of the team that we built and the number of surgeons who are committed to helping all of us and all of us get better.
Actually, one last question. I just thought that this is where we're wrapping up. Robotic surgery, single-site, and anything, are there any examples that you've used a robot with this stuff, that you're using any additional besides straight laparoscopy? I assume that's traditional, what you've done. Is that something that's being done, is being talked about, using vNOTES in combination with robotic surgery?
[Dr. Jan Baekelandt]
With the current existing systems, I tried a couple of years ago, and looked with the da Vinci Xi whether we could do vNOTES. We did 30 or 40 cases, and it works. It's just there's no benefit. It's making life difficult. It's not made for it and there's no space for the four arms. You can do it with three, but there's a lot of arm collisions. It just adds a lot of extra time to the surgery and no benefit.
I think there, no, but I think there's a lot of development in robotics and there's a lot of new systems coming. Single-site system, you have the SP system from Intuitive. I work a bit with Momentis there. They're developing a robot for transvaginal use, specifically for vNOTES, and actually, they're on the market. I'm in Europe. It's not on the market here, but it is on the market in the US.
[Dr. Mark Hoffman]
Is that the one that goes behind the uterus and looks up laparoscopically?
[Dr. Jan Baekelandt]
And retroflexes. Again, I think we're going to need studies, we're going to need evidence, and it's going to be hard. vNOTES, endoscopically, is not that difficult. Our procedure times are getting so short compared to laparoscopy that to prove a robotic benefit to that is going to take time, but I think it's going to be the same as with robotics transabdominally. We also don't have a lot of evidence yet, but there is a group of surgeons that feels more comfortable doing it that way, and then that's absolutely great because that's better for the patient. There'll be a group of surgeons that feels more confident doing it endoscopically, laparoscopically, or via vNOTES.
I think whichever technique gives you the most confidence to do it safely for your patient is the one that you should choose. I think there'll be a place for it in time, for sure, with developments of more and more new robotic systems. It will come, but I think at the moment, yes, it's for a specific niche.
Podcast Contributors
Dr. Jan Baekelandt
Dr. Jan Baekelandt is a gynecologic surgeon in Mechelen, Belgium.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2023, August 31). Ep. 31 – The vNOTES Procedure [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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