**9. Conclusions**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

prophylactic surgery.

through this approach.

**8. Oncology applications**

**8.1 Endometrial cancer**

**8.2 Ovarian cancer**

**8.3 Cervical cancer**

entering the pouch of Douglas will be low.

**7.5 Non-gynecologic procedures**

and a pelvic washing for cytology can be obtained. In standard transvaginal surgery for adnexectomy adequate visualization to safely remove the entire tube and ovary is not always possible. The vNOTES approach also avoids an abdominal scar for a

In most circumstances laparoscopic appendectomy is a relatively straightforward procedure and can be safely accomplished by a vNOTES approach. Abdominal wall adhesions can be visualized and safely taken down which may alleviate some patients' symptoms of abdominal discomfort. Small umbilical hernias can be closed primarily or repaired with mesh against the abdominal wall

Women with endometrial cancer are often obese and have multiple medical comorbidities. There are many reports of performing transvaginal hysterectomy on those patients who may not tolerate an abdominal procedure. However, that approach does not always permit visualization and removal of the tubes and ovaries. Nor does it allow for sampling of the lymph nodes. VNOTES permits removal of the tubes and ovaries, a pelvic washing can be performed, the entire abdomen can be explored, and lymph nodes can be removed. Multiple reports in the literature document the ability to perform Sentinel lymph nodes by this approach as well as pelvic lymphadenectomy and even aortic lymphadenectomy [13–16]. Given that the recommendation currently for staging endometrial cancer is to utilize a minimally invasive technique, vNOTES can provide an additional method to achieve this goal.

In general ovarian cancer debulking is not performed with a minimally invasive

technique; however, there are exceptions. When patients are treated with neoadjuvant chemotherapy and have an excellent response, robotic or laparoscopic approach can be performed to remove any small residual disease. Early stage disease can also be staged by a minimally invasive route. A vNOTES approach can remove adnexal masses, the omentum, lymph nodes, and perform a full exploration of the abdominal cavity. The diaphragm can be reached with the appropriate instruments through the vagina to perform biopsies and visualization. Bulky disease in the pelvis would be a contraindication to a vNOTES approach as the likelihood of successfully

There are no reports in the literature currently on utilizing vNOTES to treat cervical cancer. Theoretically a radical vaginal hysterectomy could be performed with vNOTES and pelvic lymph nodes can be removed so it is only a matter of time before some surgeons become skilled enough at this technique to perform such an operation. While there is currently controversy regarding a possible decreased survival with a minimally invasive radical hysterectomy [17], data on a radical vaginal

approach does not appear to have a deleterious effect on outcome [18].

**82**

vNOTES has been shown to be a safe and feasible alternative approach to most gynecologic procedures. The technique is still in its infancy and is analogous to the early use of laparoscopy for advanced gynecologic surgery. There are distinct advantages with this approach including decreased pain, shorter recovery, and optimal cosmetics over standard laparoscopy. There is no doubt that vNOTES will be adopted by the surgical field. Instrumentation specific for vNOTES is beginning to be brought to the marketplace. Patient satisfaction with the technique will also drive more surgeons to these procedures. With vNOTES a gynecologist is able to offer the best aspects of laparoscopy with the ideal approach through the vagina.
