**8. Oncology applications**

#### **8.1 Endometrial cancer**

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.

#### **8.2 Ovarian cancer**

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 entering the pouch of Douglas will be low.

#### **8.3 Cervical cancer**

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].

**83**

**Author details**

Alexander F. Burnett1

Little Rock, Arkansas, United States

Little Rock, Arkansas, United States

provided the original work is properly cited.

\*Address all correspondence to: aburnett@uams.edu

\* and Martha O. Rojo2

1 Division of Gynecologic Oncology, University of Arkansas for Medical Sciences,

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 UAMS School of Nursing, University of Arkansas for Medical Sciences,

*Vaginal Natural Orifice Transluminal Endoscopic Surgery for Gynecologic and Gynecologic…*

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.

Video 1. vNOTES hysterectomy with bilateral salpingectomy. https://youtu.be/

Video 2. vNOTES adnexal removal. https://youtu.be/fVxE3tErnwU

*DOI: http://dx.doi.org/10.5772/intechopen.96082*

**9. Conclusions**

**Video materials**

RvQcZfWEKDc

*Vaginal Natural Orifice Transluminal Endoscopic Surgery for Gynecologic and Gynecologic… DOI: http://dx.doi.org/10.5772/intechopen.96082*
