**7. Current applications**

#### **7.1 Hysterectomy**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

avoided with the use of endoscopic bags.

**5. Instrumentation for vNOTES**

**6. Contraindications to vNOTES**

virginal women.

visualization of the uterine vessels. These are cauterized and cut followed by resection of the broad ligament up to the fundus. The round ligament can be transected, but the adnexal attachments remain in place until completion of dissection of the right side. Attention is then focused on the right side of the uterus where the cervix is again manipulated medially and cranially and the uterine vessels are secured. One dissects the broad ligament of the right side and then one can resect both the round ligament and the adnexa (or utero-ovarian pedicle if the adnexa is to be preserved). Finally the left adnexa are managed in a similar fashion. This will free the uterus of all its attachments and it can be delivered through the vagina. Any portion of the tubes and ovaries can be removed with the uterus. The abdomen is then explored and ancillary procedures can be performed if necessary including omentectomy, peritoneal biopsies, appendectomy, lysis of adhesions, or umbilical hernia repair to name a few. As with abdominal laparoscopy any concern for specimen spill can be

In some circumstances surgeons will perform a total vaginal NOTES whereby the retractor is placed into the vagina and circumcision of the cervix, entry into the anterior and posterior cul-de-sac, and the remainder the procedure are all performed by laparoscopic techniques through the vagina without placing the retractor into the peritoneal cavity. This technique may be helpful in women with a very high cervix (no descent) or a narrowed vagina such as may occur in post-menopausal or

VNOTES techniques can also be utilized for adnexal surgery without removal of the uterus. In this situation an incision is made in the posterior cul-de-sac of the vagina between the uterosacral ligaments. A smaller Alexis retractor is then placed into the posterior cul-de-sac through which the laparoscope and instruments are introduced and surgery performed. This can be used for salpingectomy, oophorectomy, ovarian cystectomy, resection of ectopic pregnancy, or myomectomy.

The instruments for performing vNOTES are similar to those used with transabdominal single incision laparoscopy. The V-Path Alexis retractor (Applied Medical, Rancho Santa Margarita, CA) has been approved by the FDA specifically for this procedure. Most surgeons utilize a 10 mm laparoscope. Because the field of surgery is so close to the retractor, the camera does not interfere with the other instruments and the larger aperture produces better lighting and visualization. A 0° or a 30° scope can be used depending on individual preference. Alternatively, some surgeons have access to 3D laparoscopes which provide better depth of field. Flexible laparoscopes do not appear to be advantageous for this procedure as they often collide with the pelvic tissues. Other instruments utilized during vNOTES include a vessel sealing instrument, a bipolar cautery instrument, and a grasping instrument such as a laparoscopic Maryland forcep depending on the individual surgeon's preference. Endoscopic bags can be used for specimen retrieval. Smoke evacuators and suction/irrigation are rarely necessary with the vNOTES approach as blood loss is generally minimal and smoke rarely interferes with visualization. The operative

costs are no different than a standard single-incision laparoscopy.

Most contraindications to vNOTES must be considered relative based on the expertise of the surgeon. If one considers contraindications to abdominal

**80**

Over 400 hysterectomies performed by vNOTES have been reported in the literature since 2012. There is a global registry that has currently amassed about 1800 cases from 40 vNOTES surgeons around the world with the majority including hysterectomy. Virtually any uterine pathology has undergone vNOTES hysterectomy including uteri greater than 2000 g. Uterine descent is not necessary for this procedure nor is prior cesarean delivery a contraindication. This approach can be used in morbidly obese women who will experience the most benefit from not having an abdominal incision. Myomectomy can also be performed from a vNOTES approach utilizing either the anterior or posterior cul-de-sac depending on the anatomic location of the myoma. Again the procedure itself is identical to that performed using transabdominal laparoscopy. The attached **video 1** demonstrates a vNOTES hysterectomy with bilateral salpingectomy.

#### **7.2 Adnexal surgery**

In women who wish to preserve their uterus but have an adnexal mass, vNOTES can be performed through the posterior cul-de-sac. The adnexal surgery may include removal of the fallopian tubes for sterilization, resection of ectopic pregnancy, ovarian cystectomy, or salpingo-oophorectomy. It is also possible to utilize this approach for diagnostic laparoscopy. This saves the patient from an abdominal incision and reduces the postoperative pain. The attached **video 2** demonstrates removal of an adnexal mass while leaving the uterus in place.

#### **7.3 Pelvic support**

Support of the vaginal cuff can be readily achieved through vNOTES. At the completion of the hysterectomy the visualization of the ureters permits very high plication of the uterosacral ligaments. An excellent demonstration of this technique can be seen in the following video by Dr. Howard Salvay https://www.youtube.com/ watch?v=yYyPvuXEbxg. Sacrocolpopexy can also be performed using vNOTES, as demonstrated in a published series of 26 cases with correction of significant pelvic organ prolapse utilizing a Y-mesh to placate the sacral promontory to the anterior and posterior upper vagina [12]. This resulted in excellent postoperative results though long-term follow-up is still pending.

#### **7.4 Additional gynecologic procedures**

This approach is ideal for risk-reducing surgery in that the entire ovary and fallopian tube can be removed with a portion of the infundibulopelvic ligament 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 prophylactic surgery.

#### **7.5 Non-gynecologic procedures**

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 through this approach.
