**4. Technique**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

The use of endoscopic procedures to visualize the abdomen is over 100 years old. Visualization of the pelvis through the vagina was developed by Decker who first reported the procedure in 1944 [1]. The term culdoscopy was used to describe placement of a scope into the posterior cul-de-sac with the patient in knee-chest position. This was originally used for diagnostic purposes but later modified for treatment of ovarian conditions, ectopic pregnancy and tubal ligation. However, the technique was never utilized by a wide audience of gynecologists, and abdominal and traditional transvaginal procedures continued to dominate the field. In the 1990s as fiber-optic cameras and improved instrumentation developed, abdominal laparoscopy came into vogue and has since exploded as a dominant method of performing gynecologic surgery along with its more recent counterpart, robotic surgery. Laparoscopy has replaced a large percentage of abdominal procedures permitting faster recovery, less pain, and better cosmetics for our patients. Unfortunately, as laparoscopic techniques and instrumentation continued to improve, the percent of hysterectomies performed transvaginally diminished. For example, the percent of hysterectomies performed vaginally dropped from 25% in 1998 to 17% in 2010 and continues to fall [2]. This despite the recommendation by the American College of Obstetricians and Gynecologists [3] and the AAGL [4] that transvaginal hysterectomy is the preferred method for benign gynecological disease as the optimum approach for patient safety and recovery. Younger gynecologists in academic and community settings are performing fewer transvaginal techniques. As a consequence, they are less likely to train resident physicians in transvaginal

The earliest utilization of a vNOTES approach was for general surgery procedures such as cholecystectomy and appendectomy [5]. In Asia in 2012, Ahn reported on the use of the single-port placed into the posterior vagina to remove the adnexa [6]. At the same time, the first series of vNOTES hysterectomies was published [7]. These authors utilized an Alexis retractor (Applied Medical, Rancho Santa Margarita, CA) placed into the anterior and posterior cul-de-sac with a surgical glove attached on the outer ring through which the glove fingers were used as laparoscopic ports. In Europe in 2013 Jan Baekelandt adapted the GelPoint device (Applied Medical, Rancho Santa Margarita, CA) to the transvaginal approach and has been the major developer and promoter of vNOTES surgery in the West [8, 9]. The GelPoint has the advantage of ease of set up, better ergonomics, and simplicity in specimen removal over a glove fastened to an Alexis. A group of American gynecologists (including the author of this chapter) trained with Dr. Baekelandt beginning in 2017 and brought the technique to the United States. To date, this core of vNOTES surgeons has trained approximately 100 gynecologists in this country. In 2019, a port specifically created for vNOTES (VPath, Applied Medical, Rancho Santa Margarita, CA) was developed and

VNOTES takes advantage of the laparoscopic expertise of today's surgeons and brings it to a transvaginal platform. This combines the best of vaginal and laparoscopic surgery. The surgeon has the visualization, instrumentation and panoramic abdominal perspective of laparoscopy combined with the reduced morbidity, rapid recovery and cosmesis of vaginal surgery. The majority of vNOTES procedures can be performed as an outpatient procedure and require minimal postoperative

**2. History of the technique**

**78**

approved by the FDA.

**3. Why perform vNOTES?**

surgery.

vNOTES begins similar to a transvaginal hysterectomy. A circumferential incision is made in the cervix down to the level of the pubo-cervical fascia. The anterior and posterior aspects of the vaginal mucosa are dissected away from the cervix to gain access to the anterior and posterior cul-de-sacs. These spaces are entered, the uterosacral ligaments are clamped, cut and ligated. These pedicles may later be incorporated into cuff closure for vault support. An Alexis retractor is placed into the anterior and posterior space. The outer ring of the Alexis either has the cap attached or a glove attached depending on which one is available. The patient is placed in 20o Trendelenburg position and insufflation of the abdomen is performed. In general lower pressures and flow rates are sufficient for adequate visualization compared to abdominal laparoscopy. The remaining attachments to the uterus are on either lateral side. The laparoscope is introduced into the retractor, most frequently either a 0o or 30o 10 mm scope is used. A vessel sealing device is most commonly used along with a grasping instrument that may be a cautery instrument as well. Beginning on the patient's left side, the cervix is pushed medially and cephalad to give direct

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 avoided with the use of endoscopic bags.

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 virginal women.

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.

### **5. Instrumentation for vNOTES**

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.

#### **6. Contraindications to vNOTES**

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

**81**

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

laparoscopic surgery 20 years ago (prior surgery, endometriosis, obesity) one sees that with the evolution of techniques these are no longer applicable. Factors such as parity, prior cesarean delivery, lack of uterine descent, uterine size and concern for malignancy are not necessarily contraindications to vNOTES procedures. Most surgeons would avoid operating on women who have had low colorectal surgery, known obliteration of the posterior cul-de-sac, or prior pelvic radiation to reduce the risk of injury with the posterior entry. In addition, cervical myomas, depending on the position and size, may contribute to anatomic difficulties in placement of the retractor.

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

In women who wish to preserve their uterus but have an adnexal mass, vNOTES

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

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

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

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

vNOTES hysterectomy with bilateral salpingectomy.

removal of an adnexal mass while leaving the uterus in place.

though long-term follow-up is still pending.

**7.4 Additional gynecologic procedures**

**7. Current applications**

**7.1 Hysterectomy**

**7.2 Adnexal surgery**

**7.3 Pelvic support**

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

laparoscopic surgery 20 years ago (prior surgery, endometriosis, obesity) one sees that with the evolution of techniques these are no longer applicable. Factors such as parity, prior cesarean delivery, lack of uterine descent, uterine size and concern for malignancy are not necessarily contraindications to vNOTES procedures. Most surgeons would avoid operating on women who have had low colorectal surgery, known obliteration of the posterior cul-de-sac, or prior pelvic radiation to reduce the risk of injury with the posterior entry. In addition, cervical myomas, depending on the position and size, may contribute to anatomic difficulties in placement of the retractor.
