**3. Why perform vNOTES?**

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

**79**

0o or 30o

**4. Technique**

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

pain medication. Most patients fully recover within two weeks of surgery, although

For the surgeon, the distance to the operative field is closer than with abdominal laparoscopy which translates in less collision of the instruments and permits larger scopes to be used with improved visualization. As opposed to abdominal laparoscopy where one works farther and farther down to the apex of a cone-shaped pelvis, vNOTES is constantly moving the uterus in a cephalad manner where there is more room to maneuver safely. This can be particularly advantageous with large myomatous uteri which can be manipulated farther into the abdomen as the case progresses. In addition, the major blood supply to the uterus is taken very early from a vNOTES approach which can significantly reduce blood loss. In patients with extensive adhesions from prior upper and mid abdominal surgery, vNOTES can avoid these adhesions altogether. The majority of surgeons perform this procedure while they and their assistants are seated and the ergonomics are far improved with minimal muscle strain over standard laparoscopy. This procedure is well adapted to the morbidly obese patient and can overcome surgical difficulties with standard laparoscopy including long distance to the pelvic organs, torque from traversing instruments through thick abdominal wall, and challenge of choosing appropriate port placement sites. The obese patient has the most to gain by avoidance of abdominal incisions and rapid recovery. To date there has been one randomized trial comparing vNOTES hysterectomy with laparoscopic hysterectomy as an outpatient procedure. In this trial 70 women with benign indications for hysterectomy were randomized to either standard four incision laparoscopy for removal of the uterus or received four skin incisions without cutting through the fascia and had a vNOTES procedure [10, 11]. This permitted blinding for the patients and the investigators to which technique had occurred. There were no conversions in the study. The mean operative time for vNOTES was shorter than laparoscopy (41 minutes versus 75 minutes). More women left the hospital within 12 hours after vNOTES (77% versus 43%). Overall hospital stay was shorter for vNOTES and overall use of analgesics during the first seven days after surgery was less in the vNOTES group (eight versus 14 units). The vNOTES group also reported significantly lower Visual Analog Scores (VAS) for pain. There were also significantly fewer postoperative complications in women treated by vNOTES (9% versus 37%). In this elegant study, the outcome parameters clearly favored

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

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

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

vaginal rest continues as with any hysterectomy.

vNOTES over total laparoscopic hysterectomy.

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

pain medication. Most patients fully recover within two weeks of surgery, although vaginal rest continues as with any hysterectomy.

For the surgeon, the distance to the operative field is closer than with abdominal laparoscopy which translates in less collision of the instruments and permits larger scopes to be used with improved visualization. As opposed to abdominal laparoscopy where one works farther and farther down to the apex of a cone-shaped pelvis, vNOTES is constantly moving the uterus in a cephalad manner where there is more room to maneuver safely. This can be particularly advantageous with large myomatous uteri which can be manipulated farther into the abdomen as the case progresses. In addition, the major blood supply to the uterus is taken very early from a vNOTES approach which can significantly reduce blood loss. In patients with extensive adhesions from prior upper and mid abdominal surgery, vNOTES can avoid these adhesions altogether. The majority of surgeons perform this procedure while they and their assistants are seated and the ergonomics are far improved with minimal muscle strain over standard laparoscopy. This procedure is well adapted to the morbidly obese patient and can overcome surgical difficulties with standard laparoscopy including long distance to the pelvic organs, torque from traversing instruments through thick abdominal wall, and challenge of choosing appropriate port placement sites. The obese patient has the most to gain by avoidance of abdominal incisions and rapid recovery.

To date there has been one randomized trial comparing vNOTES hysterectomy with laparoscopic hysterectomy as an outpatient procedure. In this trial 70 women with benign indications for hysterectomy were randomized to either standard four incision laparoscopy for removal of the uterus or received four skin incisions without cutting through the fascia and had a vNOTES procedure [10, 11]. This permitted blinding for the patients and the investigators to which technique had occurred. There were no conversions in the study. The mean operative time for vNOTES was shorter than laparoscopy (41 minutes versus 75 minutes). More women left the hospital within 12 hours after vNOTES (77% versus 43%). Overall hospital stay was shorter for vNOTES and overall use of analgesics during the first seven days after surgery was less in the vNOTES group (eight versus 14 units). The vNOTES group also reported significantly lower Visual Analog Scores (VAS) for pain. There were also significantly fewer postoperative complications in women treated by vNOTES (9% versus 37%). In this elegant study, the outcome parameters clearly favored vNOTES over total laparoscopic hysterectomy.
