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vNOTES Surgery: Understanding & Applying the vNOTES Technique

Author Melissa Malena covers vNOTES Surgery: Understanding & Applying the vNOTES Technique on BackTable OBGYN

Melissa Malena • Mar 30, 2024 • 32 hits

Vaginal natural orifice transluminal endoscopic surgery, also known as vNOTES, is a transvaginal endoscopic entry technique that provides a less invasive alternative to abdominal entry incisions. Although associated with faster patient recovery times, the vNOTES procedure requires surgeons to have a skill set in both vaginal and endoscopic techniques. vNOTES expert Dr. Jan Baekelandt recommends procedural and educational standardization of the procedure to optimize patient outcomes and lower implementation learning curves. Read on to learn more about Dr. Baekelandt’s vNOTES surgery techniques, and his perspectives on the role of vNOTES in contemporary gynecologic surgery.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The Backtable OBGYN Brief

•When growing a vNOTES practice, vNOTES caseload and case difficulty should increase over time in accordance with the surgeon’s comfort with the technique.

•Strong surgical skills, in both endoscopic and vaginal techniques, are required for successful implementation of the vNOTES procedure.

•Over the years, vNOTES hysterectomy procedures have increased in speed due to the standardization of transvaginal ports.

•The future of vNOTES lies in increased procedural standardization to inform surgical education and optimize patient outcomes.

vNOTES Surgery: Understanding & Applying the vNOTES Technique

Table of Contents

(1) The Evolution of vNOTES

(2) Building vNOTES Proficiency

(3) vNOTES Standardization

The Evolution of vNOTES

vNOTES is a transvaginal endoscopic technique that can be implemented in many gynecological surgeries, providing an alternative to abdominal incisions. Transvaginal techniques were introduced fifty years ago in Europe by the ‘father of laparoscopy,’ Kurt Semm, however, lighting and instrument deficiencies rendered the technique incompatible with the time’s technology.

Technological advancements and adjustments of instruments have now allowed the vNOTES technique to flourish. Dr. Baekelandt has been doing vNOTES procedures for over a decade and now his practice has grown from 25% vNOTES cases to 95%. vNOTES incisions should be implemented at a concurrent pace with the surgeon's comfort and confidence level, with the number of cases increasing linearly. Although traditional laparoscopic techniques might be more familiar to practitioners, vNOTES procedures are less invasive to the patient and provide faster recoveries.

[Dr. Jan Baekelandt]
vNOTES, it's a complicated term just to say that we're doing laparoscopy through the vagina instead of through the abdominal wall to make it easy. vNOTES stands for Vaginal Natural Orifice Transluminal Endoscopic Surgery. It's an acronym because we operate endoscopically through the lumen of another organ, so not directly through the abdominal wall via natural body orifice.

For gynecology it makes sense to choose the vagina as the natural body orifice of choice to operate through, but there's other types of natural orifice surgery. You can operate transorally, you can operate transanally. The colorectal surgeons do TEO procedures transanally, but for gynecology it makes sense to do our natural orifice surgery transvaginally.

Basically what we do in vNOTES is we do pretty much all gynecological operations by now without making any abdominal wall incisions. The entire procedure is performed transvaginally, and we do this endoscopically like we would operate laparoscopically with the same instruments. We insufflate the abdomen with CO2, but we use all those instruments transvaginally.

[Dr. Mark Hoffman]
It makes sense. In my own training, I'm a mixed surgeon and so I do almost everything laparoscopically. I trained at an institution where they had strong urogynecology, so we didn't get a ton of vaginal surgery. Vaginal surgery in general is one of those things that I think in our training seems to be, we have a harder time teaching that, I think, than we used to. While it's great that we're adding robotic and laparoscopic surgery for our patients, it doesn't seem like we're maintaining the level of vaginal surgery volumes to help a lot of us get comfortable. Personally, it's something I don't do very often, but is that something you've always continued to do? Is it something with vNOTES that you reintroduced into your practice? Talk about how you got interested in vNOTES.



[Dr. Jan Baekelandt]
We all have a different threshold up to what level we're comfortable with doing. Let's talk hysterectomies, vaginally, and some of us, the ones that have a big prolapse and they're basically hanging out and we feel comfortable doing that and some very skilled vaginal surgeons will take out a one-and-a-half-kilo uterus without prolapse as well. I think we all have a different threshold as to where we decide we're going to do this vaginally or we're going to do this laparoscopic, speaking pre-vNOTES now.

I think many of us don't or didn't do as many vaginal hysterectomies as we technically could because we've gotten spoiled with laparoscopy and robotics. We've got better hemostatic control. We've got these fantastic bipolar instruments and sealing devices that just give us better control and we can see so well what we're doing.

I think that's the main thing is, when we're operating vaginally, a lot of things that could be within our skillset that we could be doing, we don't do because we just feel this little bit more confident in doing it laparoscopically because we know it's dry and we know we've seen everything well and we just feel it's safer for the patient. I think that's why many of us moved away from vaginal surgery for many cases into laparoscopic or even robotic surgery just because of that confidence of visualization and hemostatic control.

That's now what vNOTES brings back. Now we can operate vaginally, which is the least invasive way for the patient, and have our patients recover quicker, but we can still have that hemostatic control and that visualization that we've gotten so spoiled in laparoscopy. I think that's actually what vNOTES brings to the table and helps broaden the indications for vaginal surgery again.

Listen to the Full Podcast

The vNOTES Procedure with Dr. Jan Baekelandt on the BackTable OBGYN Podcast)
Ep 31 The vNOTES Procedure with Dr. Jan Baekelandt
00:00 / 01:04

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Building vNOTES Proficiency

vNOTES proficiency requires a double skill set with expertise in gynecological and endoscopic techniques. Although vaginal surgery is more difficult to teach due to visualization compromisation, it is just as vital as endoscopic education. When building a vNOTES practice, Dr. Baekelandt recommends surgeons attend training programs with colleagues to cultivate multiple technical viewpoints within a department. Applying the vNOTES technique to the hysterectomy can be of great benefit; standardization of transvaginal port placement can reduce surgery time and invasiveness.

[Dr. Jan Baekelandt]
Yes. My first hysterectomies took four hours via vNOTES. Now vNOTES hysterectomies are significantly faster than laparoscopic hysterectomies, but at the time it took me a lot longer. We didn't have good ports. We were making the ports ourselves, and now we have standardized ports that are approved for transvaginal use. That sort of made it difficult because we were developing the steps of the procedure as well still. I think by now the procedure is, or it has been for a long time now, it's been established. We know step by step what we should do, which instruments we should use. We know in which order we should be doing the steps. That makes it a lot easier to do it now.

As for the learning curve of an established procedure for somebody who has been trained in the technique and in a proper training setting, I think that also depends on your skill set beforehand. I think one of the weaknesses of vNOTES is that you actually need a double skillset. You need to be confident in basic vaginal surgical skills and you need to be confident in basic laparoscopic skills. I think for most vNOTES procedures, the laparoscopic skills aren't that hard because it's more grab-and-cut surgery. There's not a lot of need for retroperitoneal dissection. I think if you have a basic skillset in vaginal surgery and in laparoscopic surgery, the adoption after proper training is quite quick. Most of the studies say 20 to 30 cases, but it all depends on how confident you are as a surgeon to start.

I think if you have no vaginal skills or no vaginal experience at all, then your learning curve's going to be significantly longer and vice versa, if you are just a vaginal surgeon with no laparoscopic expertise, but I think there's not that many of those around anymore, then it's hard as well. I think with previous training in both, it's quite a short adoption curve.

[Dr. Mark Hoffman]
We've recently gone through the training. We had the folks come down from Applied and do a course. My group is me and another big surgeon and we have two urogynecologists that are in the next office over, next door, not in the next office building, but a close group who worked together often, and we're just getting started. My partner's done a few. I've not even done one yet, so that's why I was excited to get you on. Having a couple MIG surgeons like my partner and I who, honestly, just most of us are not trained in vaginal surgery even though we're supposed to be minimally invasive surgeons and TVH is the least invasive.

Most MIGS fellowships are really laparoscopic robotic fellowships. Our decision to start doing it had to be very systematic and safe, and we had to have the right people in the room. Having commitments from both urogynecologist and MIGS is a great way for both divisions to improve their skillset to be able to do more and everybody wins. It's been nice to have that partnership. It is something that I think vaginal surgery and colpotomy is a bit of a lost art for some of us.

[Dr. Jan Baekelandt]
Yes, it's always a huge advantage if you can start with more than one person in the department, go to the training together, go and observe with somebody with experience together, and then it's just easier to be two to get started, and it's safer for the patient. I think that's exactly what happened over the years is teaching vaginal surgery, A, we're a bit less comfortable doing it because we don't see everything so well, but it's definitely a whole lot more difficult to teach vaginal surgery than to teach laparoscopic surgery because of that visualization issue.

I think with vNOTES now, it actually becomes easier to teach vaginal surgery again because now you can see endoscopically what your assistant or your registrar, whoever your teaching is doing. I'm hoping we're going to broaden the teaching of vaginal surgery again with this.

[Dr. Mark Hoffman]
Yes, when you get in there and see it, it is pretty incredible to watch and you go, "Okay, ah, that makes sense." I think there's going to be some part of that learning curve that is visual cues, and there's certain things I look for. Your brain just notices things when you do hundreds or thousands of cases, and that's something that will just take time from a different approach. I think that's something,it does take a commitment to doing a lot to get good at anything, especially a new surgical approach. Aside from cosmesis, what are the benefits that you've seen and that we're finding out that happen for patients when it comes to vNOTES and maybe also for physicians?

vNOTES Standardization

According to Dr. Baekelandt, mastering vNOTES requires a strong education and procedure standardization. Standardization of the technique reduces inter-procedure variation and lowers the learning curve of implementation. Standardization can be achieved through attendance of vNOTES educational programs across Europe, Australia and the United States. To determine the success rates of vNOTES compared to other entry techniques, more studies through the international database should be done. Dr. Baekelandt emphasizes that the educational vNOTES background of surgeons should be noted in such studies to observe whether complications are related to a lack of education or to the technique itself.

[Dr. Mark Hoffman]
That's something I noticed just even doing just the training and watching videos is again, as I've mentioned earlier, so much of what we do is visual cues like, okay, I need to see the ring, our colpotomy ring as we're pushing up. I need to see that full ring, my posterior dissection inter dissection, always opening all those spaces up, skeletonizing completely, all those things. Big uterus, little uterus, 10 C-sections, doesn't matter. I want these same views, I want these same visual cues so I can understand where I am and where my anatomy is and where I can operate safely. That develops over time.

When you start out, you're taking little bites and as you get further along you're where you can be a little more, I won't say aggressive, but a little bit more comfortable versus where you really need to dial things in. That's something that seems like it just takes years, which is what surgery is, but to develop an entirely new approach to surgery, I think, and I'll again speak for myself, I think it's very intimidating to think about jumping into a new approach like that. Is it something that, are you seeing it being taught in residency? Because again, if we're teaching our residents, our trainees primarily to get comfortable that way, then it becomes a shift in how we practice as opposed to just a few select surgeons around the country.

[Dr. Jan Baekelandt]
You make a very good point. I think the key to a safe implementation is standardization and good teaching. I think that's what we've been trying to focus on most is to really get the technique standardized because the more standardized it is, the less room of variation there is in people in their learning curve and the lower the learning curve's going to be.

Then it's, yes, proper training. I think that's where you mentioned applied medical's helped us a lot with those standardized training courses. We now give exactly the same training courses all over Europe, all over the US, in many other countries, in Australia. It's all standardized content. It's exactly the same presentation, it's exactly the same steps. I think that will really help in keeping our complication rates down.

It is something that worries me because most techniques go through that Gartner cycle, where it takes a long time in the beginning to get the adoption going, and then all of a sudden there's a lot of excitement about the technique and a lot of people get started and not everyone necessarily goes through the right training steps and you get a peak, a lot of cases get done, but then you get to a level where you start seeing the complications coming, and then there's going to be a bit of discredit to the technique because there's going to be reports on complications.

At that point, we're going to need the evidence to prove that in the hands of people who've been properly trained in a standardized way, this is what our complication rates are and they are not higher than they are in standard other techniques. I think that's where the studies are important and where the big complication or case registry is. The international society has a big case registry that's been going since 2015 where a lot of surgeons put their data in and they will be able to see now what actually the complication rates are in the hands of experienced surgeons.

Hopefully, when that dip comes and the complications start coming in, people who haven't gone through the proper training, that's what will help us defend the technique because what we see in the studies is that the complication rates are not higher than in other techniques if not even a bit lower. I think that's the job for science now, to get the technique established.

Podcast Contributors

Dr. Jan Baekelandt discusses The vNOTES Procedure on the BackTable 31 Podcast

Dr. Jan Baekelandt

Dr. Jan Baekelandt is a gynecologic surgeon in Mechelen, Belgium.

Dr. Mark Hoffman discusses The vNOTES Procedure on the BackTable 31 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, August 31). Ep. 31 – The vNOTES Procedure [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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