vNOTES Surgery: Understanding & Applying the vNOTES Technique

[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.

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[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.

[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.