Podcast Transcript: The vNOTES Procedure

[Dr. Mark Hoffman]
What are specific complications? What are the complications that are unique to vNOTES? Because again, as I think about going through and doing a hysterectomy laparoscopically, I have the same steps. Every case is the same. Again, it doesn't matter on the uterus, it's just like always the same steps, just different amounts of time spent on each one, but with my uterines, taking them more medially, so if it retracts, I've got a nice pedicle. How do you chase a pedicle laterally outside of the ring and those kinds of things? What are specific challenges and complications that one can expect when starting to introduce vNOTES into your practice?

[Dr. Jan Baekelandt]
I think what you say on the uterine arteries is really important there because obviously, bleeding is our most common complication in all procedures we do, all techniques. I think specifically to vNOTES, if we're talking hysterectomy, now if you take uterine artery, you get it right at the start of the case, not at the end of the case, and without going retroperitoneal, so that's a benefit.

A downside is that if you don't seal it properly and you cut it, it will retract behind the Alexis ring, and then it becomes more challenging to catch it. Now, if that happens, we take the ring out, you pull on your uterosacral pedicle, and then you can grab it vaginally, but that's a moment where you need some vaginal experience to grab that. I think the main thing we always stress in teaching is that just take your time for that uterine artery and don't just take it once with the sealing device and be confident with it.

It will work 9 out of 10 or 98 out of 100, but there will be a couple of cases on a larger uterus where you're putting more traction where that is not enough of a seal. Take it a couple of times next to each other with your sealing device or with a standard bipolar before you cut it. Take your time on that uterine artery, and then it's never an issue. Also, once you've done that, the rest of your hemostasis is easier. Then you can speed up and don't need to worry so much.

[Dr. Mark Hoffman]
I imagine the ring provides some hemostasis, a little bit on the little stuff, too. When I think about our transvaginal tissue extraction, when we put the ring in, put the bag in, it's putting significant pressure on the vaginal cuff for the time that we're doing our morcellation. When you go back up above and close the cut, there's been somebody holding pressure circumferentially for whether it's 10 minutes or an hour and a half, depending on the uterus, and you're providing some hemostasis. Does the ring itself provide some additional hemostasis and vNOTES in the same way?

[Dr. Jan Baekelandt]
It does. It's exactly like you said. It compresses, but once you take it off, you have to check your hemostasis. Again, I think a second thing that it does is it lateralizes your urogen. We did some cadaver study to look at that, but because that Alexis ring pushes on the pelvic sidewall, it automatically pushes your ureter more lateral. We saw when we did the dissection without the Alexis in place, we had two inches between the pelvic sidewall and then a natural position of the ureter, and where we put the ring in place, that reduced to an inch. It lateralizes your ureter about an inch, and that, I think, helps.

I think that's what we've seen in the studies that have been published so far is that we have less ureteric injuries than in laparoscopic surgery or in laparoscopic hysterectomy, but we have a slightly higher rate of cystotomy. I think it makes sense because you're doing that dissection vaginally.

[Dr. Mark Hoffman]
That's what we all fear. That's what we all fear is doing that colpotomy is getting in from above, or from below. I think that's the kind of thing that, with time, I think that rate will go down, but you just have to understand there are trade-offs.

[Dr. Jan Baekelandt]
That is the one to be aware of. I think it's logical that our cystotomy rates are a little bit higher in the vNOTES studies than in the conventional vaginal hysterectomy studies because we're tackling more challenging cases. We're doing bigger uterine, and bigger myomas and multiple C-sections. I think what helps there is, but this is now very technical, but I'll stay brief, is that instead of making your colpotomy as you do on a vaginal hysterectomy, just with cold scissors and a forceps is to actually make it endoscopically, so you can place your inner Alexis ring in a way that it is between the vaginal mucosa and the still closed peritoneum. Then you can make your dissection for your anterior colpotomy with endoscopic instruments. I think with that, we now see that our cystotomy rates are going down.

[Dr. Mark Hoffman]
I saw that on a video because I think about patients who had two or three or four C-sections, and you know there's going to be some scarring in the lower uterine segment, but there's always that safe space between the scar from the cesarean and your uterine arteries. Because most of us, if we're doing C-sections, and I haven't done one in a while, but I'm pretty sure they still try to avoid the uterine arteries.

When they're closing your hysterotomy and the C-section and scarring, there's always that little window, that little safe window just anteriorly. Even if your uterus is plastered to the anterior abdominal wall, dissect posteriorly, jump over the uterines, and just bluntly just push whatever's there and just isolate your uterines. I watched a video as part of the training and could see it vaginally where they placed the ring, not, because they hadn't made the colpotomy yet, placed it up against that C-section scar, and blew it up.

You could see that black dark because it was insufflated from the posterior colpotomy, so that black, thin, single layer of peritoneum, you could see your uterines that you'd already gotten or were going to get on a lateral aspect, but just interior to that, I could see the back side of that, and it was a very light bulb moment for me. I was like, "There it is. That's the spot. I've found it."

On the other side, it took me seeing it to realize what it was, and all of a sudden, you go, "Okay, officially, I get it now." I can imagine how once you find those opportunities because there's, like any surgery, where are your safe spaces? Where are your opportunities for success? I saw that and went, "Okay, now that makes so much more sense. There's a completely safe space. I can just see it clear as day." Again, that was a moment for me where I thought vNOTES was pretty cool.

[Dr. Jan Baekelandt]
You describe it beautifully. I can't describe it any nicer than you did, but that was exactly what I felt the very first time I tried it. Because I thought, "How can I try and reduce this rate? Can I place the ring," and tried all sorts of setups. The first time we put the ring that way and saw that, it was like now we can do these difficult colostomies, where in a normal vaginal hysterectomy, you're stuck. You can make your posterior colpotomy tie off these vesicles, but if you can't make an anterior colpotomy, you have to convert your laparoscopy.

[Dr. Mark Hoffman]
In a vaginal hysterectomy, you're pulling the uterus down, you're compressing that tissue, you are making it more difficult. What kept stressing was pushing that uterus away, push the uterus away, push the uterus away, just like you're doing from below with the colpotomy laparoscopic. You're doing it yourself, and by pushing it away, you're exposing those windows to allow you to visualize those small spaces much more largely.

[Dr. Jan Baekelandt]
Exactly. You have a double flow of carbon dioxide. You have your flow that goes behind the uterus and opens the space in the abdomen. Because you have that empty space there, as you describe it, it's blue or black, the peritoneum, because there's nothing behind, and where your bladder is, it's actually white. There is something behind it. That really helps. If it's one of those uterines that's plastered to your abdominal wall, you can basically do your whole hysterectomy and just leave the uterus hanging on the C-section scar, and at the end, you shave the scar like you shave in endometriosis.

[Dr. Mark Hoffman]
That's the same way we do it laparoscopically. I think many of us, when we first get in there, when you're doing an abdominal hysterectomy in training, that's where you start because that's where your abdominal incision is, is right on top of the mess, is right in the scar. When you get in laparoscopically, and you learn that's the last thing we do. If you see someone start chipping away the scar first, it's like, "Whoa, whoa, whoa, stop. Let's get all the blood supply, and then we have a little dead uterine we can chip away."

Seeing that done from below with the camera was pretty exciting. I thought that was pretty neat.

I think the other thing I was trying to visualize that will take some time is the ureters. Because as we have that ring in, the bladder's anterior to us, the ureters are coming in lateral. The ring, like you said, pushes it out of the way completely. Once you've gotten the uterines first, I imagine the ureters are just now nowhere near, not that you ever ignore them, but they're nowhere near where we're operating once the uterines are taken.

[Dr. Jan Baekelandt]
I think the moment when you're closest to the ureter is when you're coagulating the uterine artery, and that's actually the only moment when you're close to it. If there's no endometriosis and they're in the normal position, the whole bend of the ureter into the bladder is behind the plastic sheet. I think laparoscopically, where we have our ureteric injuries, is not where we go and dissect it to find it. It's usually when we coagulate too close to the vaginal cuff. It's right where the ureter goes into the bladder, the point where you normally don't even dissect it laparoscopically. That area is protected by the alexis sheet. Then the ureter at the level of the uterine artery is lateralized a bit because of the pressure of the ring.