Vnotes (vaginal natural orifice transluminal endoscopic surgery)

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

vNOTES: Is This the Future of Gynaecological Surgery? Yoong W, Sampson V, Mwenechanya L, Baekelandt J. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery? TOG 2023;25:97–100. doi:10.1111/tog.12860

6–10 mmHg 41 vs 75 min 20 cases VNOTES INSUFFLATION (VS 12–16 OPERATING TIME, VNOTES VS TLH (RCT, SUGGESTED INITIAL LEARNING CURVE LAPAROSCOPY) P<0.001)

DO N' T-M IS S FA C TS

  1. Insufflation pressure 6–10 mmHg (laparoscopy 12–16); Alexis® O-Retractor or GelPOINT® V-Path platform seals the vaginal cuff

  2. Only hysterectomy RCT: operating time 41 vs 75 min, stay 0.8 vs 1.3 days, 77% vs 43% home within 12 hours

  3. Absolute contraindications: cul-de-sac-obliterating endometriosis/dense adhesions, ICS III–IV prolapse, previous rectal surgery, gynaecological malignancy, pelvic radiotherapy, previous total hysterectomy, mesh sacrocolpopexy, virginity

  4. Indications: benign uterine/adnexal pathology (ectopic, ovarian cyst) and high BMI where laparoscopy is difficult

  5. Learning curve ~20 cases if already skilled in laparoscopic and vaginal surgery

  6. Adnexal RCT (n=67): less pain/analgesia but trend to more adverse events – spillage and postoperative bleeding

  7. Cost ~£130 more than LAVH (disposables); similar to TLH

  8. Status: technique under evaluation; >3000 cases in the iNOTESs registry

STEPS AT A GLANCE

  1. GA + Trendelenburg 2. Circumcise vaginal mucosa around cervix, mobilise 3. Alexis® O-Retractor behind colpotomy

  2. Pneumoperitoneum 10 mmHg 5. Laparoscope + energy devices via port 6. Specimen out per vaginam

  3. Close colpotomy with absorbable suture

ABBREVIATION KEY

vNOTES — vaginal NOTES (natural orifice endoscopic surgery) ICS — International Continence Society

LAVH — laparoscopic assisted vaginal hysterectomy iNOTESs — international NOTES Society

TLH — total laparoscopic hysterectomy

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — this the future of gynaecological surgery? TOG 2023;25:97–100. doi:10.1111/tog.12860

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