vNotes (Vaginal Natural Office Transluminal Endoscopic Surgery): A New Era in Laparoscopy

Introduction

vNOTES or vaginal Natural Orifice Transluminal Endoscopic surgery is a new paradigm shift in gynaecological surgery. We saw a first paradigm shift from conventional surgery into laparoscopic surgery in the 1980’s and 1990’s. With vNOTES we now see a shift from 90° to parallel surgery. Almost all benign gynaecological operations can be performed via vNOTES. From our own experience, the first 1000 vNOTES cases included hysterectomies (up to 3361 grams), adnexectomies (up to 20cm), ovarian cystectomies, salpingectomies (for ectopic pregnancy and sterilization), myomectomies, appendectomies, omentectomies for borderline ovarian cancer, and endometrial cancer. In this book chapter we will mainly focus on benign hysterectomy and the potential use of vNOTES in endometrial cancer.

Hysterectomy is the surgical removal of the uterus. It is the most commonly performed major gynecologic surgical procedure in the United States of America, where more than 400,000 hysterectomies are performed annually (Corona et al., 2015). The most common benign indications for a hysterectomy are: fibroids 30%, dysfunctional uterine bleeding (20%), endometriosis and/or adenomyosis (20%), genital prolapse (15%), chronic pelvic pain (10%) and endometrial hyperplasia (6%) (Carlson et al., 1993).

Conrad Langenbeck performed the first reported elective hysterectomy in 1813 (Table 1) using a vaginal approach (Nieboer et al., 2006) and in 1863 the first elective abdominal (subtotal) hysterectomy was performed by Charles Clay (Nieboer et al., 2006). Harry Reich performed the first laparoscopic-assisted vaginal hysterectomy in 1989 and the first total laparoscopic hysterectomy in 1993 (Nieboer et al., 2006).

Table 2 presents the different hysterectomy techniques. Traditionally a hysterectomy could be performed via these 3 approaches: abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy. The laparoscopic hysterectomy can be divided into 3 categories: Laparoscopic Assisted Vaginal Hysterectomy (LAVH), Laparoscopic Hysterectomy (LH) and Total Laparoscopic Hysterectomy (TLH). With the introduction of surgical robots, hysterectomies can now also be performed robotically (RH). The technique of a RH is similar to that of a TLH, but robotic arms hold the surgical instruments and the surgeon manipulates them remotely from behind a console. Laparoscopic and robotic hysterectomies can both be performed through multiple small abdominal incisions or through one larger umbilical incision. More recently a new approach to hysterectomy via Natural Orifice Transluminal Endoscopic Surgery (NOTES) has been introduced (Table 2).

In the next section we will focus further on the different hysterectomy techniques by vNOTES, where the uterus is removed endoscopically leaving no visible scars. In section 3 we will discuss the use of vNOTES hysterectomy for benign indications. In section 5 we will look at the potential benefits of vNOTES in the treatment of endometrial cancer.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (Vnotes)

The advantages of laparoscopy over traditional laparotomy have been accepted worldwide for many years (Burpee et al., 2002). To further reduce surgical morbidity, the evolutionary trend has been towards even less invasive techniques, such as single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES). Minimally invasive surgery improves cosmetic outcome, and also reduces surgical injury, which in turn decreases the inflammatory and neuroendocrine responses, and leads to less postoperative pain and quicker recovery (Grande et al, 2002).

NOTES reaches the abdominal cavity by scar-free means. To this end, numerous surgical procedures are performed via a natural body orifice. In recent years this technique has gained popularity among general surgeons, gynecologists, urologists and gastroenterologists, and its feasibility and safety have been approved (Rattner & Kalloo, 2006).