© 2021 MJH Life Sciences and Contemporary Obstetricians and Gynecologists. all rights reserved.

© 2021 MJH Life Sciences™ and contemporary obstetricians and gynecologists. all rights reserved.

The reality is that traditional laparoscopic surgery can provide excellent results, good surgical exposure, and flexibility to deal with almost any clinical situation. Therefore, this is a high threshold that needs to be overcome-vNOTES is essentially a single port vaginal surgery.

In this month's contemporary OB/GYN®, we convened a group of gynecological surgeons to discuss their experience of using vaginal natural orifice endoscopic surgery (vNOTES) in gynecological surgery.

vNOTES is a hybrid of NOTES and single port surgery in some respects, both of which became very popular 10 to 15 years ago. 1 NOTES The surgery is performed through the vagina, stomach, and rectum, and is mainly performed by general surgeons.

There have been many innovations in several new devices developed for suture and retraction. However, due to various factors, the enthusiasm gradually weakened. This includes reimbursement issues, because insurance companies consider this method to be experimental. In addition, the operation time is prolonged, the technical requirements are high, and additional equipment is required, and these equipment are not always available.

Single port surgery has undergone a similar evolution, initially with enthusiasm and then decline, although there are still surgeons who provide this type of surgery to patients. Due to instrument collisions, single-port surgery using traditional laparoscopic instruments is challenging, and patient results seem to be the same as those of traditional laparoscopic surgery. 1 Robotics companies have developed solutions that make it easier for surgeons to triangulate instruments, so maybe we will see a resurgence of enthusiasm for single-port surgery. 2

A few years ago, I joined the single port/NOTES trend and developed a procedure called Orifice Assisted Single Incision Surgery (OASIS). 3 This is an attempt to separate the optical path from the operating instrument. It had some hope at first, but it proved to be logistically difficult due to the lack of appropriate equipment, and more importantly, there was no significant difference in patient outcomes. Therefore, I jumped out of the single-port/NOTES trend shortly thereafter.

The reality is that traditional laparoscopic surgery can provide excellent results, good surgical exposure, and flexibility to deal with almost any clinical situation. Therefore, this is a high threshold that needs to be overcome-vNOTES is essentially a single port vaginal surgery. Its advantage is that the vaginal access is larger than traditional single-port incisions, so the instruments can be spaced farther apart, reducing instrument collisions. When dealing with uterine fibroids or appendage masses, vNOTES also provides an excellent natural orifice extraction port. The absence of a 2.5 to 3 cm umbilical cord incision in vNOTES is also advantageous, both for cosmetic purposes and because it eliminates the risk of subsequent umbilical hernia.

However, vNOTES does have some disadvantages. There are some learning curves in instrument settings and inverted angle work. This operation is not universally applicable, such as occlusion of a dead end due to stage 4 endometriosis, and suture-intensive operations, such as extensive hysteromyomectomy, which are not suitable for this method.

Where is vNOTES in the arsenal of gynecologists? For surgeons who are accustomed to vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy, this seems to be an ideal operation. Surgeons with experience in single port surgery may also be more likely to transition to this type of surgery. We need more high-quality evidence (randomized controlled trials) to compare vNOTES with other access methods, such as total vaginal hysterectomy and total laparoscopic hysterectomy.

Once we have these evidences and more clinical experience, we will see where vNOTES stands, and whether it is just a temporary “fashion” like NOTES, or in certain operations (such as hysterectomy and accessory resection) It is widely accepted by gynecologists.

Time will tell, but the early results are certainly encouraging. 4