Vaginal Natural Orifice Endoscopic Surgery: How It Can Be the Return of Vaginal Surgery

Hysterectomy is an ancient procedure, with documentation of it being performed dating back to circa 160 ad. The first “modern” hysterectomy procedure was performed vaginally in the early 19th century by “artificially prolapsing and extirpating the uterus and appendages” although correct attribution to the first surgeon is debatable. This was followed in 1853 by the first successful abdominal hysterectomy. ¹ The approach to hysterectomy and pelvic surgery went without much change (although better materials, sterile techniques, antibiotics, and anesthesia certainly improved outcomes) until the increase in more widespread adoption of the laparoscope. However, most of the early laparoscopic procedures were limited to addressing problems of the adnexa and tubal interruptions.

In 1984, Semm described a laparoscopically assisted vaginal hysterectomy (LAVH), utilizing these adnexal techniques to assist in completing the more-cephalic portions of the procedure reliably, leaving the lower aspects to be completed via a vaginal approach. ² Then in 1989, Reich and colleagues described the first total laparoscopic hysterectomy (TLH) ³ and ushered in a revolution in laparoscopic gynecologic surgery. Rapid advances in optics, laparoscopic instruments, and suture materials led to the wide adoption of, first, LAVH, then TLH, followed by robotic hysterectomy. This had the desired effect of dramatically reducing the need for, and incidence of, laparotomy for hysterectomy and other pelvic surgeries. However, these advances also led to a drastic reduction of the number of vaginal surgeries performed in the United States. In 2008, more than 50% of minimally invasive hysterectomies in the United States were performed vaginally. By 2018, this number had dropped to 13%, with the overall rate of total vaginal hysterectomy (TVH) dropping below 12%. ⁴

Unfortunately, this shift in surgical approach was not accompanied by an improvement in outcomes when comparing other minimally invasive approaches to vaginal hysterectomy. ⁵ The American College of Obstetrics and Gynecology has consistently recommended vaginal hysterectomy as the preferred route for benign hysterectomy when feasible due to its lower morbidity and costs. ⁶ Unfortunately, these calls have not been heeded, and vaginal hysterectomy rates continue to decline and, in many practices, vaginal hysterectomies are not performed at all.

Why did we make this change? While demonstrably better for patients, vaginal surgery is not an easily taught skill. Visualization is limited to the vaginal canal, and this canal is usually only accessible to the primary surgeon (and this access often limited at that). Much of vaginal surgery is tactile and requires actual surgery to learn. Vaginal surgery is not as easily adaptable to video learning in the way the laparoscopic and robotic surgery are. Given that vaginal surgery skills are harder to teach, once a “replacement” arose, fewer trainees learned these skills, thus leading to fewer surgeons to teach succeeding generations of gynecologists how to develop and maintain vaginal-surgery techniques.

Nichols and Randall were prescient in their concern for the loss of vaginal surgery skills when, decades before the diminishing numbers of vaginal hysterectomies began, they wrote in their preface to the first edition of Vaginal Surgery: “A heritage all too readily lost, the techniques of vaginal surgery must be sought for, recorded carefully, and practiced, if competence and skills are to be maintained.” ⁷

Other reasons exist for the decline of vaginal surgeries. Ergonomically, vaginal surgery can be challenging. Gynecologists who do most of their surgeries vaginally have reported a work-related musculoskeletal disorder (WRMD) prevalence of 87% and are more likely to require medications for WRMD than surgeons who primarily use other surgical routes. ⁸ The assistant vaginal surgeon is also in prolonged static awkward positions, especially involving the trunk and neck. ⁹ There are often economic disincentives for vaginal surgery as well. Skilled partners are often required as assistants at low reimbursement rates, and TVH is reimbursed at lower rates than other modalities of hysterectomy.

So, what do we have to do to return to a more patient-centered approach to gynecologic surgery? Is there hope for reversing the trend of the loss of vaginal surgery skills? Vaginal natural orifice translumenal endoscopic surgery (vNOTES) is a technique whereby the abdominal cavity is entered and operated on via a preexisting orifice (in this case the vagina) rather than through a new abdominal incision. vNOTES was first described in 2007–2008 as an alternative approach for appendectomy and cholecystectomy.^10,11 In 2012, Ahn et al. in South Korea and Su et al. in Taiwan described vNOTES for adnexal and hysterectomy procedures respectively.^12,13 In 2015, Baekelandt in Belgium published his technique for vNOTES. ¹⁴ This involved placing a single-port laparoscopic sleeve port after anterior and posterior colpotomies were made and uterosacral ligaments ligated, and performing the remainder of the hysterectomy laparoscopically. ¹⁴ Baekelandt and colleagues then published an article about a prospective noninferiority series favorably comparing vNOTES hysterectomy to TLH. ¹⁵ Since then, trials have demonstrated the utility of vNOTES for adnexal surgery, ¹⁶ and in obese patients ¹⁷ and those with large uteri. ¹⁸

In 2019 the U.S. Food and Drug Administration approved a commercially available laparoscopic port for vNOTES (GelPOINT^® V-Path transvaginal access platform, Applied Medical, Rancho Santa Margarita, CA, USA), thus facilitating vNOTES by eliminating the need to fashion vaginal-access ports out of nonapproved (and less-convenient and less-effective) materials.

Since its introduction, vNOTES has emerged as a viable, and often preferable, technique to return gynecology to its roots of vaginal surgery. Because visualization after the vaginal port is placed uses the laparoscope, cauterization and transection of pedicles can be seen and taught more easily. All the intraperitoneal pedicles are secured laparoscopically with a monitor directly in front of the surgeon allowing proper ergonomic positioning to be achieved. Also, no highly trained surgical assistants are required because only the initial steps mirror traditional vaginal-surgery techniques. This means that the assistant is then only required to hold the laparoscopic camera head.

I would like to thank Dr. Hoffman for inviting me and my fellow authors to present this special issue of the Journal of Gynecologic Surgery on vNOTES. In the articles contained herein, we hope to show that benign hysterectomy, adnexal surgery, urogynecology, and gynecologic oncology procedures can be accomplished vaginally with benefits to patients and surgeons alike. We believe that, with a relatively small amount of training, vNOTES may be the technique that allows gynecologists to reclaim their heritage as vaginal surgeons.