Vaginal–Natural Orifice Transluminal Surgery/Adnexal Surgery A Modern “Take” on a Classic Surgical Approach

Abstract

Posterior colpotomy to create an access site to the pelvic cavity has been a historical “feather in the cap” of any gynecologist, who, unlike other surgeons, can access the intraperitoneal space with a hidden incision. Trends in adnexal surgical techniques in the past 35 years have favored a transabdominal endoscopic approach, which corresponds to what is espoused by all the major gynecologic societies in the world. Resident-education curricula have created a generation of gynecologic surgeons with distinguished laparoscopic hand–eye coordination required to perform complex surgical procedures previously only performed via laparotomy. Fear of making a classical vaginal incision to approach the same goal has been—and continues to be—a hurdle in minimally invasive gynecologic surgery. The advent of the vaginal–natural orifice transluminal surgery (vNOTES) technique via posterior colpotomy uniquely synthesizes the minimally invasive access point granted primarily to gynecologists with the benefits of endoscopic surgery, which has become a mainstay for gynecologic surgery. vNOTES for gynecologic adnexal surgery represents a modern “take” on a classic surgical approach and will help today's surgeons get their feathers back in their caps. (J GYNECOL SURG 40:100)

Introduction

The use of colpotomy in surgery has a long history, primarily in the field of gynecology, and this usage has waxed and waned in the face of technological advances over the most recent decades. Colpotomy is the surgical procedure of incising the vaginal wall to access the abdominopelvic pelvic organs for diagnostic or therapeutic interventions.

The origins of colpotomy trace back to ancient civilizations. Historical records suggest that colpotomy was prevalent in ancient Egypt as early as 1500 bce. The Ebers Papyrus and the subtly more-recent Edwin Smith Papyrus—both ancient Egyptian medical texts—mention the use of colpotomy to treat gynecologic conditions. Between the Age of Antiquity and the Age of Antisepsis, many additional scholars investigated the utility of the vagina as a means to gain access to the internal organs and as a portal through which to administer therapeutics. Infamous names, including Soranus of Ephesus (98–138 ad), Jacapo Berengario da Carpi (circa 1460–circa 1530), and James Marion Sims, AB, MD (1813–1883 ad), were involved in the examination (and unethical experimentation) of the vagina as a means to access the abdominal cavity.^1,2

In the 19th century, as surgical techniques advanced, colpotomy gained recognition as a surgical approach for diagnosing and treating pelvic diseases. Surgeons began to explore the possibilities of accessing the pelvic cavity through the vagina, avoiding the need for more-invasive abdominal incisions. The race to perform the first vaginal hysterectomy was won, via self-declarations, by Johann Nepomuk Sauter, MBChB (1766–1840 ad) in 1822, Joseph Claude Récamier (1744–1852 ad) in 1824, and Konrad Johann Martin Langenbeck, MBChB (1776–1851 ad) in ∼1839. In 1827, Dr. Sims performed one of the earliest recorded colpotomies to drain an ovarian abscess. He described the procedure in his book, Clinical Notes on Uterine Surgery: With Special Reference to the Management of the Sterile Condition.¹

In the 1890s, there was a notable surge in the popularity of vaginal operations. This shift in surgical preference sparked extensive discussions and debates regarding the suitability and safety of colpotomy. Prominent opponents of colpotomy, including Robert Michaelis von Olshausen, MBChB (1835–1915 ad) and Rudolf Chrobak, MD (1843–1910 ad), raised concerns and criticized the perceived drawbacks of the procedure. Dr. Olshausen called for a unified stance against the “senseless and dangerous expansion” of colpotomy, arguing that it was unnecessary and carried potential risks. Dr. Chrobak highlighted that injuries arising from colpotomy might not be immediately evident, unlike in laparotomies, in which the iatrogenic complications could be identified and treated promptly. Supporting this perspective, Hermann Johannes Pfannenstiel, MBChB (1862–1909 ad) justified the preference for laparotomy (and his eponymous incision) by highlighting its near-0% mortality rate, implying that colpotomies had significantly higher mortality rates, thus positioning the colpotomy as an inferior approach.

Overall, this conflict reflected a lively debate among surgeons—which exists even today—who were determining the utility of the vaginal approach and the role of colpotomy in gynecologic surgery. Despite the debate during the turn of the century, champions for colpotomy expanded its use to address various conditions, including ectopic pregnancies, ovarian cysts, and uterine fibroids.³

Sterilization and Colpotomy—a History

As a method of female sterilization, colpotomy was first described in 1895 by Alfred Dührssen, MBChB (1862–1933 ad). In 1928, William Wayne Babcock, MD (1872–1963 ad) recommended that a “vaginal approach for certain intraperitoneal operations” be used to avoid the hazards of laparotomy. From India, in 1943, Bhalchandra Nilkanth Purandare, MBBS (1911–1990 ad) suggested colpotomy for sterilization through the anterior fornix with the fimbrial ends of the tube anchored to the front of the cervix. Dr. Purandare later recommended the posterior approach due to its efficiency. During the late 1940s to the 1970s, academic gynecologists published more about the success of posterior colpotomy sterilization and its decreasing morbidity. Famous, recognizable names and institutions in gynecology were popularizing their techniques of tubal sterilization, including: Frederick Carpenter Irving, MD (1883–1957 ad), Max Madlener, MBChB (1868–1951 ad), Eliot Bishop, MD and William F. Nelms, MD for Ralph Hayward Pomeroy, MD (1867–1925 ad), Hajime Uchida, MD (1921-1996 ad), Jaroslav F. (Jerry) Hulka, MD (1930–2014 ad), Gilbert Marcus Filshie, MD, Richard K. Kleppinger, MD (1924–1996), and Parkland Memorial Hospital.⁴

By 1972, many American physicians routinely used a colpotomy for interval sterilizations. Cecil F. Whitaker, Jr., MD, presented his findings regarding “Tubal Ligation by Colpotomy Incision” at the South Atlantic Association of Obstetricians and Gynecologists, in Hot Springs, VA, January 28–31, 1979. His retrospective analysis of 585 patients demonstrated an operative time averaging under 30 minutes, with a hospital stay of <3 days. By then, the significant postoperative complication rate was <2%.⁵

The Indian sterilization campaigns in the 1970s illustrated how this popular and widely used vaginal sterilization technique fell out of favor due to the emerging complication rate. Sepsis, followed at times by secondary hemorrhage, was the leading cause of morbidity and mortality. The complications that the Indian government published led to a rule that colpotomy sterilizations require 24–48 hours of admission to rule out delayed hemorrhage. Colpotomy had remained a popular technique until 1978, when mortality associated with the procedure due to hemorrhage increased. In 14 years, 12 deaths of 29,000 procedures had occurred. This fateful complication profile overlapped the introduction of culdoscopic and laparoscopic sterilization to India in 1970. The shortcomings of culdoscopy are not reviewed here, but laparoscopy replaced it quickly. By 1979, laparoscopic sterilization usurped all other sterilization techniques, including postpartum minilaparotomy tubal sterilization, which historically was the backbone of the Indian sterilization campaign.⁶ Researchers widely cited a lower mortality rate for transitioning to laparoscopic sterilization. However, there is reason to believe that technological advances were just en vogue, and surgeons wanted to learn endoscopy.

Sterilization today

Female sterilization is the most-common form of contraception in the United States, used by 30.2% of married couples.⁷ The laparoscopic approach is more favorable than a minilaparotomy due to its ability to enable a surgeon to inspect the abdominopelvic cavity, small incision size, and ambulatory/outpatient surgical nature. The risks of transabdominal laparoscopy are not negligible, and surgeons cannot underestimate the risk of injury to the abdominal wall and hollow viscera of the abdomen, including the bladder, bowels, blood vessels, and nerves. Gynecologic surgeons can use a single-incision transabdominal operative laparoscopic approach for a tubal-coagulation procedure.

However, data in 2015 suggested that salpingectomy may be superior in women with a high risk for ovarian cancer.⁸ Yet, more–recent data (in 2023) indicate that there is no association between salpingectomy and a lower risk of developing ovarian cancer in the general population.⁹ Regardless of the potential for collateral risk reduction, the higher efficacy with little-to-no additional difference in perioperative outcomes and the opportunity to potentially decrease the risk of ovarian cancer currently favors salpingectomy. Salpingectomy typically requires other abdominal laparoscopic incisions to perform the dissection and ensure complete fimbrial resection to achieve the theoretical risk reduction. Transvaginal access via vaginal–natural orifice transluminal surgery (vNOTES) confers similar surgical advantages of laparoscopy, including abdominopelvic exploration and the ability to introduce multiple instruments, addressing the needs of the patient desiring sterilization, all with a single hidden incision.¹⁰ Surgical evolution in perioperative antibiotic prophylaxis and the ability to inspect vascular pedicles mitigates the morbidity that previously led to the disrepute of direct vaginal sterilization procedures in the 1970s.

Why Transvaginal Access?

The NOTABLE trial from 2018 provided the first randomized controlled trial comparison of adnexectomy via laparoscopy and vNOTES. This study demonstrated the noninferiority of vNOTES, compared to conventional laparoscopy, for managing adnexal structures. vNOTES had a shorter overall operative time and caused patients less postoperative pain.^11,12 The unique visceral autonomic and splanchnic innervation pattern of the posterior cul-de-sac, compared to the somatic innervation of the abdominal wall contributes to reduced postoperative pain. As demonstrated in the anesthesiology literature, shorter operative times result in less postoperative pain, which favored vNOTES in this trial.¹²

Gynecologists have historically been avant-garde, and since the NOTABLE trial was published, numerous additional publications have supported the feasibility of multiple other standard gynecologic procedures via the posterior colpotomy route.

Basic Requisite Skills Already Exist

Obstetrics and gynecology residency program graduates possess all the basic skills and knowledge to perform vNOTES surgery. Comfort with laparoscopy tends to be innate. However, a major psychologic hurdle for these surgeons is the direct vaginal entry. Skill atrophy in vaginal entry, much like other surgical skills and techniques, can be remediated with educational courses, simulation, collaboration, and mentorship with other surgeons who are comfortable with vaginal surgery. Easily accessible and focused courses on instrumentation are encouraged to allow surgeons to meld their training to deliver this hybrid minimally invasive procedure to their patients. Fellowship and discussion with other surgeons will enable new vNOTES surgeons to evolve their practices and receive the support needed to adopt this technique into their armamentariums.

Preoperative Considerations

Counseling for transvaginal surgery should begin with discussing the access and vantage point. When thought of as the neck of a funnel, the posterior colpotomy endoscopic access point represents a singular entry point that has the potential to complete the intended procedure safely. If limitations in visualization, access, instrumentation, or skill preclude safe performance, then pivoting to another minimally invasive access technique should be utilized to the surgeon's comfort level. When the goals of the surgery are at the forefront of the discussion, the surgical technique favors the “minimally-est” of invasive approaches. When considered on a continuum, vNOTES represents the most minimally invasive technique, followed by conventional laparoscopy and laparotomy. A successful transvaginal approach can result in a shorter operative time and decreased postoperative pain.

As with all transvaginal procedures, appropriate perioperative antibiotic prophylaxis and discussion of pelvic rest postoperatively are recommended. Reluctance to avoid pelvic rest soon after a transvaginal procedure can sometimes result in a patient favoring a transabdominal approach. Still, the advantages of a successful vNOTES approach, including cosmesis, less pain, and shorter length of anesthesia time, cannot be understated.

Techniques for vNOTES Access for Adnexal Procedures

Given that a clear posterior cul-de-sac is mandatory for a safe posterior colpotomy entry for vNOTES adnexectomy, a thorough rectovaginal examination is the first step to accessing the intraperitoneal cavity. The incision-site selection will commence if the rectovaginal examination is free of any studding, thickening of the uterosacral ligament, or immobile masses.

Whereas a colpotomy incision for a hysterectomy favors the cervicovaginal junction, the posterior colpotomy for adnexal surgery is ∼1 cm more posterior than the typical incision site. A multilayer closure favors suturing like-to-like, which is why a more-posterior incision is favorable. A typical cervicovaginal incision would lead to a closure that would bring together the posterior vagina and the cervix, potentially leading to bleeding, adhesion formation, and dyspareunia. By placing the incision in the posterior fornix, the incision is in the middle of the vagina, and closure of the edges with heavy delayed absorbable suture will appose vagina-to-vagina.

Infiltration of the incision site with the surgeon's preferred anesthetic and vasoactive solution is standard. After visualizing the incision site, the surgeon places 2 Allis clamps anterior and posterior to the site. A sharp, large deliberate incision with Mayo scissors can be used to enter the intraperitoneal cavity reliably.

The alternative, layer-by-layer technique is also helpful and parallels a standard vaginal hysterectomy approach.

After entry into the intraperitoneal cavity, it is paramount to plicate the peritoneum to the vagina at the 4 cardinal directions to ensure a hemostatic closure at the end of the procedure. A retractor deflects the rectum posteriorly and maintains intraperitoneal visualization. Digital exploration of the colpotomy will reveal the bilateral uterosacral ligaments, uterus, and if present, adnexal masses.

V-Path placement

In the United States, it is commonplace to use manufactured surgical systems to establish the pneumoperitoneum and radial traction of the colpotomy, and to introduce instrumentation. Constructing a similar system using off-label devices can achieve similar functionality but is not recommended. The Applied GelPOINT^® V-Path Transvaginal Access Platform (Rancho Santa Margarita, CA, USA) comes with an introducer to allow the Alexis-O ring to be placed through the colpotomy reliably and enables the surgeon to feel confident about its depth within the pelvic cavity.

The surgeon needs to deploy the inner Alexis-O ring into the peritoneal cavity and tighten the outer ring twice to enable the inner ring to apply even circumferential radial traction to improve visualization. The GelSeal cap is docked, facilitating introduction of multiple trocars and instruments into the pelvic cavity and maintaining the pneumoperitoneum. After establishing the pneumoperitoneum, an anatomical survey is performed using standard endoscopic instrumentation, followed by the intended procedure.

Sterilization and salpingectomy

The surgeon achieves hemostasis and performs surgical cutting using only advanced bipolar devices. The varying degrees of traction placed on anatomical structures during dissection preclude the tension-free coaptation of vessels needed for use of ultrasonic devices. Laparoscopic graspers mobilize the fimbriated end of the fallopian tube under the uterus, exposing the tubo-ovarian ligament and the pelvic sidewall. The surgeon can use an advanced bipolar device or cold scissors to lyse adhesions that limit the mobility of the adnexa. A standard lateral-to-medial approach frees the fallopian tube from the mesosalpinx. The surgeon transects the utero-tubal junction and places the specimen in the posterior cul-de-sac for retrieval.

If a salpingo-oophorectomy is required, the surgeon exposes the infundibulopelvic (IP) ligament by placing the ovary and fallopian tube on anteromedial traction. Keeping the adnexa elevated will ensure that the transperitoneally visible ureter is safe from potential harm. Once the IP is visible, it is coagulated and transected. A lateral-to-medial approach ensuring coaptation of a bilayer of the peritoneum (a “sandwich”) will yield a hemostatic resection. The surgeon needs to inspect all cut peritoneal surfaces for hemostasis prior to extraction.

Most colpotomies measuring 3–5 cm can enable retrieval of specimens easily without needing a retrieval bag. If a specimen requires a bag, the 5–10-mm or the 10–12 mm trocar in the GelSeal cap is used to deploy a retrieval bag.

Other procedures

With the advent of the vNOTES technique, many gynecologic surgeons have molded standard procedures to conform to the transvaginal platform. Surgical management of ectopic pregnancy with a hemoperitoneum via posterior colpotomy has advantages, including easy evacuation with Yankauer suction and being immediately presented with the target anatomy for extirpation.^13,14

Ovarian cystectomy starts by packing the bowel away in the posterior cul-de-sac with moist gauze prior to placement of the GelSeal cap. The advantage of vNOTES is that gravity will make the adnexal lesion fall into the field of operation, obviating the need for a separate instrument to elevate the lesion from the underlying viscera and extremes in the Trendelenburg position. The surgeon performs a standard technique for cystectomy with monopolar scissors and graspers. Modest-sized lesions are extracted directly or bagged for convenience.^15,16

Risk-reducing bilateral salpingo-oophorectomy, per the National Comprehensive Cancer Network^© starts with exploring the upper abdomen using a 30° or 70° angled telescope with photo documentation.¹⁷ A suction irrigation device is used to wash the pelvis with 50 cc of normal saline, and fluids are suctioned and sent for cytologic analysis. The surgeon exposes 2 cm of each IP ligament by placing the adnexa on anteromedial traction. The above-noted technique is performed after dissecting >2 cm of IP before coagulating and transecting the vascular pedicle. The utero-tubal junction is transected while “hugging” the cornua medially. The surgeon resects any peritoneum surrounding the fallopian tubes or ovaries and performs retrieval after bagging the specimens.¹⁷

Prior cesarean sections are advantageous in vNOTES adnexal surgery, with the uterus tethered to the anterior abdominal wall, creating a larger surgical space. When surgical space is limited, the surgeon places a uterine manipulator before applying the GelSeal cap. This technique is also used to troubleshoot a potentially enlarged or bulky uterus obstructing the posterior cul-de-sac. Rotation of the manipulator will enable additional posterior and lateral access.

Myomectomy, especially if performed on a posterior leiomyoma, enables improved visualization and extraction through the posterior colpotomy. Chromopertubation with a transcervical-catheter dye infusion and direct endoscopic visualization of the tubes also enables fertility-cautious surgeons to determine the viability of the fallopian tubes during myomectomy. Myometrial suturing via a midline laparoscopic needle driver averts the need for compound needle angles, enabling simple needle-angle geometry and rotation of the surgeon's hand.¹⁸ Anterior and fundal myomectomies are also candidates for a vNOTES approach but are subject to surgeon skill.¹⁹ Patients who undergo this approach have a quicker recovery, likely due to the decreased morbidity associated with multiple incisions.²⁰

Uterine-sparing procedures, such as uterosacral ligament hysteropexy, take advantage of improved ureteric visualization, thus avoiding injury and/or mesh complications, improving cosmesis, and performing a durable apical-prolapse repair without the additional morbidity conferred by transabdominal surgery.^21,22

Exploration of the pelvis for perforated intrauterine devices and retrieval through the posterior colpotomy also results in quicker recovery and enables pivoting to transabdominal laparoscopy if upper abdominal exploration is needed.

Closure

After completing the intended procedure, the surgeon removes the Alexis-O port and deflates the pneumoperitoneum intentionally by elevating the anterior abdominal wall manually through the colpotomy with 1 hand and placing pressure on the upper and middle abdomen externally with the other hand. After satisfactory evacuation of the pneumoperitoneum, closure of the colpotomy with delayed absorbable suture commences. The surgeon ensures peritoneum and vagina are plicated meticulously and achieves hemostasis.

Conclusions

From its ancient origins to its modern applications for minimally invasive gynecologic surgery, the colpotomy plays a significant role in improving patient outcomes and evolving the practice of medicine. Rehoning surgical skills in transvaginal entry will ensure that surgeons can continue to be the masters of minimal access into the abdominopelvic cavity. vNOTES as a technique is in the forefront of gynecologic surgery and has already adapted and evolved when pitted against the current standard. Adoption of vNOTES by this generation's gynecologic surgeons will ensure that vaginal surgery is not lost and propel the platform's capabilities to more-advanced interventions, much like laparoscopy did during the past 35 years.

Acknowledgments

Applied Medical Resources Corporation provided education honoraria for instructing vNOTES courses.

Footnotes

Author Disclosure Statement

No financial conflicts of interest exist.

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