Back to the Future: Transvaginal Endoscopic Surgery

Last year, we published an editorial on robotic surgery. ¹ This surgical approach was introduced gradually into gynecologic surgery in the late 1990s and now is commonly used in this field in the United States.

While the oldest route for gynecologic surgery is the transvaginal approach, it is now applied to a minority of patients undergoing hysterectomy. The declining rate of vaginal hysterectomy (VH) was considerably enhanced by the increasing use of sophisticated laparoscopic surgery in the late 1980s. VH has well-known advantages over laparoscopic hysterectomy, among them being lower cost, fewer equipment requirements, no abdominal-wall trauma, avoidance of infrequent but serious major complications (trocar injuries), and a reduced incidence of ureteral injury.

Recovery with both routes is comparable. Laparoscopic surgery offers some advantages over VH, even for uncomplicated cases, such as better visualization of intra-abdominal anatomy, improved exposure for some procedural steps, and relative ease of adnexectomy and ergonomics. Moreover, most practitioners who teach gynecologic surgery now have greater familiarity with the laparoscopic approach. Beyond uncomplicated hysterectomy, a vast spectrum of complicated gynecologic procedures are performed laparoscopically.

A surgeon must select from among 3 routes for performing a hysterectomy: vaginal; open abdominal; or laparoscopic. In addition, there are variations of these approaches that include robotic and vNOTES [vaginal natural-orifice transluminal endoscopic surgery].

The current issue contains the Special Topic vNOTES. Jerry Matkins, Jr., MD, a nationally known authority on this subject, has assembled an outstanding group of gynecologic surgeons who have surgical expertise on the various aspects of this relatively new route of surgery and who have provided excellent articles and videos for us. Surgeons, like myself, who were unfamiliar with this approach are treated, in this issue of Gynecologic Surgery, to an abbreviated surgical course on the subject.

There are several aspects of the vNOTES approach worthy of comment. As the authors point out, vNOTES combines some of the advantages of vaginal and laparoscopic surgical approaches, extending the vaginal reach to some ancillary procedures and potentially reducing the difficulty of some otherwise particularly challenging VHs. The authors do acknowledge that vNOTES has some limitations. Without the benefit of firsthand experience, this approach impresses me as being potentially difficult to both learn and teach. In my own surgical region, there has not yet been significant incorporation of vNOTES, and it strikes me that the technique may require some strong and specific skill sets that many of us lack. Yet, keeping an open mind, I do think vNOTES is an innovative gynecologic surgical approach that holds a lot of promise. Further surgical advances in vNOTES will occur, likely resulting in utilization of this approach by a larger community of gynecologic surgeons.

This Special Topic in this issue on vNOTES provides a good foundation for understanding the basics and potentials for this new and innovative approach to gynecologic surgery. I look forward to seeing how vNOTES evolves and encourage interested gynecologic surgeons to delve deeper into this subject.