The reality is that traditional laparoscopic surgery provides excellent outcomes, great surgical exposure, and the flexibility to tackle almost any clinical situation. As such it is a high bar to overcome—vNOTES is essentially single port vagin*l surgery.
For this month’s edition of Contemporary OB/GYN®, we convened a group of gynecologic surgeons to discuss their experience using vagin*l natural orifice transluminal endoscopic surgery (vNOTES) in gynecologic surgery.
vNOTES is in some respects a hybrid between NOTES and single port surgery, both of which became very popular 10 to 15 years ago.1 NOTES procedures were performed through the vagin*, stomach, and rectum and mostly by general surgeons.
A lot of innovation took place with several novel instruments that had been developed for suturing and retraction. However, enthusiasm gradually waned becasue of several factors; these included reimbursem*nt issues because insurance companies considered the approach experimental. Additionally, surgeries were prolonged, and technically demanding and required extra equipment that wasn’t always available.
Single port surgery experienced a similar evolution, with initial enthusiasm, then a decline, although there are still surgeons who offer this procedure to patients. Single port surgery using traditional laparoscopic instruments is challenging because of instrument clashing, and patient outcomes did not seem to differ from those of traditional laparoscopic surgery.1 Robotics companies have developed solutions that enable surgeons to triangulate instruments with greater ease, so perhaps we will see a resurgence in enthusiasm for single port surgery.2
I jumped on the single port/NOTES bandwagon several years ago and developed a procedure called orifice assisted single incision surgery (OASIS).3 This was an attempt to decouple the optical access from the operating instruments. It held some promise initially but proved to be logistically difficult because of a lack of appropriate equipment and, more importantly, no apparent difference in patient outcomes. I therefore jumped off the single port/NOTES bandwagon shortly thereafter.
The reality is that traditional laparoscopic surgery provides excellent outcomes, great surgical exposure, and the flexibility to tackle almost any clinical situation. As such it is a high bar to overcome—vNOTES is essentially single port vagin*l surgery. Its advantage is that vagin*l access is larger than with a traditional single port incision and therefore instruments can be spaced farther apart, reducing instrument clashing. vNOTES also provides an excellent natural orifice extraction port when dealing with a fibroid uterus or adnexal masses. The absence of a 2.5- to 3-cm umbilical incision in vNOTES is also advantageous, both cosmetically and because of elimination of the subsequent risk of umbilical hernia.
vNOTES does have some drawbacks, however. A bit of a learning curve exists in the setup of instruments, as well as in working at an upside-down angle. The procedure is also not universally applicable, such as with an obliterated posterior cul-de-sac because of stage 4 endometriosis, and with suture-intensive procedures, such as extensive myomectomy, which are not well suited for this method.
Where does vNOTES fall in the armamentarium of the gynecologic surgeon? It seems like an ideal procedure for surgeons who are used to performing vagin*l hysterectomies and laparoscopically assisted vagin*l hysterectomies. Surgeons with experience with single port surgery will probably also have an easier time transitioning to this procedure. We require more high-quality evidence (randomized controlled trials) to compare vNOTES to other modes of access, such as total vagin*l hysterectomies and total laparoscopic hysterectomies.
Once we have this evidence and more clinical experience, we will see where vNOTES falls and whether it is just a temporary “fad” like NOTES or gains wide acceptance among gynecologic surgeons for certain procedures, such as hysterectomy and adnexectomy.
Time will tell, but the early results are certainly encouraging.4
References Siddaiah-Subramanya M, Tiang KW, Nyandowe M. A new era of minimally invasive surgery: progress and development of major technical innovations in general surgery over the last decade.Surg J(N Y). 2017;3(4):e163-e166. doi:10.1055/s-0037-1608651
Misal M, Magtibay PM, Yi J. Robotic LESS and reduced-port hysterectomy using the da Vinci SP surgical system: a single-institution case series.J Minim Invasive Gynecol. 2021;28(5):1095-1100. doi:10.1016/j.jmig.2020.08.009
Einarsson JI, Cohen SL, Puntambekar S. Orifice-assisted small-incision surgery: case series in benign and oncologic gynecology.J Minim Invasive Gynecol. 2012;19(3):365-368. doi:10.1016/j.jmig.2011.12.017
Housmans S, Noori N, Kapurubandara S, et al. Systematic review and meta-analysis on hysterectomy by vagin*l natural orifice transluminal endoscopic surgery (vNOTES) compared to laparoscopic hysterectomy for benign indications. J Clin Med.2020;9(12):3959. doi:10.3390/jcm9123959
The vNOTES specialized instruments are placed through the vagin* into the pelvic cavity, giving access to the uterus, fallopian tubes and ovaries without the need for abdominal skin incisions. This allows complex surgery to be performed without visible incisions with faster recovery and return to normal activities.
The vNOTES port is then placed and insufflated. Starting on the patient's left side, the cervix is pushed medially and cephalad to expose the uterine vessels, which are transected with the bipolar device, followed by the transsection of the broad and round ligaments.
As a relatively new technique, and without any official guidance from CMS and the AMA, some authorities have opined that the codes for TVH (58260-58294) are the most appropriate hysterectomy codes. However, others have favored the use of the LAVH codes (58550-58554).
V-NOTES widens the indications of vagin*l hysterectomies by removing limitations such as large uterus, absence of prolapse, and history of caesarean. Moreover, this technique allows adnexal surgery to be performed by vagin*l access.
Insertion of a port catheter is a minor surgery and requires a skin incision about an inch in length. This port incision is made with local anesthetic below the clavicle. The catheter is connected to the port, placed under the skin and then into the neck vein, and the port is placed beneath the skin.
A port is a device placed, in most cases, under the skin of your chest below your collarbone. It is made of plastic, stainless steel, or titanium. It's about the size of a quarter, but thicker. It looks like a small bump under your skin.
In a vNOTES procedure, surgeons use specialized instruments inserted through the vagin* instead of making incisions in the abdomen. In addition to hysterectomies, vNOTES can be used for other gynecologic procedures: Fallopian tube or ovarian procedure. Permanent sterilization.
The vNOTES specialized instruments are placed through the vagin* into the pelvic cavity, giving access to the uterus, fallopian tubes and ovaries without the need for abdominal skin incisions. This allows complex surgery to be performed without visible incisions with faster recovery and return to normal activities.
The length of a VNOTES hysterectomy was shorter than that of LESS (80.76 min versus 112.09 min; MD -31.34 min; 95% CI -40.24 to -22.43 min; P < 0.001).
The CPT-code 58661 (Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/ or salpingectomy)) and ICD-10 code Z30. 2 (Encounter for sterilization are the appropriate codes for the bilateral salpingectomy) are the appropriate preventive codes for a bilateral salpingectomy.
When coding for laparoscopic or robotic procedures, code the standard laparoscopic CPT code, example 58552 for a laparoscopic or robotic vagin*l hysterectomy, for uterus 250 g. or less with removal of tube(s) and ovary(s) or as another example 58571 laparoscopic or robot- ic total hysterectomy for uterus 250 g. or less ...
1. What is included in CPT's surgical package? The global surgical package concept includes the preoperative, intraoperative and postoperative services, and are considered included in the specific CPT code.
Indications for a vNOTES procedure include, a) benign uterine and adnexal pathology such as ectopic pregnancy and ovarian cyst; and b) patients with high body mass index when conventional laparoscopy becomes challenging.
Using a specialized transvagin*l access device, vNOTES provides better surgical visibility and increased access to remove the uterus, fallopian tubes, and ovaries. The result is a streamlined procedure with a shorter hospital stay (often less than 24 hours), less pain, no external incisions, and no visible scarring.
Introduction. Transvagin*l natural orifice transluminal endoscopic surgery (vNOTES) is an emerging form of minimally invasive surgery that permits access to the peritoneal cavity through the vagin*.
All ports are placed in the midline, with the 12-mm camera port by the umbilicus, and the robotic working ports spaced 3 to 4 cm superiorly and inferiorly (Fig.
Usually, a 5-mm trocar is placed on the right and a 12-mm trocar on the left. In addition, a 5-mm trocar is placed approximately 8 cm above and parallel to the lower left trocar site. This port will, in most cases, end up being nearly parallel to the umbilical trocar.
There are three main access sites for the placement of central venous catheters, namely internal jugular, common femoral, and subclavian veins. These are the preferred sites for temporary prominent venous catheter placement.
Depending on the procedure, the access port is often placed in the infra- or supraumbilical region. However, the initial site of port placement should be chosen according to the suspected pathology and the planned therapeutic procedure, with particular attention to avoiding previous abdominal scars.
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