Identifying the Right Candidates for vNOTES

In: Atlas of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) · 2025 · pp. 19–24 · doi:10.1007/978-3-031-83713-5_4 · W4411282057
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Transvaginal access for hysterectomy offers an adhesion-free route, avoiding abdominal incisions and potentially improving outcomes compared to traditional abdominal approaches, especially when prior surgeries distort anatomy.

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This chapter discusses selecting appropriate candidates for vaginal natural orifice transluminal endoscopic surgery (vNOTES), contrasting it with abdominal entry routes that surgeons are more accustomed to. It outlines how prior abdominal surgeries, abdominal wall defects, and implanted foreign bodies can distort anatomy and increase intra-abdominal injury risk, and notes that a transvaginal approach may use a potentially adhesion-free access area, potentially improving cosmetic outcomes and reducing pain. The chapter also includes cited literature on vNOTES hysterectomy feasibility and outcomes, and on pelvic imaging and diagnostic tools for endometriosis. It does not explicitly present original data for vNOTES candidate selection, instead functioning as an atlas chapter with literature context. Relevance to endometriosis: the chapter cites multiple endometriosis diagnostic and imaging studies (e.g., sliding sign and MRI/sonography consensus) in addition to vNOTES surgical material, though its main focus is vNOTES candidate identification.

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Abstract

Gynecologic surgeons use different methods for entering the abdomen during surgical procedures. In most cases, the abdominal route is preferred, as surgeons are more comfortable with this approach due to their training in performing laparotomies or laparoscopic procedures. Previous surgeries, defects in the abdominal wall (such as vessels, hernias, and adhesions), and foreign bodies (like mesh and other implants) can distort the anatomy and increase the risk of intra-abdominal injury during surgery. Prior abdominal surgeries are traditionally considered risk factors for developing abdominal adhesions, which can make abdominal entry more challenging. Transvaginal access offers surgeons a potentially adhesion-free area, avoiding the need for abdominal incisions and potentially improving cosmetic outcomes and reducing pain. Access this chapter Tax calculation will be finalised at checkout Purchases are for personal use only Similar content being viewed by others

References

Nulens K, Kempenaers R, Baekelandt J. Hysterectomy via vaginal natural orifice transluminal endoscopic surgery in virgin patients: a first feasibility study. J Obstet Gynaecol. 2022;42(1):116–21. https://doi.org/10.1080/01443615.2020.1867972. Naval S. vNOTES lateral window approach to hysterectomy in a case with previous history of multiple surgeries resulting in keloid scars and enlarged uterus with dense bladder adhesions. J Minim Invasive Gynecol. 2022;29(2):193. https://doi.org/10.1016/j.jmig.2021.08.020. Pascoal E, Wessels JM, Aas-Eng MK, Abrao MS, Condous G, Jurkovic D, et al. Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research. Ultrasound Obstet Gynecol. 2022;60(3):309–27. Hudelist G, Ballard K, English J, Wright J, Banerjee S, Mastoroudes H, et al. Transvaginal sonography vs. clinical examination in the preoperative diagnosis of deep infiltrating endometriosis. Ultrasound Obstet Gynecol. 2011;37(4):480–7. Reid S, Lu C, Casikar I, Reid G, Abbott J, Cario G, et al. Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign. Ultrasound Obstet Gynecol. 2013;41(6):685–91. Hudelist G, Fritzer N, Staettner S, Tammaa A, Tinelli A, Sparic R, et al. Uterine sliding sign: a simple sonographic predictor for presence of deep infiltrating endometriosis of the rectum. Ultrasound Obstet Gynecol. 2013;41(6):692–5. Mick I, Marien M, Leonardi M. ‘Triangle sign’: novel and needed supplement to sliding sign for evaluation of obliterated cul-de-sac in patients with retroverted uterus. Ultrasound Obstet Gynecol. 2024;63(5):702–3. https://doi.org/10.1002/uog.27555. Nisenblat V, Bossuyt PMM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;2:CD009591. https://doi.org/10.1002/14651858.CD009591. Tong A, VanBuren WM, Chamié L, Feldman M, Hindman N, Huang C, et al. Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the society of abdominal radiology endometriosis disease-focused panel. Abdom Radiol. 2020;45(6):1569–86. https://doi.org/10.1007/s00261-020-02483-w. Guerriero S, Condous G, van den Bosch T, Valentin L, Leone FPG, Van Schoubroeck D, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016;48(3):318–32. Kaya C, Yıldız Ş, Alay İ, et al. The comparison of surgical outcomes following laparoscopic hysterectomy and vNOTES hysterectomy in obese patients. J Invest Surg. 2022;35(4):862–7. https://doi.org/10.1080/08941939.2021.1927262. Bouchez MC, Delporte V, Delplanque S, et al. vNOTES hysterectomy: What about obese patients? J Minim Invasive Gynecol. 2023;30(7):569–75. https://doi.org/10.1016/j.jmig.2023.03.014. Schmitt JJ, Carranza Leon DA, Occhino JA, Weaver AL, Dowdy SC, Bakkum-Gamez JN, Pasupathy KS, Gebhart JB. Determining optimal route of hysterectomy for benign indications: clinical decision tree algorithm. Obstet Gynecol. 2017;129(1):130–8. https://doi.org/10.1097/AOG.0000000000001756. Nulens K, Bosteels J, De Rop C, Baekelandt J. vNOTES Hysterectomy for Large Uteri: A Retrospective Cohort Study of 114 Patients. J Minim Invasive Gynecol. 2021;28(7):1351–56. https://doi.org/10.1016/j.jmig.2020.10.003. Epub 2020 Oct 14. PMID: 33065258. Baekelandt J, Kapurubandara S. Benign gynaecological procedures by vaginal natural orifice transluminal endoscopic surgery (vNOTES): complication data from a series of 1000 patients. Eur J Obstet Gynecol Reprod Biol. 2021;256:221–4. https://doi.org/10.1016/j.ejogrb.2020.10.059. Wang X, Li J, Hua K, et al. Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy for uterus weighing ≥ 1 kg. BMC Surg. 2020;20(1):234. https://doi.org/10.1186/s12893-020-00897-3. Author information Authors and Affiliations Editor information Editors and Affiliations 4.1 Electronic Supplementary Material(s) Positive sliding sign—free cul-de-sac (MP4 15,577 kb) Negative siding sign—complete cul-de-sac obliteration (MP4 14,916 kb) Negative sliding sign and triangle sign—complete obliteration of the cul-de-sac (MP4 14,978 kb) Positive sliding sign and triangle sign—normal cul-de-sac (MP4 14,917 kb) Rights and permissions Copyright information © 2025 The Author(s), under exclusive license to Springer Nature Switzerland AG About this chapter Cite this chapter Dueñas Garcia, O.F., Leonardi, M., Shishkina, A. (2025). Identifying the Right Candidates for vNOTES. In: Dueñas Garcia, O.F., Baekelandt, J.F., May, G. (eds) Atlas of Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). Springer, Cham. https://doi.org/10.1007/978-3-031-83713-5_4 Download citation DOI: https://doi.org/10.1007/978-3-031-83713-5_4 Published: Publisher Name: Springer, Cham Print ISBN: 978-3-031-83712-8 Online ISBN: 978-3-031-83713-5 eBook Packages: MedicineMedicine (R0)

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