By Marti Webb Slay
Heidi Straughn, MD, ob/gyn at Brookwood Women's Health, P.C., readily admits that taking a class in vNOTES (vaginal natural orifice transluminal endoscopic surgery) sounded like a good idea in large part because it was an excuse to go to New Orleans. She had seen references to the surgery in medical publications, but she didn’t fully understand the concept. Once she saw the procedure, however, she recognized what it could mean for her patients. The minimally invasive, no-scar surgery is now her choice for hysterectomies and other gynecological procedures.
vNOTES uses a vaginal incision, eliminating the need for any incisions in the abdomen. The vNOTES device is inserted in the small incision, and a camera provides visualization for the uterus, fallopian tubes and ovaries. The procedure promises a shorter hospital stay, less postoperative pain, and faster recovery than laparoscopy.
vNOTES uses a special gel port for all the instruments. “We put two incisions around the cervix, and we put in an Alexa retractor,” Straughn said. “Then we put the gel port outside the vagina. We insert the instruments through that and go through the vagina and past the cervix.
“It’s hard to visualize, but once I took the class, I realized I wanted to do this. I like vaginal surgery, and I like laparoscopy, and this is the natural progression. This gives us a route that is more minimally invasive than any other. You don’t even have to get new credentials for this, because it uses techniques we are already doing.”
Straughn saw the benefits to her patients immediately. “My patients were doing so well and going home quickly,” she said. “Now that I’m getting more comfortable with it, I’m letting them go home the afternoon of the surgery, which is not that different from robotic surgery, but I’ve had some patients go home and not take any narcotic pain medication afterwards, so it’s pretty impressive.” In fact, one of her patients returned to work a week later without any narcotics post surgery.
The improved visualization enables Straughn to make better decisions during surgery. “It allows you to do anything that involves the tubes or the ovaries, which is hard to do without the vNOTES component, because you can’t always see the tubes and ovaries without vNOTES,” she said. “We are taking the tubes out of most women with hysterectomy because it lowers the risk of cancer in the future. vNOTES allows me to always take the tubes when I take the uterus. If I need to take the ovaries out for some reason, I can do that. Or if they have a cyst on their ovary, I can take that out also.
“Usually, when a surgeon approaches the uterus from above, the blood supply is below the incision, but with vNOTES, blood supply is one of the last pedicles taken. It’s really good for limiting blood loss.”
She also sees benefits for teaching medical students with vNOTES. “I hope this takes off in terms of teaching,” she said. “One of the problems with vaginal surgery is you can’t see when you are assisting. Only the person doing the surgery has visualization. With this, you have the camera in there, and the visualization is amazing. It helps with understanding the anatomy, so it’s a teaching tool. It’s going to be really useful in training.”
Straughn is still learning about the procedure and how much can be done with vNOTES. “I haven’t done a really large uterus yet,” she said. “I think a 14-week uterus is the biggest I’ve done. It’s hard to remove just a cyst from the ovary, technically. It’s more challenging, and I haven’t done that. Some of the more difficult cases I’ve posted to possibly change the approach if I’ve needed to, but I haven’t had to.”
According to the vNOTES website, Straughn is the only surgeon in the Birmingham area doing the surgery, but she said her partners and others at Brookwood are now beginning to take the course and do the surgery as well. She anticipates it will continue to be embraced by the ob/gyn community as they become more familiar with its benefits. “It’s my preferred method of hysterectomy if I can do it that way,” she said. “I want to see more surgeons doing this surgery. I keep asking why we aren’t promoting this more. It’s the greatest thing since sliced bread!”