vNOTES (transvaginal Natural Orifice Translumenal Endoscopic Surgery) salpingectomy technique
Figure 3. Mini-gel port is inserted into the vaginal opening after vaginal hysterectomy.
When the adnexae is noted to be high in the pelvis or when it is adherent to the pelvic sidewall, I recommend the vNOTES technique. It involves insertion of a mini-gel port into the vaginal opening. (Figure 3.) A 5-mm or 10-mm scope is inserted through this port for visualization. The fallopian tube can be grasped with a laparoscopic grasper and the mesosalpinx sealed and divided using a vessel-sealing device. (Figure 4.) Often, because the bowel is already retracted up with the vaginal pack, insufflation is not necessary with this procedure.
Figure 4. As demonstrated in a cadaveric model, vNOTES salpingectomy can be accomplished by grasping the adnexa with laparoscopic grasper, then sealing and dividing the fallopian tube along the mesosalpinx using a vessel-sealing device.
The change in our understanding of the etiology of ovarian cancer calls for salpingectomy during hysterectomy. With such tools, devices, and techniques that facilitate the vaginal removal of the fallopian tubes, the need for prophylactic salpingectomy should not be a deterrent to pursuing a hysterectomy vaginally.
Dr. Kho is head of the section of benign gynecology at the Cleveland Clinic.
References
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