Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And today, our discussion is going to focus around vaginal natural orifice transluminal endoscopic surgery, or vNOTES, as we're going to refer to it in the show today. Joining me is Dr. Rochelle Joly. She's an Assistant Attending Obstetrician-Gynecologist at New York-Presbyterian Hospital Weill Cornell Medical Center. And she's an Assistant Professor of Clinical Obstetrics and Gynecology at Weill Cornell Medical College - Cornell University.

Dr. Joly, it's such a pleasure to have you with us today. So, what is vNOTES? Now, I just said that whole long name, but it really doesn't tell the listener what that is, and why do we even have a surgery like this?

Dr Rochelle Joly: Thanks for having me. This is a pleasure. vNOTES in more layman's term is a approach to what's called a vaginal hysterectomy, and it is sort of modernized in the sense that a vaginal hysterectomy is the oldest rite of passage of the gynecologist to perform a hysterectomy through the vaginal route. It is considered the most minimally invasive and always has been.

What is modern about it that vNOTES adds is the option to do a laparoscopy introduction combined with the vaginal surgery. What this means is that, for example, if we make a vaginal incision the way we've always done it, we now have the opportunity to put a camera in through the vaginal opening, which adds an extra element and a layer of our surgical skill so that we can, for example, reach organs that are higher up in the pelvis that may have been difficult before.

For example, if a person had an ovary that was pulled high up in the pelvis, and perhaps they're an elderly age of 70 or 75 and they're having a hysterectomy for a benign indication, it's possible that in the past we may have left the ovary if it was difficult to remove. But with the addition of a laparoscopy, we can introduce the camera and visualize the ovary so that we can more safely remove it while the surgeon struggles less, decreasing the overall time of surgery and the overall time that the patient may be under anesthesia.

Melanie Cole, MS: Wow, that's really cool. What an advancement, Dr. Joly. So as you've mentioned the types of surgeries. You said if an ovary is lifted, and you mentioned hysterectomy for a number of reasons, any other surgeries? I mean, we have fibroids, we have cysts. Is it for all of those things too?

Dr Rochelle Joly: Well, in theory, it is based on the surgeon's skill. And if you have a surgeon that has been using it for a large volume of patients., All the procedures that a gynecologist can offer, then they can do everything through a vaginal approach. The main surgeries that are being conducted with the vNOTES right now is a vaginal hysterectomy, and also adnexal surgery. Adnexal refers to the ovaries and the fallopian tubes, and people are having their tubes removed vaginally, and ovarian cysts. Some surgeons are also using vNOTES for what is called ectopic pregnancy removal. It's really based on the surgeon's skill and the patient's history and whether or not they are a candidate for having the vaginal approach.

Melanie Cole, MS: So, I think you touched on the benefits both for the surgeon, the technically experienced surgeon you mentioned. But for the patient as well, as far as recovery, hysterectomies used to be a long, big deal, week in the hospital kind of thing. Now, they are more minimally invasive. But what is this change for the patient as far as recovery?

Dr Rochelle Joly: The main advantage of using a vNOTES entry is that the surgeon can avoid making any incisions on the abdomen and pelvis. And therefore, a patient typically has less pain when they're recovering because they don't have any incisions on the skin. They can typically have mobility a little bit more quickly and getting up, moving around, and sometimes faster return to work, less risk of scar because there are no scars on the abdomen when a vNOTES is used. And many people experience less pain because there are no incisions on the abdomen.

Melanie Cole, MS: So, no visible scars. How soon can they get back to normal work to resume activities? Is there a feeling of pulling? Do we have to still be careful of bleeding? That sort of thing.

Dr Rochelle Joly: Well, many people recover more quickly from a vNOTES hysterectomy than the traditional laparoscopy, or the old-fashioned hysterectomy, which comes from the abdomen. But we'll focus only on the laparoscopic comparisons because most people who are having the odes are people that would qualify for a minimally invasive surgery in general, such as a traditional laparoscopy or a vaginal hysterectomy.

And so, a person who would qualify for that typically would have a faster recovery than what was called an open hysterectomy with an abdominal incision. These type of people would usually recover within two to six weeks. So, there's a big variation depending on the person's mobility and function before the surgery. But the advantage of the vNOTES is that it decreases the pain and the mobility, and many patients are back at work within two weeks. People still have to be cautious because there is what's called the vaginal colpotomy, the incision in the vagina. And so, like any hysterectomy where the uterus and cervix is removed, and we have what's called a vaginal cuff that is healing, the people have to have pelvic rest, which means no intercourse and nothing in the vagina for at least six, sometimes eight weeks, to allow the cuff and those sutures to heal properly.

Regarding bleeding, there should be minimal to no bleeding after the hysterectomy, but that portion again depends on the person the same way it would for a traditional laparoscopy or an abdominal hysterectomy, and how the vaginal cuff is healed and typically with very minimal or scant bleeding.

Melanie Cole, MS: Dr. Joly, does a surgery like this open up patient selection? Are more people candidates for it or is it still very specific?

Dr Rochelle Joly: Well, it increases the selection. For patients that are a candidate for a vaginal hysterectomy, for example, a person who had vaginal births or just one C-section or very few or zero surgeries in their pelvic and abdominal area, that person may be a candidate for a vaginal hysterectomy. In general, what the vNOTES portion offers is the ability to offer this procedure to patients who have a larger uterus or may have adnexal surgery, such as someone who has a fibroid uterus up to 15 weeks of size.

In the past, it may have been more technically challenging to remove the uterus vaginally because the surgeon may have had a hard time clamping what's called the adnexa, so separating the uterus from the sidewall. But with the addition of the vNOTES and introducing the camera, the surgeon can look at that area directly and know that they are clamping what's called the adnexa in a safe way, allowing the removal of a larger uterus through the same orifice. And additionally, there are some people who may have had adnexal surgery in the past, such as a tubal ligation or salpingectomy, removing the fallopian tubes. And at times this can cause a little bit of adhesions, preventing the uterus and cervix to descend in the way we normally wanted to for a vaginal hysterectomy. And if the surgeon feels comfortable doing the colpotomy, meaning separating the anterior and posterior portion of the vagina, then they will be able to introduce the camera, the laparoscopy vNOTES portion, to then disconnect the point where the uterus joins the sidewall and do this safely, even if there are some slight adhesions.

Melanie Cole, MS: Do most hospitals offer this? I do a lot of shows and I haven't talked about this. So, it doesn't seem like it's that common just yet. And how does someone know if their doctor is trained in this? Tell us about the training involved.

Dr Rochelle Joly: The training involved is actually relatively simple for surgeons that are already doing vaginal hysterectomy and laparoscopy. It is basically just a combination where we have the advantage of joining the two together. Typically, we go to a training course that is one day, which shows the natural way that we can put together the laparoscope, meaning the camera into the vaginal cavity where we usually use the addition of something called a gel port, which the surgeons, us, we are already familiar with. We use it abdominally. But here, it's a special size that fits in the vagina. And if a patient were to Google it, they would see an actual circular device. It kind of looks like a Petri dish, but it's just a sterile gel. And we have the ability to introduce the laparoscopic ports into the gel port. And that helps hold the camera and allow us to inflate the abdomen in the normal, traditional way that we do from the abdomen, but through the vagina, holding the gas inside so that the abdomen is insufflated, we call it. And we have excellent visualization of the uterus, the fallopian tubes, the ovaries, and all the surrounding organs.

So, most OB GYN surgeons, or I should say all, are trained in vaginal surgery and laparoscopy in the United States when they go through residency. If a person continues to do surgery, then that's when a surgeon may choose to take on vaginal surgery exclusively or laparoscopic surgery exclusively, or to do both of them together. And patients have the ability to search for healthcare professionals providing this exact service on the vNOTES.com website. A patient can search for healthcare professionals in their zip code to see which surgeon in their area provides the procedure.

Melanie Cole, MS: This is fascinating, Dr. Joly. So interesting to hear. It feels to me or seems to me like this, it's really a game changer. I'd like you to wrap this up by telling listeners what you want them to know. If you think this will be the standard for certain types of gynecologic surgery in the future, if you think this is something? Would you like to see this be the standard of care? Give us your best advice here for people that are very interested about this.

Dr Rochelle Joly: Absolutely. I think for people that are interested in this, you should definitely ask your gynecologist or look on the vNOTES website for a gynecologist that provides the surgery. Have a consultation to see if you are a candidate, and it is definitely a better outcome in the sense that you have a faster recovery, whether it's to work or to family obligations or general mobility with less pain and less scarring, so that whether you're having a hysterectomy or adnexal surgery such as a salpingectomy for sterilization, you can try to have this procedure because it is really the optimum way to go to improvise on those areas.

Melanie Cole, MS: Thank you so much, Dr. Joly, for joining us today and really giving us an educational eye-opening informational show about something that we didn't know that much about, but is really upping the game for gynecologic and obstetric surgery. So, thank you so much for joining us. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcast, Spotify, iHeart, and Pandora. And for more health tips, please visit weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. So many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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