Why vNOTES Make Sense for My Patients

Speaker 1:

Welcome to Contemporary OB/GYN podcast, why vNOTES make sense for my patients. Brought to you by Applied Medical. Today, Scott Kober your podcast host, will be talking about the clinical benefits of vaginal natural orifice transluminal endoscopic surgery or vNOTES. Scott Kober will be joined by Dr. Lamarr Tyler, medical director of inpatient services in the women's division at Intermountain Healthcare in Las Vegas, Nevada, as well as Christine Shelton, one of Dr. Tyler's patients. And now here's your host, Scott.

Scott Kober:

So, Dr. Tyler. In a general sense, what are the advantages of vNOTES compared to a traditional vaginal hysterectomy?

Dr. Lamarr Tyler:

Well, first of all, I think it's really important that we describe what vNOTES really is. NOTES surgery, which is natural orifice surgery, is something that's really gaining a lot of popularity in a minimally invasive realm, in terms of surgery done through the mouth, the anus, the rectum, bladder, in our case, obviously done through the vagina. As a trained vaginal surgeon, this really represents a major enhancement in terms of my offerings to patients in trying to maintain the least invasive option for a hysterectomy. It's gaining a lot of popularity, I think, in terms of NOTES procedures. I think we're starting to see a tremendous amount of popularity in terms of requests with training. When I trained, literally a year and a half ago, I think it was maybe 80 physicians who were doing vNOTES surgery. I think currently now we're starting to get beyond 300 and looking to expand upon that even more.

Dr. Lamarr Tyler:

The main advantage I see is that it really combines the best of both worlds. It combines the world of laparoscopic surgery along with the world of vaginal surgery. As I said before, vaginal hysterectomy has always been the least invasive, the original minimally invasive procedure performed. We’ve gone away from that, in lieu of the laparoscopic and robotic approaches of hysterectomy. The most important thing I think is that it provides optimal visualization. So, in that regard, it becomes a very safe procedure, in that you can see what you're doing. I can see surrounding organs, primarily the bladder, the bowel, the rectum. I can even explore the upper abdomen, as well as identify the ureters. It's truly a single site procedure, in that we're not requiring abdominal incisions at all. This is all done through the vaginal approach. Because of that, there's just less tissue trauma.

Dr. Lamarr Tyler:

We're not really using these big, huge metal retractors that we do in traditional vaginal hysterectomy. On the other hand, we're not doing that crush, clamp, and tie, that we normally do with sutures with vaginal hysterectomy. So, we're able to use these advanced bipolar systems because we're able to use this GelPOINT V-Path access platform, This is what I'm able to insert into the vagina. With that, I'm able to now attach this GelPOINT device, which allows me to have trocars for the scope to be placed, and for me to actually operate through the procedure. So, in that respect, I think it becomes a safer procedure in that I can actually visualize what I'm doing.

Scott Kober:

So, you talked about how you went through training about a year and a half ago for this. What did that training involve, and how challenging is the learning curve?

Dr. Lamarr Tyler:

Good question. The training was offered by Applied Medical. My former fellow, who's actually part of the faculty now for Applied Medical, was really the first one who told me that I should really look at getting into vNOTES. And my response initially was, "I know how to do vaginal hysterectomy. I don't need to know how to do anything beyond that in terms of an added platform. But Applied Medical was very forthright in terms of offering webinars. I was able to visualize this and really started to see how this could truly be something that could be worthwhile to learn. When I took the didactic session, which was on a weekend in Los Angeles, I quickly saw some of the real benefits compared to what my traditional approach was to hysterectomy. The learning curve for me was actually pretty quick. As I said before, I was a trained vaginal surgeon. I really, when I was in residency training, did a tremendous amount of vaginal hysterectomies. So, now I was able to really start to see what I was doing. And I think I really had a good hang of this within the first three cases. I often tell physicians who are learning to do this that 10 cases is probably the learning curve. If you compare that to your traditional laparoscopic and robotic, historically, that's a lot faster learning curve than those procedures.

Scott Kober:

So, have you transitioned all of your patients over to vNOTES or is it kind of on a case-by-case basis, determining whether you're going to use this procedure versus traditional hysterectomy?

Dr. Lamarr Tyler:

A lot of it is going to be based on the patient's clinical presentation, her anatomy, and whether I really have good opportunities for vaginal access. I am actually looking and thinking about vNOTES first as my primary route for hysterectomy, but I still use robot and laparoscopic approaches as well, based on other pathology.

Scott Kober:

How do you typically describe to your patients the potential benefits of vNOTES and some of the potential risks?

Dr. Lamarr Tyler:

First of all, I impress upon them that this is a purely outpatient procedure. I'm fortunate to say that 95% of all my hysterectomies go home the same day. So, whether I do it laparoscopically, robotically or vaginally, they go home the same day. vNOTES patients just do different. They just do better. I think because we're not doing a lot of this metal retraction, we're not pulling down on the tissues here. We're actually doing the surgery in a much gentler fashion. I'm doing it under complete visualization. I'm able to inspect the vaginal pedicles afterwards. I'm able to make sure there's no bleeding. Because it's a single incision procedure, the incisions are completely inside the vaginal area. There's less pain, less inflammation, less use of narcotics. Most patients usually get by just primarily with anti-inflammatories. And just a quicker return to normal function.

Scott Kober:

So, Christine, what do you remember about your initial conversation with Dr. Tyler and some of the questions you had and some of the initial concerns you had?

Christine Shelton:

I remember I had a long laundry list of questions. Just from, do I get to go home this same day? Am I going to be in a lot of pain? What's my recovery going to look like? And mostly it was, I was excited to have this procedure, whether it's vNOTES or another, but just to have a hysterectomy in general. But going over my questions... In one fell swoop from start to finish, I had my questions in my hand and Dr. Tyler went over the procedure, went over what to expect. I looked down at my notes. Like, "Do you have any more questions?" And, I had none. He explained to me in such a way that I felt confident and prepared.

Scott Kober:

How would you describe the procedure itself from a patient perspective? How did you prepare for it? How long did the procedure take? What was the aftereffects, that sort of stuff?

Christine Shelton:

I think I was lucky because Dr. Tyler did prepare me so well with what to expect. I was pretty nervous going in, with no expectations. And then him preparing me with what to expect. I was looking forward to being out of pain for the surgery, after the surgery. And, I don't know, it was just easy. From a patient perspective, the procedure was just easy.

Scott Kober:

Okay.

Christine Shelton:

Admitting was easy. Preparing for the surgery was easy. I didn't feel like I had to do a lot of prep. And, then recovery. Overall, I just have to say it was easy.

Scott Kober:

So, were you expecting a longer recovery?

Christine Shelton:

Yes, absolutely. My mom had a hysterectomy when I was younger, and I remember her being kind of out of commission for about six weeks. So that's what kind of stuck in my mind, that I was just going to be in pain for a long time.

Scott Kober:

Okay. So then how long was it until you were sort of up and about again?

Christine Shelton:

I'm kind of embarrassed to say, and maybe I wasn't supposed to be, but I was pretty up and around the next day. We have stairs in our house and so I carefully would walk up and down, but I expected to be down for the count, and I wasn't. I was able to get out of bed the next day.

Scott Kober:

So, Dr. Tyler, in your experience, how typical is that, and what do you tell your patients to expect?

Dr. Lamarr Tyler:

Well, I always tell my patients to expect, because we're doing these procedures in a minimally invasive manner, is that first and foremost, their body does not know these were done in a minimally-invasive technique. It's still a hysterectomy, whether it's done abdominally, laparoscopic, robotically, or vaginally. So, I always try to tell patients that each day is a progression from the day before. And, I really have very simple rules: nothing heavy, nothing strenuous, nothing vaginally. The other thing I really try and encourage patients to understand is what is the component of pain. Most pain is really going to be inflammatory. So, a lot of this really starts in that preoperative process. What I try to tell patients all the time is that the most important medication, well the core medication for them, is going to be using anti-inflammatories. So, that's going to be Tylenol. It's going to be anti-inflammatories. It's going to be ibuprofen, those medications here. We really don't really require a lot of narcotics. I give them narcotics to take home as a transition, but most of my patients come back and say they maybe used one or two, or not at all. And yes, Christine, most patients usually are up and about the next day. So, you did good.

Scott Kober:

Now, will you typically see patients postoperatively to kind of follow up and check to make sure that everything went well?

Dr. Lamarr Tyler:

Yes, because we're sending these patients home the same day. Ideally, we will have a follow-up phone call the next day or two after surgery. Then, I generally see them back a week after surgery, because we're having them go home so soon. Again, this is a major operation, so I really want to feel comfortable that they are doing well and transitioning well for them. And again, I'm very happy to say that we just really have not had any major issues. What Christine is describing as her recovery has really been my typical response for vNOTES. And I have to say, that is better than what I've had with my traditional vaginal hysterectomies, robot or laparoscopic cases. Even though they go home the same day, they take a few more days when they get to the point that Christine was the next day.

Scott Kober:

So, Christine, what would you sort of tell patients, tell women who are on the fence between what they're used to hearing, what perhaps their mother went through, and the vNOTES procedure?

Christine Shelton:

I would tell them to seek out a surgeon who does vNOTES, because it was surprising how good I felt. I really was prepared to be pretty down for the count for a while. And, so, I would tell them to seek somebody out who can provide that to them.

Scott Kober:

And Dr. Tyler, what about you? What about for surgeons who are on the fence about learning a new procedure and perhaps saying traditional hysterectomy is good enough. I'm used to it, and it works for my patients?

Dr. Lamarr Tyler:

Yeah. I really try to, once again, kind of historically go back to what ACOG has recommended. And, what really, the whole foundation of minimally invasive surgery started with vaginal hysterectomy. So, vaginal hysterectomy is still the least invasive option. The unfortunate part of that is that in the late eighties, early nineties, when I trained, so I hope I'm not dating myself here, Harry Reich was the original person, physician who really developed the LAVH, which is the Laparoscopic Assisted Vaginal Hysterectomy. The whole goal was really, how do we reduce the number of abdominal hysterectomies and increase the rate of vaginal hysterectomies? That was really kind the “A-HA” moment. Then we really were starting to move more to a less invasive form here. Today, unfortunately, we have accomplished the first goal. That is, we definitely have reduced the number of abdominal hysterectomies. Unfortunately, what we have not done, we have not changed the rate of vaginal hysterectomies, as the laparoscopic and robotic approaches have really become the one and two main options of physicians to do.

Dr. Lamarr Tyler:

I really try to let physicians understand that this now takes the familiarity that we have with laparoscopic and robotic surgery. That we're able to see what we do. And, now transfer that to the vaginal approach where we can actually visualize what we do, which is usually the hesitation that most physicians have. They can't see what they're doing. They're very afraid that they're not going to be able to have access to the tubes and ovaries, if they need to be removed. Now taking the vaginal approach and using a laparoscope vaginally gives us the same visual access that we have above, top down using laparoscope or a robot.

Speaker 1:

This has been a terrific discussion about some of the benefits of vNOTES, both from the perspective of the surgeon and the patient. Thank you for joining us today. You've been listening to Contemporary OB/GYN podcast: Why vNOTES Makes Sense for my Patients. This podcast is brought you by Applied Medical. Visit vNOTES.com for more information and find a vNOTES course near you.