A novel approach using vaginal natural orifice transluminal endoscopic surgery (vNOTES) for a wide local excision vaginal intraepithelial neoplasia (VaIN)

Abstract

Objective To demonstrate first case of vaginal natural orifice transluminal endoscopic surgery (vNOTES) approach to excise VaIN. Design Stepwise demonstration of surgical technique with a narrated video. Setting Vaginal intraepithelial neoplasia (VaIN) can be treated by means of surgical excision which is the preferred approach for treatment of persistent high grade VaIN due to the potential for malignancy in the final specimen (1,2). The procedure was performed on a 51 year old (G2P2) patient presenting with recurrent high grade vaginal intraepithelial neoplasia (VaIN) with a previous history of large loop excision of transformation zone and subsequent total laparoscopic hysterectomy the management of high grade cervical intraepithelial neoplasia. She represented with high grade VaIN 3 which was initially managed with fluorouracil and laser therapy. Due to persistent biopsy proven VaIN 3 at the vaginal fornices, she proceeded to have a vNOTES approach to excise the vaginal lesion which took place as a day only procedure as the lesion was challenging to access and visualize using traditional vaginal access. This novel approach allows the procedure to be performed by combining the best of vaginal approach to the surgical site with endoscopic magnification and capacity for microscopic dissection. Interventions vNOTES approach to wide local excision of VaIN 3 lesion. Vaginal lesion was delineated using Lugol’s iodine. A small (7.5cm) V-path gel port (Applied Medical) with a plastic guard is inserted to maintain the pneumovagina whilst keeping the port in place. Insufflation Stabilisation Bag (Applied Medical) connected to gel port to minimize pressure fluctuation. A monopolar hook with an inbuilt aspirator and suction function is used to incise the vaginal epithelium around the lesion with the goal of wide local excision of the VaIN lesion. Once haemostasis was confirmed, the gel port was removed, and the vaginal epithelium was closed with interrupted sutures utilizing braided absorbable suture (Vicryl 2/0). The perioperative course and care were uneventful with the patient going home on the same day. The final pathology was consistent with VaIN 2 with clear margins. Follow up at 6 weeks demonstrated a well healed vaginal vault with the plan to repeat vault smear 6 months post procedure. Conclusion Traditionally excision of VaIN is by vaginal surgery. We describe the first case of VNOTES approach to excision of VaIN in the setting where the lesion was technically difficult to access and visualise using conventional vaginal surgery. This approach is considered new and only to be considered in the clinically appropriate and carefully counselled patient as the long-term complications and cure rates of VaIN are unknown. In keeping with the IDEAL recommendations for surgical innovation, we describe the feasibility of this approach in the form of this video case report (3).