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10 steps to approach large ovarian masses through vNOTES
  1. Levon Badiglian-Filho1,
  2. Glauco Baiocchi1 and
  3. Jan Baekelandt2
  1. 1Gynecologic Oncology, ACCamargo Cancer Center, Sao Paulo, Brazil
  2. 2Department of Obstetrics and Gynecology, Imelda Hospital, Bonheiden, Belgium
  1. Correspondence to Dr Levon Badiglian-Filho, Gynecologic Oncology, ACCamargo Cancer Center, Sao Paulo 01424-000, Brazil; levonbfilho{at}

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vNOTES (vaginal Natural Orifices Transluminal Endoscopic Surgery) is a technique that allows abdominal cavity access, merging traditional vaginal surgery techniques1 with modern laparoscopic ones.

Frequently, the gynecologic oncologist is faced with large ovarian masses that exhibit benign characteristics but demand a surgical approach guided by oncologic principles. Laparoscopy is used in many of these cases with acceptable results from an oncologic perspective.

A prospective trial that compared vNOTES adnexectomy to laparoscopy reported that vNOTES was associated with shorter operating times and lower pain scores.2

Usually, the contraindications for the vNOTES procedure are rectovaginal endometriosis, a history of a severe pelvic inflammatory disease, or pelvic radiotherapy. Multiple previous cesarean sections can be considered as a relative contraindication.3

Although the vNOTES approach for ovarian masses has been performed for some years,4 standardization is needed for specific situations as we propose here in 10 steps:

Step 1. Selecting the case.

Step 2. Positioning the patient and the surgical team.

Step 3. Accessing the cavity.

Step 4. Vaginal port.

Step 5. Cavity inspection.

Step 6. Sealing and division.

Step 7. Bag the cyst.

Step 8. Cavity revision.

Step 9. Revise the inner ring of the vaginal port.

Step 10. Closing the vaginal vault.

Video 1 Large ovarian masses and vNOTES

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All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Twitter @glaucobaiocchi

  • Contributors LB-F: conceptualization, writing original draft, guarantor. JB: methodology, review. GB: supervision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.