Vaginal natural orifice transluminal endoscopic surgery (vNOTES): a minimally invasive approach in gynecology. A comprehensive review.

ObjectiveThis study aimed to assess the comparative effectiveness of indocyanine green and methylene blue in the marking and identification of sentinel lymph nodes during sentinel lymph node biopsy procedures in patients diagnosed with endometrial cancer undergoing staging surgery through vaginal natural-orifice transluminal endoscopic surgery.MethodsIn this retrospective cohort study conducted at a tertiary center, we analyzed 80 patients with endometrial cancer who underwent vaginal natural orifice transluminal endoscopic staging surgery. Patients were classified into two cohorts based on the tracer used for sentinel lymph node sentinel lymph node mapping: indocyanine green (n = 40) or methylene blue (n = 40). The primary endpoints, including sentinel lymph node detection rates (overall and bilateral) and number of nodes retrieved, along with surgical outcomes, were compared between the groups.Findings: Eighty patients (indocyanine green group, n = 40; methylene blue group, n = 40) were included in the study. The vaginal natural orifice transluminal endoscopic surgery identification rate was significantly higher in the indocyanine green group (95%) than in the methylene blue group (82.5%) (p = 0.045). The mean number of sentinel lymph nodes identified in the indocyanine green group (3.2 ± 1.1) was significantly higher than that in the methylene blue group (2.5 ± 0.9) (p = 0.021). The rate of bilateral vaginal natural orifice transluminal endoscopic surgery identification was higher in the indocyanine green group (80%) than in the methylene blue group (65%); however, the difference was not statistically significant (p = 0.112). Surgical time, blood loss, and complication rates were similar between the two groups. Histopathological examination revealed a similar number of positive sentinel lymph nodes in both the groups.ConclusionIn the context of sentinel lymph node biopsy for staging surgery and natural orifice transluminal endoscopic surgery for endometrial cancer, indocyanine green has demonstrated a superior sentinel lymph node identification rate and a higher yield of sentinel lymph nodes compared to methylene blue. Given the advantage of real-time imaging, indocyanine green has emerged as a promising agent for sentinel lymph node biopsy in minimally invasive approaches, such as vaginal natural orifice transluminal endoscopic surgery.

Natural orifice transluminal endoscopic surgery in gynecology: What do we know till now?

This study aimed to evaluate the effect of vaginal natural orifice transluminal endoscopic surgery in hysterectomy. A retrospective analysis of 80 patients who underwent hysterectomy at the Maternity & Child Care Center in Qinhuangdao, China from October 2022 to October 2024 was conducted. The patients were randomly divided into a transumbilical laparoendoscopic single-site surgery group and a vaginal natural orifice transluminal endoscopic surgery group. The surgical time of 40 cases of the vaginal natural orifice transluminal endoscopic surgery group tended to stabilize, and learning curve showed no marked fluctuations. The anal exhaust time, indwelling catheter time, hospital stay, and degree of pain in vaginal natural orifice transluminal endoscopic surgery group were less than the transumbilical laparoendoscopic single-site surgery group. On the first day after surgery, compared to the transumbilical laparoendoscopic single-site surgery group, the vaginal natural orifice transluminal endoscopic surgery group had higher superoxide dismutase and glutathione peroxidase levels and lower malondialdehyde and advanced oxidation protein products levels. We conclude that vaginal natural orifice transluminal endoscopic surgery has less postoperative pain than transumbilical laparoendoscopic single-site surgery, which reduces patients' postoperative stress responses and facilitates postoperative recovery.

Background. This study was conducted to investigate the effectiveness of vaginal natural orifice transluminal endoscopic surgery (vNOTES) gynecologic scarless surgery in benign and malignant class 2 and class 3 obese patients. Materials and methods. The class 2 and class 3 obese women undergoing vNOTES scarless surgery for benign and malign indications at a tertiary referral medical center between January 2019 and April 2021 were retrospectively analyzed and surgical outcomes were measured. Results. In this study, 81 class 2 and class 3 obese patients underwent gynecological procedures using vNOTES scarless surgery. Of the 81 operations, 55 of the class 2 obese patients with benign pathologies, and 26 of the class 3 obese patients had malign pathologies. No conversion to conventional laparoscopy or even laparotomy was needed in any of the procedures. All of the surgeries were performed by the same surgeon (Prof. Dr Ahmet Kale). vNOTES scarless surgery was performed on 26 class 3 obese patients with malign pathologies. Of the 26 class 3 obese patients, 22 of the class 3 obese patients with early-stage endometrial carcinoma had very high mean body mass index 41.5kg/m2 (range 20.6-56) and 4 of the class 3 obese patients had ascites with unknown cause and diagnosed with peritoneal carcinomatosis. The mean postoperative pain VAS scores of class 2 obese patients undergoing vNOTES scarless surgery with benign pathology at 6, 12, and 24h were 3.19, 1.11, and .66, respectively, and the mean postoperative pain VAS scores of class 3 obese patients underwent vNOTES scarless surgery with malign pathology at 6, 12, and 24h were 3.30, 1.76, and 1.03, respectively. Conclusion. vNOTES scarless surgery is an alternative surgical method for diagnosis and treatment not only in benign obese cases, but also in severely obese patients with early stage endometrial cancer and patients had with ascites with unknown cause. In the near future, vNOTES scarless surgery will become more preferable by experienced surgeons in benign and malignant obese cases as it has increased satisfaction with esthetic results such as less pain, and improved postoperative quality of life in the short and long term.

The aim of this study was to observe the feasibility of the tubal/adnexal approach using vaginal natural orifice transluminal endoscopic surgery and compare its contribution with surgeon ergonomics and postoperative patient comfort with that of conventional laparoscopy. We completed this study retrospectively with 47 patients. Patients were followed at their postoperative first month. We analyzed the usability of the vaginal natural orifice transluminal endoscopic surgery method over conventional laparoscopy by comparing the demographics, surgical data, and postoperative findings collected between the two groups. Patients in the conventional laparoscopy group were older (39.1±3.3 years) than those in the vaginal natural orifice transluminal endoscopic surgery patient group (p=0.005). Pain intensity 24 h after surgery was lower in the vaginal natural orifice transluminal endoscopic surgery group (p=0.003), while sexual function and dyspareunia did not differ between the two groups in the first month. Patients in the vaginal natural orifice transluminal endoscopic surgery group were more relieved about painlessness and the comfort it brought than the conventional laparoscopy group (p=0.027, χ2=12.56). Patients subjected to the vaginal natural orifice transluminal endoscopic surgery procedure showed higher levels of satisfaction, less postoperative pain, and greater comfort than those subjected to conventional laparoscopy.

To identify the learning curve in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery. Data consist of consecutively ordered patients who underwent ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery between May 2020 and June 2023. The learning curve of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery was measured in terms of the operating time adjusted by multivariate linear regression. A cumulative sum analysis was performed to establish the learning curve. Patients' characteristics and surgical outcomes were compared based on the inflection points of this curve. The learning curve was divided into two unique phases: phase 1 (1-26 patients), and phase 2 (27-40 patients). The expected operating time in phase 2 was shorter than in phase 1 (86.4 ± 11.2 min vs. 102.0 ± 22.7 min, p = 0.021). The time to first postoperative flatus was shorter in phase 2 compared with phase 1 (14.6 ± 6.5 h vs. 20.6 ± 6.3 h, respectively, p = 0.008). No significant differences were observed in terms of patient's age, BMI, tumor size, parity, bilateral ovarian tumor, pathological diagnoses, estimated blood loss, postoperative pain score, or perioperative complications between the two phases. Proficiency in ovarian cystectomy by vaginal natural orifice transluminal endoscopic surgery was achieved after 26 surgeries based on cumulative sum analysis. These findings may provide insight for structured training programs of ovarian cystectomy via vaginal natural orifice transluminal endoscopic surgery.

Simplifying Vaginal Natural Orifice Transluminal Endoscopic Surgery (VNOTES) in Ten Steps

Natural orifice surgery is a novel surgical technique with increasing use across different medical disciplines (Pearl et al, Journal of Gastrointestinal Surgery12, no. 7 (2008): 1293-1300). In gynaecology, Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) offers alternative access to the intra-abdominal space eliminating the need for abdominal incisions with a better cosmetic outcome and less post-operative pain. This approach could be particularly helpful in women with high BMI or those with suspected abdominal rather than pelvic adhesions where laparoscopic abdominal entry is often difficult to achieve.

The introduction of laparoscopic techniques in the late 1980s and early 1990s has ushered in a novel era in the surgical treatment of human diseases. Following the first laparoscopic nephrectomy done by Clayman et al . in 1991 [1], the initially noted advantages of minimally invasive urological surgery were later proved [2,3]. This soon led to the transition from novelty to the current concept of established ‘expectations’. Despite the success of conventional laparoscopic urological surgery, incisions ranging from 1 to 3 cm in length and three to five ports in number are still required. Each additional working port increases the inherent risk of bleeding, infection, concordant organ damage, hernia formation and decreased cosmetic outcome.

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. PROSPERO, CRD42022327490.

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging approach used across surgical disciplines. This review seeks to assess the growing body of literature on experiences and outcomes using vaginal NOTES (vNOTES) in gynecologic surgery. Many limitations of vaginal surgery including lack of descensus or restricted vaginal space can be overcome with vNOTES whereas avoiding risks of abdominal incisions in traditional laparoscopy. vNOTES may have superior outcomes in pain, length of stay, and satisfaction for multiple gynecologic indications however additional data is needed to assess cost-effectiveness and long-term outcomes. Surgeons implementing this technique should have adequate experience with both traditional vaginal and laparoscopic approaches. The current body of high-quality studies is heavily influenced by single site, single surgeon studies and as such may not be fully applicable to all practices incorporating this novel technique, and adequate training should precede implementation of Vnotes. Vaginal surgery is considered the least invasive approach, however, may not be appropriate in all cases. vNOTES presents a novel approach that combines the access and visualization afforded by endoscopy whereas avoiding the risks associated with transabdominal entry and can be considered as a feasible option in gynecologic surgery.

Background and Objectives: Transgender people are defined as individuals whose gender identity does not entirely match their sex assigned at birth. Gender surgery typically represents the conclusive and irreversible step in the therapeutic process, especially for the impact on the reproductive sphere. The increased awareness of gender dysphoria and the expanding array of medical and surgical options, including minimally invasive techniques, contribute to the gradual increase in the social impact of transgender surgery. There are several surgical techniques for "gender assignment", such as vaginal, laparotomic, laparoscopic, and robotic, and the novel approach of vaginal natural orifice transluminal endoscopic surgery to perform a hysterectomy and bilateral salpingo-oophorectomy (BSO). The purpose of this review is to assess the various surgical approaches (hysterectomy and salpingo-oophorectomy) for gender reassignment in order to determine the best option in clinical practice for the female-to-male population in terms of surgical outcomes such as operative time, surgical complication, hospital discharge, postoperative pain, and bleeding. Materials and Methods: This systematic review includes studies from 2007 to 2024. Special consideration was given to articles documenting the characteristics and management of female-to-male reassignment surgery. Finally, eight papers were included in this review. Results: The literature analysis considered surgical techniques ranging from traditional surgery to innovative methods like vaginal natural orifice transluminal endoscopic surgery and robotic-assisted laparoscopic hysterectomy. Vaginal natural orifice transluminal endoscopic surgery and the robotic approach offer potential benefits such as reduced postoperative pain and shorter hospital stays. While vaginal natural orifice transluminal endoscopic surgery may encounter challenges due to narrow access and smaller vaginal dimensions, robotic single-site hysterectomy may face instrument conflict. Conclusions: The conventional laparoscopic approach remains widely used, demonstrating safety and efficacy. Overall, this review underscores the evolving landscape of surgical techniques for gender affirmation and emphasizes the necessity for personalized approaches to meet the specific needs of transgender patients.

Chemotherapy and radiation therapy can cause gonadal dysfunction in women of reproductive age. Ovarian tissue cryopreservation is performed to restore fertility by allowing transplantation of the patient’s frozen-thawed ovarian tissue or through future in vitro maturation and in vitro fertilization of frozen-thawed oocytes. Herein, we describe our initial experience with vaginal natural orifice transluminal endoscopic surgery for ovarian tissue preservation in a young woman with malignant tumor. A 23-year-old woman with anaplastic lymphoma kinase-positive malignant lymphoma was scheduled for hematopoietic stem cell transplantation after experiencing relapse following R-cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy. Ovarian tissue cryopreservation was selected as only MII2 oocytes were collected. Vaginal natural orifice transluminal endoscopic surgery was performed to excise the left ovary. Ovarian tissues were frozen using the vitrification method. The operative time was 37 min, and blood loss was minimal. Pathological examination revealed no metastatic findings of malignant lymphoma and no thermal damage to the ovarian tissue due to bipolar disorder. The patient was discharged on the first day postoperatively, and her postoperative course was uneventful. The vaginal natural orifice transluminal endoscopic surgery technique can provide a safe and effective alternative to laparoscopy or laparotomy for the cryopreservation of ovarian tissue in young patients with cancer. We believe this method has potential application in sexually mature female cancer survivors.

Take NOTES (Natural Orifice Transluminal Endoscopic Surgery)

Background: Hereditary cancer syndromes such as BRCA1/2 and Lynch syndrome significantly increase the lifetime risk of ovarian, fallopian tube, and endometrial cancers. Risk-reducing salpingo-oophorectomy (RRSO) and hysterectomy are standard preventive strategies. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has recently emerged as a minimally invasive, scarless alternative that may enhance patient acceptance while maintaining oncologic safety. Objective: This narrative review aims to synthesize the current evidence regarding the role of vNOTES in risk-reducing gynecologic surgery for women with hereditary cancer syndromes, focusing on surgical feasibility, technical considerations, oncologic safety, and patient-reported outcomes. Methods: A structured literature search was conducted in PubMed and Web of Science for studies published between January 2000 and April 2025, using terms related to vNOTES, prophylactic gynecologic surgery, BRCA mutations, and Lynch syndrome. Inclusion criteria focused on studies reporting outcomes of vNOTES in risk-reducing or oncologic contexts. A total of eight studies were included for qualitative synthesis. Results: vNOTES has demonstrated technical feasibility and favorable surgical outcomes in risk-reducing procedures such as RRSO and hysterectomy in BRCA and Lynch syndrome carriers. Comparative studies report lower postoperative pain, faster recovery, and high patient satisfaction, with oncologic standards maintained through specimen containment, peritoneal inspection, and adherence to the SEE-FIM protocol. Limitations include the learning curve and restricted access to the upper abdomen, which may necessitate hybrid approaches in selected cases. Conclusions: vNOTES offers a promising, patient-centered surgical approach for hereditary cancer prevention, combining oncologic safety with enhanced recovery and cosmetic benefits. Further research is needed to standardize protocols, evaluate long-term outcomes, and define its role within broader personalized cancer prevention strategies.