vNOTES and Robotic vNOTES
Vaginal natural orifice transluminal endoscopic surgery (vNOTES) provides endoscopic access through a vaginal incision. Robotic vNOTES adds a robotic platform, but its instruments, camera route and approved procedures depend on that system. Conventional vaginal surgery, nonrobotic vNOTES, robotic vNOTES and transabdominal robotic surgery are distinct approaches; evidence for one cannot automatically be assigned to another.
For the urologic reconstructive application, see Transvaginal Ureteral Reimplantation.
Access and Platforms
| Approach / platform | What it adds | Important limit |
|---|---|---|
| Conventional vNOTES | Endoscopic visualization through vaginal access, with compatible laparoscopic instruments | Instrument configurations vary; it is not defined by an absolute absence of articulating instruments. |
| da Vinci SP vNOTES | An articulating camera and three jointed instruments through a vaginal access system in published reports | Published feasibility does not establish that every gynecologic procedure is covered by the local SP label. Check the actual model and indication. |
| Hominis, renamed Anovo by Momentis in 2022 | Purpose-designed articulated robotic arms for transvaginal work | US authorizations cover specified adult benign, laparoscopic-assisted transvaginal procedures; later 6N/6Ne clearances also include transabdominal ventral-hernia repair. This system uses an abdominal laparoscopic camera in the described configuration, so it is not automatically free of abdominal incisions.[1][2] |
Some vNOTES techniques avoid abdominal incisions; others use laparoscopic assistance or require an additional incision for access, extraction or conversion. “Scarless” should not be used as a universal promise: the vaginal incision still needs to heal. The da Vinci SP and Anovo camera/access arrangements are different.
Patient and Procedure Selection
Access planning must account for vaginal exposure, the proposed colpotomy, prior surgery, adhesions, suspected endometriosis, uterine/adnexal pathology and safe specimen extraction. Severe disease or altered pelvic planes may require a different route or additional assistance. Obesity, nulliparity or a narrow introitus cannot be reduced to one universal eligibility rule across platforms and procedures.
Benign hysterectomy is the best-studied application on this page. Reports of myomectomy, adnexal surgery, deep-endometriosis resection and prolapse procedures include technical reports and small series. A successful case involving one large fibroid or a patient with severe obesity does not establish an ideal patient profile, fertility benefit or an emergency-care standard. Suspected malignancy requires an oncology-specific plan; successful node identification alone does not establish oncologic equivalence.
The changing orientation requires deliberate identification of the bladder, ureters, uterine vessels and rectum. This overview is not a step-by-step colpotomy, morcellation or mesh-placement protocol. Use the relevant operative technique and current device instructions for those decisions.
Comparative Evidence
The 2023 Cochrane review of hysterectomy for benign disease included two vNOTES-versus-laparoscopy trials with 96 women and found the evidence too limited to establish a patient benefit reliably. Its broader conclusions favor a vaginal approach over abdominal hysterectomy when feasible, while recognizing tradeoffs between vaginal, laparoscopic and other approaches. Those conclusions are not a specific endorsement of robotic vNOTES.[3]
The 2026 VANH trial provides a direct comparison with conventional vaginal hysterectomy: 113 patients at two Dutch centers, with same-day discharge in 87.3% after vaginal-assisted NOTES versus 71.4% after VH (OR 2.76; 95% CI 1.04–7.25). This short-term discharge result does not establish equivalent rare-event safety or a benefit from robotic assistance.[11]
A 2026 randomized trial of 90 women found better immediate pain/recovery outcomes with conventional vNOTES than total laparoscopic hysterectomy under its study pathway. It studied low-risk elective patients (ASA I–II) at one center and did not isolate the value of robotic assistance or establish long-term pelvic-floor, sexual or oncologic outcomes.[4]
| Robotic or mixed-route study | Findings with their actual scope |
|---|---|
| Lowenstein 2021: prospective 30-patient Hominis hysterectomy series | No conversion or intraoperative complication reported; median procedure time 57 minutes, blood loss 50 mL and hospital stay three days. This was a short-follow-up feasibility study, not a randomized demonstration of faster recovery.[5] |
| Kanno 2025: retrospective matched SP-versus-conventional vNOTES | 65 patients per group after matching. Reported outcomes did not differ significantly; hospital stay was four days in both groups. The study does not support a universal same-day-discharge claim or prove equivalence for uncommon injuries.[6] |
| Guan 2024: 28 SP-vNOTES hysterectomies, most with endometriosis excision | Mean total operative time 188.7 minutes versus console time 97.3 minutes. One patient needed a mini-laparotomy for specimen extraction; cuff cellulitis and UTI were reported. Combining console/hysterectomy time with total time gives a misleading speed comparison.[7] |
| Lim 2025: retrospective 773-patient mixed-technique cohort | Included 211 vNOTES procedures, of which only 58 were robotic, and 562 laparoscopic-assisted vaginal hysterectomies. The 3.8% versus 0.5% finding concerned intraoperative hematuria, not overall complications. Selection differences limit causal comparisons.[8] |
The 2026 urinary-injury network review contained only 48 vNOTES participants, with very wide estimates for uncommon injuries. Its trial base largely predates these newer discharge/recovery studies; it cannot reliably rank vNOTES or robotic routes as safest.[12]
Reported low blood loss or absence of conversion in selected series does not exclude serious injury. Keep total operating time, console time, extraction time, discharge timing and follow-up definitions separate when comparing techniques.
Oncology and Prolapse Evidence Boundaries
The 2025 sentinel-node study compared 24 conventional vNOTES cases with 52 robotic cases; it did not study robotic vNOTES. Its high node-detection proportions are not proof of equivalent staging, recurrence or survival. It should not be used to label robotic vNOTES an established cancer-staging indication.[9]
Similarly, evidence about transabdominal robotic sacrocolpopexy is not evidence about a transvaginal robotic mesh procedure. Refer to the prolapse treatment atlas for the specific operation, mesh route and outcome evidence.
Training, Costs and Counseling
Training requires vaginal and endoscopic anatomy, platform-specific access/docking skills, proctoring and assessment of competence. A learning curve from one experienced surgeon does not establish that every surgeon is proficient after ten cases. ACOG's 2020 guidance emphasizes appropriate training, quality assurance and choosing technology according to patient benefit; it calls for better evidence identifying who benefits from robotic assistance over other minimally invasive approaches.[10]
Compare costs using the local procedure, equipment, service, consumables, reprocessing and operating-room pathway. A historical cost comparison of transabdominal robotic and abdominal hysterectomy does not establish the current cost of robotic vNOTES. Discuss expected access and extraction, possible additional ports/conversion, urinary or bowel injury, bleeding, infection and vaginal healing using the evidence for the actual procedure.
See Also
- Vaginal Hysterectomy
- Single-Port Robotics
- Robotic Platforms & Manufacturers
- Reconstructive Applications
- Transvaginal Ureteral Reimplantation
References
1. US FDA. Hominis Surgical System, De Novo DEN190022, February 26, 2021. Classification and indications. FDA. Anovo 6Ne K251761, July 2025. Momentis. Hominis-to-Anovo name change, July 2022.
2. SAGES Technology and Value Assessment. Anovo Surgical System, October 31, 2025: device configuration and abdominal camera access. Assessment.
3. Pickett CM, Seeratan DD, Mol BWJ, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2023;CD003677. doi:10.1002/14651858.CD003677.pub6. Full Cochrane review.
4. Acil F, Dedeoğlu A, Andıç O, et al. vNOTES vs total laparoscopic hysterectomy: a randomized controlled trial of pain, opioid use, and quality of recovery. J Minim Invasive Gynecol. 2026. doi:10.1016/j.jmig.2026.06.032.
5. Lowenstein L, Mor O, Matanes E, et al. Robotic vaginal natural orifice transluminal endoscopic hysterectomy for benign indications. J Minim Invasive Gynecol. 2021;28:1101–1106. doi:10.1016/j.jmig.2020.10.021.
6. Kanno K, Taniguchi R, Higuchi N, et al. Single-port robotic versus conventional laparoscopic vNOTES hysterectomy: a propensity score-matched comparison of surgical outcomes and literature review. Eur J Obstet Gynecol Reprod Biol. 2025;315:114757. doi:10.1016/j.ejogrb.2025.114757.
7. Guan X, Yang Q, Lovell DY. Assessing feasibility and outcomes of robotic single port transvaginal NOTES hysterectomy: a case series. J Minim Invasive Gynecol. 2024;31:1041–1049. doi:10.1016/j.jmig.2024.08.018.
8. Lim JC, Yang LY, Lin WL, et al. Redefining hysterectomy: robotic versus conventional approaches in transvaginal natural orifice transluminal endoscopic surgery and laparoscopically-assisted vaginal hysterectomy. J Formos Med Assoc. 2025. doi:10.1016/j.jfma.2025.07.005.
9. Şimşek E, Karakaş S, Karaaslan O, et al. Comparison of robotic and natural orifice transluminal endoscopic surgical technique procedures in patients undergoing sentinel lymph node biopsy during endometrial cancer surgery. Surg Oncol. 2025;63:102282. doi:10.1016/j.suronc.2025.102282.
10. ACOG. Robot-Assisted Surgery for Noncancerous Gynecologic Conditions: Committee Opinion No. 810. Obstet Gynecol. 2020;136:e22–e30. doi:10.1097/AOG.0000000000004048.
11. Bekkers IPW, Wintraecken FRM, Smeets NAC, et al. Vaginal hysterectomy versus vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy; results of a randomised controlled trial. BJOG. 2026. doi:10.1111/1471-0528.70260.
12. Cassani C, Spinillo A, Dominoni M, Gardella B. Revisiting urological injury risks in minimally invasive hysterectomy for benign indications: a rare-events network meta-analysis with sensitivity analyses. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06566-y.