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vNOTES and Robotic vNOTES

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) uses a posterior or anterior colpotomy as the working access for endoscopic pelvic and abdominal procedures, eliminating abdominal incisions. Robotic vNOTES (RvNOTES) docks a robotic platform — most commonly the da Vinci SP — through the vaginal port, adding wristed instruments, 3D visualization, and tremor elimination to the narrow vaginal corridor.[1][2][3]

For the urologic reconstructive analog applying this access route to ureteral reimplantation, see Transvaginal Ureteral Reimplantation.

Concept and Rationale​

Traditional vaginal surgery has the shortest hospital stay and fastest recovery for hysterectomy but is limited by restricted visualization and confined working space.[4] Conventional vNOTES adds endoscopic optics through a colpotomy but still uses rigid, non-articulating instruments.[6][7] Robotic vNOTES retains the scarless access while restoring the dexterity of articulating instruments, addressing the principal limitations of both predecessor approaches.[1][3]

Robotic Platforms​

PlatformUse case
da Vinci SP (Single Port)Most widely reported platform for RvNOTES. Single-arm design docks easily through a vaginal gel port (e.g., Gelpoint V-Path); a metal cannula carries three articulating instruments and a flexible camera. Multi-arm robots struggle with arm-angle constraints in the narrow vaginal space; the SP avoids this.[2][8][9]
Hominis Surgical SystemPurpose-built for RvNOTES. Two-center prospective study of 30 hysterectomies: zero conversions, median OR 57 min, median EBL 50 mL, postop pain VAS 3/10.[10]

Surgical Steps​

  1. Lithotomy under general anesthesia.
  2. Posterior or anterior colpotomy.
  3. Gel port (e.g., Gelpoint V-Path) inserted through the colpotomy.
  4. Pneumoperitoneum established.
  5. Robotic system docked through the vaginal port.
  6. Procedure performed using single-incision robotic technique.
  7. Specimen extracted transvaginally (intact or morcellated).
  8. Colpotomy closed with absorbable suture.

The entire surgery is performed "upside down" relative to the standard transabdominal laparoscopic perspective — the surgeon must remap the locations of the uterine artery, ureter, and rectum.[1]

Indications and Procedures​

ProcedureNotes
Hysterectomy (benign and malignant)Most commonly reported.[2][10][8][9]
MyomectomyDemonstrated for fibroids up to 8 cm; precise multilayer suturing enabled by robotic articulation.[1]
Endometriosis resectionIncluding DIE involving parametrium and bowel.[3]
SacrocolpopexyPelvic-organ-prolapse repair.[11][12]
Adnexal surgeryOvarian cystectomy, detorsion, salpingectomy.[13][14]
Sentinel lymph node biopsyEndometrial-cancer staging — SLN detection rate 96–97%, comparable to transabdominal robotic surgery.[15]
Ureteral reimplantation (urologic application)Early experience with single-port robotic transvaginal retroperitoneal access — see Transvaginal Ureteral Reimplantation.

Patient Selection​

  • Adequate vaginal space for port placement.
  • BMI, uterine weight, prior vaginal delivery, and history of abdominal surgery predict OR time and approach selection.[16]
  • May be particularly advantageous in morbid obesity (BMI ≥40) where abdominal access is challenging.[14]
  • For myomectomy, ideal candidates have a single large posterior fibroid with desire for fertility preservation.[1]
  • Nulliparity or very narrow introitus may limit feasibility.

Outcomes​

  • Operative time: RvNOTES hysterectomy 57–102 min depending on complexity. Propensity-matched comparison vs conventional vNOTES showed no significant difference (75.4 vs 83.8 min, p = 0.05).[10][8][2]
  • Blood loss: Consistently low, typically 30–100 mL.[1][10][9]
  • Conversion: Very low to zero in reported series.[10][8][9]
  • Hospital stay: Same-day discharge feasible for many procedures; median 1–3 days.[1][10][9]
  • Postoperative pain: Minimal (VAS 1–5 in first 24 h).[10][9]
  • Complications: Vaginal cuff cellulitis, UTI, intraoperative hematuria — 3.8% in vNOTES vs 0.5% in LAVH in one large comparison.[16][9]

A 773-patient retrospective comparison found vNOTES had shorter OR time and lower blood loss vs LAVH; robotic assistance was associated with slightly longer OR time vs conventional laparoscopy.[16]

Advantages​

  • No abdominal incisions — true scarless surgery.
  • Wristed instruments overcome the limited range of motion of conventional vNOTES, enabling precise suturing and multilayer closure.[1]
  • 3D visualization improves tissue discrimination in confined space.[3]
  • Improved ergonomics — reduced surgeon musculoskeletal strain.[4][17]
  • Faster recovery vs abdominal approaches.[4]
  • Expands the indications for vaginal surgery to large uteri, endometriosis, and obesity.[2][14]

Limitations​

  • Cost — robotic surgery remains the most expensive technique. Average total cost for robotic hysterectomy ~€6,528 vs €4,401 for abdominal hysterectomy in one European analysis.[18]
  • No haptic feedback.[4]
  • Nonstandardized training and credentialing.[19][4]
  • Limited high-quality evidence — most data are retrospective single-center single-surgeon; RCTs lacking.[4][7]
  • "Upside-down" orientation requires significant spatial adaptation.[1]
  • Vaginal-space constraints in some patients.

Learning Curve​

For surgeons experienced in laparoscopic single-site and abdominal robotic surgery, proficiency in RvNOTES is reached after approximately 10 cases, with 10–20 port placements / docking procedures.[1] ACOG notes that for general robotic surgery, OR-time efficiency is typically attained after 20–30 cases, with continuous improvement through the first 100.[4] Training should include didactics, simulation, hands-on docking, and proctored cases — Fundamentals of Robotic Surgery and Robotic Training Network are standardized curricula.[4]

Guideline Perspectives​

  • ACOG Committee Opinion No. 810 (2020). Vaginal surgery remains the approach of choice when feasible for hysterectomy; robotic surgery provides an alternative MIS tool with perioperative outcomes equivalent to conventional laparoscopy but improved outcomes vs laparotomy.[4]
  • RCOG Scientific Impact Paper No. 71 (2022). Robotic surgery may be particularly beneficial for complex gynecologic surgery and patients with BMI ≥30 or pulmonary comorbidities.[17]

Both organizations emphasize that well-designed studies are needed to determine which patients benefit most.

See Also​

References​

1. Sunkara S, Guan X. Robotic vaginal natural orifice transluminal endoscopic myomectomy. Fertil Steril. 2022;118(2):414–416. doi:10.1016/j.fertnstert.2022.05.009

2. Kanno K, Higuchi N, Taniguchi R, Andou M. Vaginal-assisted natural orifice translumenal endoscopic surgery hysterectomy for large uterus using the da Vinci SP. J Minim Invasive Gynecol. 2025;32(5):415–416. doi:10.1016/j.jmig.2025.01.008

3. Guan X, Welch JR, Wu G. Robotic transvaginal natural orifice transluminal endoscopic surgery for resection of parametrial and bowel deeply infiltrated endometriosis. J Minim Invasive Gynecol. 2022;29(3):341–342. doi:10.1016/j.jmig.2021.11.020

4. Robot-Assisted Surgery for Noncancerous Gynecologic Conditions: ACOG Committee Opinion, Number 810. Obstet Gynecol. 2020;136(3):e22–e30. doi:10.1097/AOG.0000000000004048

6. Ozceltik G, Yeniel AO, Atay AO, Itil IM. Simplified two-step technique for transvaginal natural orifice transluminal endoscopic surgery. Fertil Steril. 2020;114(3):665–666. doi:10.1016/j.fertnstert.2020.05.002

7. Reddy H, Kim SW, Plewniak K. Applications of vaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologic surgery. Curr Opin Obstet Gynecol. 2022;34(4):220–226. doi:10.1097/GCO.0000000000000799

8. 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

9. Guan X, Yang Q, Lovell DY. Assessing feasibility and outcomes of robotic single-port transvaginal NOTES (RSP-vNOTES) hysterectomy: a case series. J Minim Invasive Gynecol. 2024;31(12):1041–1049. doi:10.1016/j.jmig.2024.08.018

10. Lowenstein L, Mor O, Matanes E, et al. Robotic vaginal natural orifice transluminal endoscopic hysterectomy for benign indications. J Minim Invasive Gynecol. 2021;28(5):1101–1106. doi:10.1016/j.jmig.2020.10.021

11. Lawrie TA, Liu H, Lu D, et al. Robot-assisted surgery in gynaecology. Cochrane Database Syst Rev. 2019;4:CD011422. doi:10.1002/14651858.CD011422.pub2

12. Daykan Y, Rotem R, O'Reilly BA. Robot-assisted laparoscopic pelvic floor surgery: review. Best Pract Res Clin Obstet Gynaecol. 2023;91:102418. doi:10.1016/j.bpobgyn.2023.102418

13. Lovell DY, Yang Q, Guan X. SP robot-assisted vNOTES for a right ovarian cystectomy. J Minim Invasive Gynecol. 2026. doi:10.1016/j.jmig.2026.03.015

14. Sendukas E, Guan X. Robotic-assisted vNOTES for emergency detorsion in a patient with morbid obesity: case presentation. J Minim Invasive Gynecol. 2025. doi:10.1016/j.jmig.2025.05.004

15. 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

16. 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

17. Nobbenhuis MAE, Gul N, Barton-Smith P, et al. Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022). BJOG. 2023;130(1):e1–e8. doi:10.1111/1471-0528.17242

18. Delameilleure M, Timmerman S, Vandoren C, et al. Approaches for hysterectomy and implementation of robot-assisted surgery in benign gynaecological disease: a cost analysis study in a large university hospital. Eur J Obstet Gynecol Reprod Biol. 2024;301:105–113. doi:10.1016/j.ejogrb.2024.07.060

19. Robot-Assisted Surgery for Noncancerous Gynecologic Conditions: ACOG Committee Opinion Summary, Number 810. Obstet Gynecol. 2020;136(3):640–641. doi:10.1097/AOG.0000000000004049